Fascial Plane Blocks and Quality of Recovery in Cardiac Surgery

Pecto-Intercostal Fascial Plane Block-Based Multimodal Analgesia to Improve Quality of Recovery After Median Sternotomy: A Randomized Non-Inferiority Trial Comparing Retro-Intercostal Fascial Plane Block and Rectus Sheath Block

In this randomized trial, the investigators will test the hypothesis that combining regional analgesia techniques-which have the potential to improve the quality of postoperative recovery following median sternotomy-with PIFB will accelerate recovery. Additionally, it is anticipated that RIFB, an alternative fascial plane block, will demonstrate non-inferior (at least as effective as) performance compared to RSB, thereby providing flexibility and ease of application in clinical practice.

Study Overview

• Status: Recruiting
• Conditions: Cardiovascular Diseases; Pain, Postoperative; Cardiovascular Surgical Procedures
• Intervention / Treatment: Procedure: Ultrasound-Guided Pectointercostal Fascial Plane Block; Procedure: Ultrasound-Guided Rectus Sheath Block; Procedure: Ultrasound-Guided Recto-Intercostal Fascial Plane Block

Detailed Description

Advances in anesthesiology throughout the first quarter of the 21st century have significantly enhanced perioperative care quality and mitigated complication risks. In particular, ultrasound (US)-guided fascial plane blocks have become prominent and widely preferred methods for providing postoperative pain control in current practice. Today, fascial plane blocks form the cornerstone of multimodal analgesia strategies developed to avoid complications associated with neuraxial analgesia methods.

Thoracic fascial plane blocks (TFB) have become one of the revolutionary advancements in cardiac anesthesia practice and have been widely adopted in cardiac surgery patients.

The pectointercostal fascial plane block (PIFB), a type of TFB, was first described by De la Torre et al. in patients undergoing breast surgery. This new technique involves blocking the anterior cutaneous branches of the T2-6 intercostal nerves, which are responsible for sensory innervation of the sternal region.

PIFB is an effective method for controlling sternotomy pain in patients undergoing open-heart surgery. The technique offers several advantages, including its minimally invasive nature, its proximity to the sternotomy line, and the flexibility to be administered at any perioperative time point following anesthesia induction without requiring the patient to change position. Furthermore, unlike neuraxial analgesia techniques, this approach circumvents serious complications associated with neuraxial techniques, such as nerve injury, dural puncture, or epidural hematoma.

In addition to median sternotomy, chest drains placed in the subxiphoid region following cardiac surgery are also a significant source of postoperative pain. This pain may result from factors such as the skin incision, continuous irritation of surrounding tissues, and direct damage to the rectus abdominis muscle caused by the chest drains. Severe postoperative pain developing in the epigastric region can disrupt respiratory mechanics, increasing the risk of pulmonary complications and leading to a delay in the extubation process.

Although the rectus sheath block (RSB) is classified as a "Plan A" block among abdominal wall blocks, when combined with the PIFB, it can provide extensive analgesia in the anterior chest wall. Anatomically, the RSB targets the anterior cutaneous branches of the T7-12 intercostal nerves, providing somatic analgesia to the anteromedial abdominal wall and the periumbilical region. In other words, the RSB can play a complementary role in analgesic efficacy by targeting areas outside the PIFB's area of effect.

In this context, RSB has become a complementary and critical component of a multimodal analgesia strategy when combined with PIFB for the management of pain associated with median sternotomy and subxiphoid thoracic drains in cardiac surgery patients.

Recently, the rectointercostal fascial plane block (RIFB) has been described as a complementary block following sternotomy, providing analgesic efficacy similar to the RSB, particularly in the subxiphoid region. The RIFB provides effective analgesia in the subxiphoid region by blocking the anterior and lateral cutaneous branches of the intercostal nerves originating at the T6-9 levels. Although it is a relatively new technique, the absence of reported complications in case reports and series in the literature suggests that RIFB represents a safe and viable alternative.

In recent studies on peripheral nerve blocks, the concept of "quality of recovery" has become a focal point among key endpoints. However, the effect of different TFB techniques used in perioperative cardiac surgical management on quality of recovery has not yet been clearly established.

A review of the literature indicates that while PIFB administered alone after cardiac surgery provides effective analgesia in the sternal region, it is limited in managing pain caused by thoracic drains, particularly in the subxiphoid region. It is anticipated that inadequate postoperative analgesia will negatively impact the quality of patient recovery.

In this randomized trial, the investigators will test the hypothesis that combining regional analgesia techniques-which have the potential to improve the quality of postoperative recovery following median sternotomy-with PIFB will accelerate recovery. Additionally, it is anticipated that RIFB, an alternative fascial plane block, will demonstrate non-inferior (at least as effective as) performance compared to RSB, thereby providing flexibility and ease of application in clinical practice.

