Comparison of the Efficacy of Combined Transversus Thoracic Plane Block and Serratus Anterior Plane Block Versus Erector Spinae Plane Block in the Management of Sternotomy Pain
STERNOTOMİ AĞRISININ YÖNETİMİNDE TRANSVERSUS TORASİK PLAN BLOK VE SERRATUS ANTERİOR PLAN BLOK KOMBİNASYONU İLE EREKTÖR SPİNA PLAN BLOK ETKİNLİĞİNİN KARŞILAŞTIRILMASI
Background and Purpose: Median sternotomy is the standard surgical approach for cardiac procedures, yet it is associated with significant postoperative pain. Inadequate pain management can lead to pulmonary complications and chronic pain syndromes. While opioids are a cornerstone of multimodal analgesia, their side effects-such as sedation, respiratory depression, and nausea-can delay recovery. Furthermore, neuraxial techniques like epidural analgesia are often avoided in cardiac surgery due to the risks associated with systemic heparinization. This study aims to compare the efficacy of two non-neuraxial regional anesthesia techniques: the combination of Transversus Thoracic Plane Block (TTPB) and Serratus Anterior Plane Block (SAPB) versus the Erector Spinae Plane Block (ESPB).
Study Design and Population: This prospective, randomized study includes 50 patients (ASA I-III, aged 18-80) undergoing elective cardiac surgery via median sternotomy. Patients are randomized into two groups:
TTPB + SAPB Group: Patients receive ultrasound-guided blocks targeting the anterior and lateral chest wall.
ESPB Group: Patients receive ultrasound-guided blocks targeting the paravertebral and intercostal spaces from a posterior approach.
Intervention and Procedures: Following standardized anesthesia induction and invasive monitoring, the respective blocks are performed under ultrasound guidance. Intraoperative hemodynamic data are recorded at key surgical stages (incision, sternotomy, CPB). In the postoperative period in the intensive care unit (ICU), all patients will receive a standardized multimodal analgesia protocol including intravenous (IV) paracetamol and IV tenoxicam. While patients are intubated, pain will be assessed using the Behavioral Pain Scale (BPS). If the BPS score is above 3, IV fentanyl will be administered as rescue analgesia.
Following extubation, pain levels will be evaluated using the Visual Analog Scale (VAS) at rest and during coughing at specific time points (0, 1, 2, 4, 8, 12, 16, and 24 hours). If the post-extubation VAS score is 4 or higher, intramuscular meperidine will be given as rescue analgesia. Additionally, IV ondansetron will be administered in case of nausea or vomiting. The study will also evaluate the time to extubation, time to clinical transport, and patient/surgeon satisfaction using a 5-point Likert scale.
Primary and Secondary Outcomes:
The primary objective of this study is to compare postoperative pain intensity between the study groups using the Visual Analog Scale (VAS) (0-10) and the Behavioral Pain Scale (BPS) (3-12).
Secondary objectives include:
Opioid Consumption: Comparison of total intraoperative and postoperative opioid (IV fentanyl and IM meperidine) consumption within the first 24 hours.
Recovery Milestones: Measurement of time to extubation, time to first mobilization, and time to clinical transport to the surgical ward.
Clinical Satisfaction and Safety: Assessment of patient and surgeon satisfaction using a 5-point Likert scale, and monitoring the incidence of opioid-related side effects, specifically postoperative nausea and vomiting (PONV) requiring ondansetron.
Expected Impact:
By identifying the most effective regional anesthesia technique (TTPB+SAPB vs. ESPB) in conjunction with a standardized multimodal analgesia protocol (IV paracetamol and tenoxicam), this study seeks to maximize postoperative pain control and patient comfort. The results aim to achieve superior analgesia with lower pain scores, thereby facilitating earlier mobilization, reducing the incidence of postoperative complications, and enhancing the overall recovery process for patients undergoing cardiac surgery via median sternotomy. This approach ultimately contributes to the development of more effective, pain-centered recovery protocols in the intensive care unit.
Study Overview
Status
Intervention / Treatment
Detailed Description
Following informed consent, patients will be randomly assigned to either Group TTPB+SAPB or Group ESPB in a 1:1 ratio using a computer-generated sequence to ensure allocation concealment. This is a prospective, observer-blinded trial. While the anesthesiologist performing the blocks is aware of group assignments, the investigators responsible for postoperative data collection will be blinded to the intervention to minimize bias.
Standardized Anesthesia Management All patients will receive a standardized anesthetic protocol. Premedication with IV midazolam will be followed by standard monitoring including ECG, SpO2, and invasive arterial pressure. General anesthesia will be induced with propofol, fentanyl, and rocuronium, and maintained with sevoflurane in an oxygen-air mixture. The Bispectral Index (BIS) will be monitored to maintain a target range between 40 and 60.
Regional Anesthesia Interventions
Blocks will be performed under ultrasound guidance after induction but before surgical incision:
Group TTPB + SAPB: Transversus Thoracic Plane Block will be performed at the T4-T5 level between the internal intercostal and transversus thoracis muscles. Serratus Anterior Plane Block will be performed over the 5th rib in the mid-axillary line targeting the lateral cutaneous branches.
Group ESPB: The T4 transverse process will be identified, and local anesthetic will be injected into the plane between the erector spinae muscle and the transverse process tip to allow for cranio-caudal spread.
