Postoperative Analgesia and Ventilation After Cardiac Surgery

Effect of Fascial Plane Blocks Providing Postoperative Analgesia on Mechanical Ventilation Duration in the Intensive Care Unit and Early Oxygenation After Cardiac Surgery

Cardiac surgery performed via median sternotomy is associated with significant postoperative pain due to extensive tissue trauma, sternal bone healing, and mediastinal retraction. Inadequately controlled postoperative pain represents an important source of morbidity in these patients and may adversely affect respiratory mechanics, leading to hypoventilation, atelectasis, and hypoxemia. These complications can delay extubation, prolong the duration of mechanical ventilation, and increase the length of stay in the intensive care unit (ICU). In addition, insufficient pain control may trigger sympathetic activation, resulting in increased myocardial oxygen consumption, a higher risk of arrhythmias, and impaired immune function. Traditionally, systemic opioids have been the cornerstone of postoperative pain management in cardiac surgery; however, opioid-based analgesia is associated with several adverse effects, including respiratory depression, sedation, nausea and vomiting, gastrointestinal dysfunction, and prolonged mechanical ventilation. These limitations have led to increasing interest in multimodal analgesia strategies aimed at improving postoperative pain control while reducing opioid consumption and related complications. In this context, regional analgesia techniques have emerged as important components of multimodal pain management protocols in cardiac surgery.

The aim of this study was to evaluate the effects of fascial plane blocks used as part of postoperative analgesia on postoperative pain control, opioid consumption, respiratory parameters, mechanical ventilation duration, and early oxygenation in patients undergoing open heart surgery via median sternotomy, compared with patients receiving conventional analgesic management.

Study Overview

• Status: Completed
• Conditions: Cardiac Surgery; Oxygenation; ICU Length of Stay; Mechanical Ventilation Duration; Fascial Plane Block
• Intervention / Treatment: Other: conventional analgesic regimen; Other: Fascial Plane Blocks

Detailed Description

Cardiac surgery is a major surgical discipline performed on hundreds of thousands of patients worldwide and is becoming increasingly common with technological advances. Median sternotomy remains the standard surgical approach for open-heart procedures, most notably coronary artery bypass grafting (CABG) and valve reconstruction or replacement.1,2 The pain resulting from sternotomy-associated extensive tissue injury, sternal bone regeneration, and mediastinal retraction is both severe and multidimensional in nature, arising from widespread irritation of the thoracic wall, pericardium, pleura, and the involved neural structures.3 Inadequately controlled postoperative pain is a significant source of morbidity in cardiac surgery and leads to serious clinical consequences. Acute pain adversely affects respiratory mechanics, predisposing patients to hypoventilation, atelectasis, and hypoxemia; it prolongs the extubation process and increases the duration of intensive care unit (ICU) stay.4,5 Insufficient analgesia can also increase myocardial oxygen demand through sympathetic activation, heighten susceptibility to arrhythmias, and compromise immunological integrity.6 In the long term, the risk of acute pain transitioning into chronic post-sternotomy pain cannot be overlooked; this condition is known to permanently impair patients' quality of life and significantly restrict functional capacity.7 Systemic opioids have traditionally formed the cornerstone of postoperative pain management in cardiac surgery. However, opioid-based analgesia is associated with a range of adverse effects including respiratory depression, sedation, nausea and vomiting, ileus, and prolonged mechanical ventilation.8 These adverse effects are particularly consequential in the vulnerable patient population of cardiac surgery, contributing to increased clinical complexity, greater utilization of hospital resources, and potential increases in mortality.9 In this context, multimodal analgesia strategies aimed at reducing opioid consumption, limiting side effects, and accelerating postoperative recovery are gaining increasing importance.10 Regional anesthesia techniques have been rapidly integrated into cardiac surgical practice in recent years as an indispensable component of multimodal analgesia protocols. Although thoracic epidural anesthesia and paravertebral block have long been established methods with proven efficacy, their use is significantly limited by factors such as coagulopathy, systemic heparinization in cardiac surgery, and high bleeding risk.11,12 Superficial fascial plane blocks, developed alongside the widespread adoption of ultrasound technology, offer a more favorable safety profile and are attracting increasing interest in cardiac surgical applications.13 The pecto-intercostal fascial plane block (PIFB) is a relatively novel technique based on local anesthetic injection into the fascial plane between the pectoralis major muscle and the external intercostal muscles. By targeting the intercostal nerve branches of the anterior thorax and afferent fibers of the cutaneous pectoral branches, PIFB provides effective analgesia along the sternotomy incision adjacent to the sternum.14,15 The serratus anterior plane block (SAPB), on the other hand, blocks the intercostobrachial nerve and thoracic intercostal nerve branches innervating the lateral thorax through local anesthetic injection into the fascial plane between the latissimus dorsi and serratus anterior muscles and the ribs.16,17 The combination of these two blocks establishes a complementary analgesic coverage encompassing the sternotomy incision, the parasternal region, and the lateral thoracic wall.18 Both techniques possess characteristics that distinguish them in cardiac surgical patients: superficial anatomical targets, ease of ultrasound-guided application, and a safe-use profile even during anticoagulation.19 Nevertheless, studies evaluating the combined application of PIFB and SAPB in open-heart surgery remain very limited in number, and comprehensive data assessing the impact of this combination on postoperative pain control, opioid consumption, and respiratory function are still insufficient.