• Study Type: Observational
• Enrollment (Estimated): 123

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Altinordu
    • Ordu, Altinordu, Turkey (Türkiye), 52200
      • Recruiting
      • Name: Ordu University Training and Research Hospital
      • Contact: Yasir Ilyas, Assistant Professor; Phone Number: +905073460233; Email: ysrilyas@outlook.com

Participation Criteria

Eligibility Criteria

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

• Sampling Method: Probability Sample

Study Population

Patients aged 18-70 years, with ASA physical status II-III, who are scheduled to undergo elective open-heart surgery via median sternotomy with cardiopulmonary bypass at a tertiary care city hospital.

Description

Inclusion Criteria:

• Patients who have provided written informed consent
• Open-heart surgery performed under elective conditions via median sternotomy with cardiopulmonary bypass (on-pump)
• American Society of Anesthesiologists (ASA) physical status class II or III
• Aged 18-70 years

Exclusion Criteria:

• Off-pump surgical procedure
• Emergency or repeat cardiac surgery
• Known allergy to induction agents or local anesthetics
• Body mass index (BMI) >35 kg/m²
• Coagulopathy
• Infection at the surgical site
• Left ventricular ejection fraction (LVEF) <40%
• Renal insufficiency (estimated glomerular filtration rate <60 mL/min/1.73 m²) or hepatic insufficiency [Presence of major systemic diseases such as acute decompensated cirrhosis characterized by bilirubin >12 mg/dL, INR >2.5, or hepatic encephalopathy, in accordance with the European Association for the Study of the Liver-Chronic Liver Failure Consortium criteria]
• Psychiatric disorders
• History of chronic pain or regular use of analgesics (corticosteroids, analgesics, anticonvulsants)
• Cognitive impairments that could interfere with the assessment of postoperative pain
• Patients with impaired physical and verbal performance