Intraoperative and Postoperative Analgesia Protocol Intraoperative hemodynamic parameters will be recorded at key stages (baseline, incision, sternotomy, CPB). If heart rate or MAP increases by >20% from baseline, a rescue bolus of fentanyl will be administered. Postoperatively, all patients will receive a multimodal analgesia regimen consisting of IV paracetamol and IV tenoxicam. Rescue analgesia will be provided based on pain scale assessments as defined in the protocol.
Statistical Analysis Sample size calculation was performed to achieve 80% power with a 5% significance level, requiring a total of 50 patients to account for potential dropouts. Continuous variables will be compared using the Student's t-test or Mann-Whitney U test, while categorical variables will be analyzed using the Chi-square or Fisher's exact test.
Study Type
Enrollment (Estimated)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Nilüfer
-
Bursa, Nilüfer, Turkey (Türkiye), 16235
- Recruiting
- Bursa Uludag University Hospital
-
Contact:
- Ali Haydar Colak, MD
- Phone Number: +902242954476 +90 506 560 35 17
- Email: alihaydarcolak@uludag.edu.tr
-
Contact:
- Onur Alp, MD
- Phone Number: +902242953131 +90 539 956 55 11
- Email: onuralp@uludag.edu.tr
-
Principal Investigator:
- Elif Basagan Mogol, Professor of Anesthesiology
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Adult
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Patients aged between 18 and 80 years.
- Patients with American Society of Anesthesiologists (ASA) physical status I, II, or III.
- Patients who provide written informed consent.
- Patients scheduled for cardiac surgery via elective sternotomy.
Exclusion Criteria:
- Pregnancy or suspected pregnancy
- Body Mass Index (BMI) > 35 kg/m²
- History of allergy to local anesthetics or opioids
- Suspected coagulopathy or infection at the injection site
- Severe neurological, psychiatric, hepatic, or renal failure
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
|
Experimental: ESPB Group
Patients in this group will receive Erector Spinae Plane Block for postoperative analgesia.
|
Erector Spinae Plane Block (ESPB) at the T4 transverse process level will be performed using 0.25% bupivacaine (0.5 mg/kg)
|
|
Experimental: TTPB+ SAPB Group
Patients in this group will receive a combination of Transversus Thoracic Plane Block and Serratus Anterior Plane Block for postoperative analgesia.
|
A combination of Transversus Thoracic Plane Block (TTPB) at the T4-T5 level will be performed using 0.25% bupivacaine (0.5 mg/kg)
Serratus Anterior Plane Block (SAPB) at the 5th rib level will be performed using 0.25% bupivacaine (0.5 mg/kg)
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Postoperative Pain Intensity
Time Frame: Up to 24 hours post-extubation.
|
Pain will be assessed using the Visual Analog Scale (VAS) (0 = no pain, 10 = worst possible pain) during rest and coughing at the 0th minute, and 1st, 2nd, 4th, 8th, 12th, 16th, and 24th hours post-extubation.
|
Up to 24 hours post-extubation.
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Behavioral Pain Scale (BPS) Scores
Time Frame: From admission to ICU until extubation (approx. 6-12 hours).
|
Assessment of pain in intubated patients (Score range: 3-12).
Higher scores indicate more pain.
|
From admission to ICU until extubation (approx. 6-12 hours).
|
|
Total Rescue Analgesic Consumption
Time Frame: Up to 24 hours post-operation.
|
The total amount (mg) of intravenous Fentanyl and intramuscular Meperidine administered as rescue analgesics.
|
Up to 24 hours post-operation.
|
|
Time to Extubation
Time Frame: From the end of surgery up to 12 hours.
|
The duration from the end of surgery until the patient meets extubation criteria and is extubated.
|
From the end of surgery up to 12 hours.
|
|
Time to Transport to Ward
Time Frame: Up to 48 hours.
|
The duration from ICU admission until the patient is stable enough to be transferred to the surgical ward.
|
Up to 48 hours.
|
|
Patient Satisfaction Score
Time Frame: At the 24th hour post-operation.
|
Evaluated using a 5-point Likert Scale (1 = very dissatisfied, 5 = very satisfied).
|
At the 24th hour post-operation.
|
|
Surgeon Satisfaction Score
Time Frame: Up to 24 hours postoperatively.
|
The primary surgeon's satisfaction with the analgesia quality and ease of the procedure, evaluated using a 5-point Likert scale (1=Very Dissatisfied, 5=Very Satisfied).
|
Up to 24 hours postoperatively.
|
Collaborators and Investigators
Sponsor
Publications and helpful links
General Publications
- Nagaraja PS, Ragavendran S, Singh NG, Asai O, Bhavya G, Manjunath N, Rajesh K. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. 2018 Jul-Sep;21(3):323-327. doi: 10.4103/aca.ACA_16_18.
- Dost B, De Cassai A, Balzani E, Tulgar S, Ahiskalioglu A. Effects of ultrasound-guided regional anesthesia in cardiac surgery: a systematic review and network meta-analysis. BMC Anesthesiol. 2022 Dec 29;22(1):409. doi: 10.1186/s12871-022-01952-7.
- Mansour MA, Mahmoud HE, Fakhry DM, Kassim DY. Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study. BMC Anesthesiol. 2024 Feb 10;24(1):63. doi: 10.1186/s12871-024-02432-w.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- 25-AKD-310
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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