In cardiac surgery patients , effective pain control is crucial to support early extubation, mobilization, and cognitive recovery, yet systemic opioids carry substantial risks such as respiratory depression, delirium, and delayed rehabilitation. While regional fascial plane blocks offer a safer, opioid-sparing alternative, no single technique provides complete analgesia for the complex and multi-dermatomal pain generated by sternotomy, graft harvesting, chest wall retraction, and drain sites. Therefore, a multimodal approach combining blocks such as parasternal nerve block , rectus sheath nerve block and femoral nerve block , may cover most of areas expected to be sources of intraoperative and post-operative pain in cardiac surgery patients.
o Scheduled for elective off-pump coronary artery bypass graft (OPCAB) surgery via median sternotomy
American Society of Anesthesiologists (ASA) physical status III - IV
Ability to provide informed consent
o Emergency or redo cardiac surgery
On-pump CABG or concomitant valve or aortic procedures
Known allergy to local anesthetics or study drugs
Coagulopathy or ongoing anticoagulant therapy contraindicating regional block
Parallel
regional nerve block with local anesthesia
Procedure/SurgeryPatients will receive bilateral superficial parasternal nerve block using 20 mL of 0.25% bupivacaine per side, in combination with a rectus sheath block (RSB) using 10 mL of 0.25% bupivacaine per side. and femoral nerve block at the side of harvesting using 10 mL of 0.25% bupivacaine.
Placebo
Procedure/SurgeryPatients will receive placebo (saline) injections administered in the same anatomical planes.
Time to Extubation
Defined as the interval (in hours) from transferal to ICU to successful tracheal extubation
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