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Group P; Bilateral pectointercostal fascial plane block (PIFB) will be administered.	Procedure: Ultrasound-Guided Pectointercostal Fascial Plane Block; Following anesthesia induction, bilateral pectointercostal fascial plane block (PIFB) will be performed under steril conditions using a high-frequency linear US probe positioned parallel to the parasternal region. The second and fourth ribs will be identified in the parasternal region under US guidance. A 100-mm echogenic peripheral nerve block needle will be advanced craniocaudally toward the fourth rib using an in-plane technique to reach the fascial plane between the pectoralis major and intercostal muscles. After confirming the target plane via hydrodissection, 20 mL of 0.25% bupivacaine will be injected into the fascial plane on each side (total 40 mL). The success of the block will be confirmed by sliding the US probe craniocaudally to directly visualize the local anesthetic spread between the pectoralis major fascia and the intercostal muscles (extending from the first to the sixth rib).
Group PRS; Bilateral rectus sheath block (RSB) will be administered in addition to bilateral PIFB.	Procedure: Ultrasound-Guided Pectointercostal Fascial Plane Block; Following anesthesia induction, bilateral pectointercostal fascial plane block (PIFB) will be performed under steril conditions using a high-frequency linear US probe positioned parallel to the parasternal region. The second and fourth ribs will be identified in the parasternal region under US guidance. A 100-mm echogenic peripheral nerve block needle will be advanced craniocaudally toward the fourth rib using an in-plane technique to reach the fascial plane between the pectoralis major and intercostal muscles. After confirming the target plane via hydrodissection, 20 mL of 0.25% bupivacaine will be injected into the fascial plane on each side (total 40 mL). The success of the block will be confirmed by sliding the US probe craniocaudally to directly visualize the local anesthetic spread between the pectoralis major fascia and the intercostal muscles (extending from the first to the sixth rib).; Procedure: Ultrasound-Guided Rectus Sheath Block; Bilateral rectus sheath block (RSB) will be performed at the end of surgery. A high-frequency linear US probe will be positioned in the epigastric region, 2-3 cm below the xiphoid process and immediately below the chest tubes, intersecting the linea alba perpendicularly. After identifying the anatomical structures (anterior rectus abdominis sheath, muscle, posterior sheath, and peritoneum) with the US probe, a 100-mm echogenic peripheral block needle will be advanced into the plane between the rectus abdominis muscle and the posterior sheath using an in-plane technique. After confirming the needle tip location via hydrodissection, a total of 20 mL of 0.25% bupivacaine (10 mL per side) will be injected into the fascial plane. Block success will be confirmed by direct visualization of the "double V"-shaped echogenic pattern formed by the spread of the local anesthetic between the fascial planes.
Group PRI; Bilateral retro-intercostal fascial plane block (RIFB) will be administered in addition to bilateral PIFB.	Procedure: Ultrasound-Guided Pectointercostal Fascial Plane Block; Following anesthesia induction, bilateral pectointercostal fascial plane block (PIFB) will be performed under steril conditions using a high-frequency linear US probe positioned parallel to the parasternal region. The second and fourth ribs will be identified in the parasternal region under US guidance. A 100-mm echogenic peripheral nerve block needle will be advanced craniocaudally toward the fourth rib using an in-plane technique to reach the fascial plane between the pectoralis major and intercostal muscles. After confirming the target plane via hydrodissection, 20 mL of 0.25% bupivacaine will be injected into the fascial plane on each side (total 40 mL). The success of the block will be confirmed by sliding the US probe craniocaudally to directly visualize the local anesthetic spread between the pectoralis major fascia and the intercostal muscles (extending from the first to the sixth rib).; Procedure: Ultrasound-Guided Recto-Intercostal Fascial Plane Block; Bilateral recto-intercostal fascial plane block (RIFB) will be performed at the end of surgery. A high-frequency linear US probe will be positioned in the sagittal plane, 3-4 cm lateral and 3-4 cm caudal to the xiphoid process. After identifying the sixth and seventh costal cartilages and the rectus abdominis muscle, a 100-mm echogenic peripheral block needle will be advanced caudo-cranially using an in-plane technique to reach the plane between the rectus abdominis muscle and the costal cartilage. After confirming the needle tip location via hydrodissection, a total of 20 mL of 0.25% bupivacaine (10 mL per side) will be injected into the fascial plane. Block success will be confirmed by direct visualization of the local anesthetic spread in a cranio-caudal direction.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Turkish version of the Quality of Recovery-15 scale (QoR-15T)	The QoR-15T scale consists of a total of 15 items, each scored on a 0-10 scale (a 11-point Likert-type scale). The total score ranges from 0 (very poor recovery) to 150 (excellent recovery). While total scores of 118 and above are generally accepted in the literature as an indicator of 'good recovery,' scores can also be classified as 136-150 (excellent), 122-135 (good), 90-121 (moderate), and 0-89 (poor). The scale covers five domains: physical comfort (items 1-4 and 13), emotional state (items 9, 10, 14, and 15), psychological support (items 6 and 7), physical independence (items 5 and 8), and pain (items 11 and 12).	In the postoperative period, the time of extubation will be considered "postoperative hour 0". The primary endpoint is the quality of early recovery, assessed at 24 hours postoperatively.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Turkish version of the Quality of Recovery-15 scale (QoR-15T)	The QoR-15T scale consists of a total of 15 items, each scored on a 0-10 scale (a 11-point Likert-type scale). The total score ranges from 0 (very poor recovery) to 150 (excellent recovery). While total scores of 118 and above are generally accepted in the literature as an indicator of 'good recovery,' scores can also be classified as 136-150 (excellent), 122-135 (good), 90-121 (moderate), and 0-89 (poor). The scale covers five domains: physical comfort (items 1-4 and 13), emotional state (items 9, 10, 14, and 15), psychological support (items 6 and 7), physical independence (items 5 and 8), and pain (items 11 and 12).	In the postoperative period, the time of extubation will be considered "postoperative hour 0". QoR-15T scores will be reassessed at 48 hours postoperatively and prior to discharge.
The Numerical Rating Scale (NRS)	NRS contains 11 digits that should be assigned according to the perceived pain intensity (0: no pain, 10: the most severe pain imaginable).	All cases will be assessed using the NRS at 0, 3, 6, 12, 24, 36, and 48 hours after extubation.
Total Tramadol Consumption	A standard analgesia protocol will be administered to all patients for postoperative pain management. No additional opioids will be given between the end of surgery and extubation. Total tramadol consumption will be recorded during the first 48 hours post-extubation to evaluate opioid use. The postoperative observation phase of the study has been defined to encompass the first 48 hours following extubation.During the observation phase, patients with a Numerical Rating Scale (NRS) score of ≥4 will receive IV tramadol (1 mg/kg, max 400 mg/day) as rescue analgesia.	Total tramadol consumption will be recorded during the first 48 hours post-extubation to evaluate opioid use.
Opioid-Related Adverse Effects During the Postoperative Observation Phase	Nausea, Vomiting, Pruritus, Constipation, Urinary Retention, and Arrhythmia	Until hospital discharge (approximately 5-7 days)
Complications Associated with Fascial Plane Blocks	Vascular Puncture, Local Hematoma, Pneumothorax, and Infection at the Injection Site	Until hospital discharge (approximately 5-7 days)

Collaborators and Investigators

• Sponsor: Ordu University

Study record dates

Study Major Dates

• Study Start (Actual): April 5, 2026
• Primary Completion (Estimated): December 5, 2026
• Study Completion (Estimated): December 20, 2026

Study Registration Dates

• First Submitted: April 20, 2026
• First Submitted That Met QC Criteria: April 22, 2026
• First Posted (Actual): April 29, 2026

Study Record Updates

• Last Update Posted (Actual): May 4, 2026
• Last Update Submitted That Met QC Criteria: April 28, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Enhanced Recovery After Surgery; Pain Management; Anesthesia, Regional; Anesthesia, Conduction; Acute Postoperative Pain; Cardiovascular Surgical Procedures
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Nervous System Diseases; Postoperative Complications; Pathologic Processes; Neurobehavioral Manifestations; Perceptual Disorders; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Pain, Postoperative; Cardiovascular Diseases; Agnosia
• Other Study ID Numbers: OrduU-AR-YI-01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

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