Postoperative pain after cardiac surgery is commonly moderate to severe due to sternotomy, thoracotomy, internal mammary artery harvesting, and chest tube placement, and may contribute to adverse systemic and pulmonary outcomes if inadequately managed. Enhanced Recovery After Surgery (ERAS) protocols emphasize opioid-sparing strategies to reduce opioid-related side effects and complications. Ultrasound-guided fascial plane blocks have increasingly been incorporated into perioperative analgesia protocols for cardiac surgery. The serratus posterior superior intercostal plane block (SPSIPB), a recently described technique, provides wide dermatomal sensory coverage and may offer effective analgesia in thoracic and cardiac surgical procedures.
This prospective, randomized controlled study aims to evaluate the analgesic efficacy of SPSIPB in adult patients undergoing off-pump minimally invasive coronary artery bypass grafting (CABG). A total of 60 ASA III patients aged 18 years or older will be randomized into two groups: SPSIPB group and control group. The SPSIPB will be performed preoperatively under ultrasound guidance using 0.25% bupivacaine, while the control group will receive standard general anesthesia without any plane block. All patients will receive standardized general anesthesia and postoperative patient-controlled analgesia with tramadol.
The primary outcome of the study is postoperative recovery quality assessed using the Quality of Recovery-15 (QoR-15) questionnaire. Secondary outcomes include intraoperative remifentanil consumption, postoperative opioid requirements, time to first rescue analgesia, numerical rating scale (NRS) pain scores at rest and during coughing, extubation time, intensive care unit and hospital length of stay, and postoperative complications such as nausea, vomiting, and atelectasis. This study aims to determine whether SPSIPB can improve postoperative recovery quality and reduce opioid consumption in patients undergoing off-pump minimally invasive CABG.
Patients aged 18-75 years
ASA physical status II-III
Scheduled for elective off-pump minimally invasive coronary artery bypass grafting (CABG) surgery
Ability to understand and use the Numerical Rating Scale (NRS)
Refusal to participate in the study
Known allergy or contraindication to local anesthetics
Coagulation disorders or ongoing anticoagulant therapy incompatible with regional anesthesia
Infection at the block injection site
Parallel
Serratus Posterior Superior Intercostal Plane Block (SPSIPB)
Procedure/SurgeryUltrasound-guided serratus posterior superior intercostal plane block (SPSIPB) will be performed prior to induction of general anesthesia under sterile conditions. Patients will be positioned laterally with the surgical side up. Using a high-frequency linear ultrasound probe, the scapular spine and the third rib will be identified medial to the scapula. After confirmation of the serratus posterior superior muscle and pleura, the needle will be advanced until contact with the third rib is achieved. Following hydrodissection with 5 mL of isotonic saline, 30 mL of 0.25% bupivacaine (1 mg/kg) will be injected between the serratus posterior superior muscle and the third rib. Cranio-caudal spread of the local anesthetic will be confirmed under ultrasound guidance. All participants will subsequently receive standardized general anesthesia and postoperative analgesia according to the institutional protocol.
Bupivacaine
DrugBupivacaine was administered as the local anesthetic for the block.
Ultrasound
DeviceUltrasound guidance was used for block placement.
Quality of Recovery-15 (QoR-15) Score
The Quality of Recovery-15 (QoR-15) questionnaire is a validated patient-reported outcome measure assessing postoperative recovery quality across five domains: pain, physical comfort, physical independence, psychological support, and emotional state. Higher scores indicate better recovery quality.
Postoperative Pain Scores (NRS)
Pain intensity assessed using the Numerical Rating Scale (NRS), ranging from 0 (no pain) to 10 (worst imaginable pain), evaluated both at rest and during coughing.
Postoperative Total Opioid Consumption
The cumulative amount of opioid analgesics (tramadol equivalent) administered via patient-controlled analgesia during the postoperative period.
Intraoperative Remifentanil Consumption
The total amount of remifentanil administered intravenously during the surgical procedure, recorded in micrograms.
Time to First Rescue Analgesia
The time interval between the end of surgery and the administration of the first rescue analgesic dose due to inadequate pain control (NRS ≥4).
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