The aim of this study is to evaluate the effect of fascial plane block on postoperative pain scores, opioid consumption, respiratory parameters, and ICU outcomes in patients undergoing open-heart surgery via sternotomy, in comparison with patients receiving conventional analgesia.

• Study Type: Observational
• Enrollment (Actual): 206

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • nilüfer
    • Bursa, nilüfer, Turkey (Türkiye)
      • Bursa City Hospital,

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

elective coronary artery bypass grafting (CABG) or heart valve surgery via sternotomy.

Description

The study included patients aged 18-80 years who underwent elective coronary artery bypass grafting (CABG) or heart valve surgery via sternotomy.

Exclusion criteria were defined as follows: off-pump surgery, thoracotomy, reoperation (redo surgery), emergency surgical conditions, development of complications requiring surgical revision in the postoperative period, and incomplete perioperative data recording.

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Group 0 (Conventional Group); group that does not have a block applied	Other: conventional analgesic regimen; At the end of the surgery, wound site infiltration and IV paracetamol 1 g and IV tramadol 100 mg were administered for multimodal analgesia. During the follow-up period in the intensive care unit (ICU), IV paracetamol 1 g and IV tramadol 50 mg were routinely administered every 6 hours. The threshold value for rescue analgesia requirement was determined as Visual Analog Scale (VAS) ≥ 4; IV meperidine 100 mg was administered as a rescue dose to patients exceeding this threshold.
Group 1 (Fascial Plane Group); combined PIFB and SAPB group	Other: Fascial Plane Blocks; PIFB: Under ultrasound guidance, 15 mL of 0.25% bupivacaine is injected bilaterally into the fascial plane between the pectoralis major and external intercostal muscles, 2-3 cm lateral to the sternal border. SAPB: Under ultrasound guidance, 15 mL of 0.25% bupivacaine is injected bilaterally into the fascial plane between the serratus anterior muscle and the ribs at the 4th-5th rib level in the midaxillary line. At the end of surgery, IV paracetamol 1 g and IV tramadol 100 mg were administered. In the ICU, IV paracetamol 1 g and IV tramadol 50 mg were given every 6 hours. Rescue analgesia (IV meperidine 100 mg) was administered for VAS ≥ 4.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mechanical Ventilation Duration	Total time on mechanical ventilator support in hours.	Up to 72 hours postoperatively
Extubation Time	Time from ICU admission to tracheal extubation in hours.	Up to 48 hours postoperatively
ICU Length of Stay	Duration of intensive care unit stay in hours, measured from ICU admission to discharge.	Up to 7 days postoperatively

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PaO₂/FiO₂ Ratio	Arterial oxygenation index calculated from arterial blood gas analysis.	Postoperative 6th, 12th, and 24th hours
Postoperative Pain Score (VAS)	Pain intensity assessed using the Visual Analog Scale (0-10).	Postoperative 6th, 12th, and 24th hours
Total Opioid Consumption	Cumulative opioid use expressed in morphine equivalents (mg)	First 24 hours postoperatively
Rescue Analgesic Requirement	Number of rescue analgesic doses (IV meperidine 100 mg) administered for VAS ≥ 4.	First 24 hours postoperatively

Collaborators and Investigators

• Sponsor: Bursa City Hospital

Publications and helpful links

General Publications

• 11. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J. 2014;35(35):2383-2431. 12. Fitzgibbon DR, Koyyalagunta D. A practical approach to acute pain management after cardiac surgery. ASA Refresher Courses Anesthesiol. 2010;38(1):37-48. 13. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68(11):1107-1113. 14. Ueshima H, Otake H. Clinical experiences of pecto-intercostal fascial block for postoperative analgesia in cardiac surgery. J Clin Anesth. 2017;36:44-45. 15. Kaushal B, Chauhan S, Saini K, et al. Comparison of the efficacy of ultrasound-guided serratus anterior plane block, pectoral nerves II block, and local infiltration analgesia for management of postoperative pain and quality of recovery in patients undergoing modified radical mastectomy. J Clin Anesth. 2019;54:118-124. 16. Portela DA, Otero PE, Briganti A. Serratus anterior plane block in canine cadavers: anatomical evaluation. Vet Anaesth Analg. 2019;46(4):516-524. 17. Hong B, Yoon SH, Huh B, Lee S, Yoon JU, Byeon GJ. Serratus anterior plane block for refractory pain after cardiac surgery. Pain Physician. 2019;22(3):E219-E224. 18. Choudhary MK, Bhaware B, Bhui A, et al. Bilateral pecto-intercostal fascial plane block with serratus anterior plane block versus both blocks individually for post-median sternotomy analgesia: a randomized controlled trial. J Cardiothorac Vasc Anesth. 2022;36(9):3348-3356. 19. Ahmed Z, Ke J, Zhong Y, et al. Combined pecto-intercostal fascial block and serratus anterior plane block for analgesia after cardiac surgery: a retrospective cohort analysis. J Pain Res. 2023;16:1785-1794.
• 1. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations. JAMA Surg. 2019;154(8):755-766. 2. Yildiz O, Doganci S. Cardiac surgery in Turkey: national database and current status. Turk Gogus Kalp Damar Cerrahisi Derg. 2020;28(1):1-6. 3. Muellejans B, Matthey-Doret D, Mey C, et al. Postoperative pain after cardiac surgery: a prospective cross-sectional multicentre cohort study. Eur J Anaesthesiol. 2021;38(2):134-142. 4. Thorpe SJ, Hyde R, Blackburn A. Pain management after cardiac surgery: an updated review. J Cardiothorac Vasc Anesth. 2021;35(9):2839-2851. 5. Richebe P, Capdevila X, Rivat C. Persistent postsurgical pain: pathophysiology and preventative pharmacologic considerations. Anesthesiology. 2018;129(3):590-607. 6. Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet. 2011;377(9784):2215-2225. 7. Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008;101(1):77-86. 8. Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: molecular mechanisms and clinical considerations. Clin J Pain. 2008;24(6):479-496. 9. De Oliveira GS Jr, Agarwal D, Benzon HT. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesth Analg. 2012;114(2):424-433. 10. Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. Anesth Analg. 1993;77(5):1048-1056.

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2025
• Primary Completion (Actual): December 31, 2025
• Study Completion (Actual): February 28, 2026

Study Registration Dates

• First Submitted: March 13, 2026
• First Submitted That Met QC Criteria: March 13, 2026
• First Posted (Actual): March 17, 2026

Study Record Updates

• Last Update Posted (Actual): March 17, 2026
• Last Update Submitted That Met QC Criteria: March 13, 2026
• Last Verified: August 1, 2025

More Information

Terms related to this study

• Keywords: cardiac surgery; mechanical ventilation; oxygenation; fascial plane block; icu lenght of stay
• Other Study ID Numbers: 2025-15/13

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared because of ethical and institutional restrictions related to patient confidentiality.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No