ASPB-PIPB Combination in Cardiac Surgery

Effects of Combined Anterior Serratus Plane and Pectoral-Intercostal Plane Blocks on Perioperative Analgesia and Enhanced Recovery After Surgery in Cardiopulmonary Bypass Surgery

Cardiopulmonary bypass surgery is associated with significant postoperative pain, which may adversely affect respiratory function, delay mobilization, prolong hospital stay, and increase postoperative complications. Within Enhanced Recovery After Surgery (ERAS) protocols, multimodal analgesia and opioid-sparing strategies have become essential components of perioperative care. Ultrasound-guided fascial plane blocks, including the anterior serratus plane block (ASPB) and pectoral-intercostal plane block (PIPB), have emerged as effective and safe regional anesthesia techniques for cardiac surgery, targeting different sensory innervation of the thoracic wall. However, evidence regarding the combined use of these two blocks remains limited. This study aimed to evaluate whether the combination of ASPB and PIPB improves intraoperative and postoperative analgesia, reduces opioid consumption, and enhances postoperative recovery and ERAS outcomes compared with standard analgesic management in patients undergoing cardiopulmonary bypass surgery.

Study Overview

• Status: Not yet recruiting
• Conditions: Postoperative Pain; Cardiac Surgery; Cardiopulmonary Bypass; Median Sternotomy
• Intervention / Treatment: Procedure: Combined ASPB and PIPB; Procedure: Anterior Serratus Plane Block

Detailed Description

Cardiac surgery performed with cardiopulmonary bypass (CPB) is associated with substantial perioperative nociceptive stimulation originating from median sternotomy, chest tube placement, internal mammary artery harvesting, and extensive mediastinal tissue manipulation. Despite advances in surgical techniques and perioperative care, postoperative pain remains a major challenge following cardiac surgery. Inadequately controlled pain contributes to impaired respiratory mechanics, ineffective coughing, reduced pulmonary function, delayed mobilization, prolonged intensive care unit (ICU) and hospital stay, and an increased incidence of postoperative pulmonary complications. Furthermore, excessive perioperative opioid administration may lead to respiratory depression, postoperative nausea and vomiting, ileus, delirium, and delayed recovery, highlighting the need for effective opioid-sparing analgesic strategies.

Enhanced Recovery After Surgery (ERAS) protocols have increasingly been adopted in cardiac surgery with the aim of reducing perioperative stress, minimizing complications, and accelerating functional recovery. Contemporary ERAS guidelines emphasize multimodal analgesia as a cornerstone of perioperative management, integrating regional anesthesia techniques with non-opioid systemic analgesics to reduce opioid consumption while improving pain control. Ultrasound-guided fascial plane blocks have gained considerable popularity because they are technically straightforward, provide effective thoracic analgesia, and have a favorable safety profile compared with neuraxial techniques in anticoagulated cardiac surgical patients. Among these techniques, the anterior serratus plane block (ASPB) effectively anesthetizes the lateral thoracic wall by blocking the lateral cutaneous branches of the intercostal nerves, whereas the pectoral-intercostal plane block (PIPB) primarily targets the anterior cutaneous branches responsible for pain arising from median sternotomy. Given their complementary anatomical distributions, combining ASPB and PIPB may provide more comprehensive analgesic coverage of both the anterior and lateral thoracic walls.

Although both ASPB and PIPB have individually demonstrated promising analgesic efficacy in cardiac surgery, evidence regarding the combined use of these two fascial plane blocks remains limited. Whether the addition of ASPB to PIPB results in superior perioperative analgesia, reduced opioid requirements, improved postoperative recovery, and enhanced compliance with ERAS pathways has not yet been clearly established. Therefore, the present study aimed to compare the effects of combined anterior serratus plane block and pectoral-intercostal plane block with standard analgesic management on intraoperative opioid consumption, postoperative pain scores, postoperative analgesic requirements, recovery parameters, and ERAS-related outcomes in patients undergoing cardiopulmonary bypass surgery.

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: MUSTAFA ALTINAY; Phone Number: 05333914422; Email: m_altinay@yahoo.com

Study Locations

• Turkey (Türkiye)
  • Istanbul, Turkey (Türkiye), 34371
    • Sisli etfal research and training hospital
    • Contact: MUSTAFA ALTINAY; Phone Number: 05333914422; Email: m_altinay@yahoo.com

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

• Patients undergoing open heart surgery via median sternotomy by the Cardiovascular Surgery Clinic
• Patients over 18 years of age
• ASA II-III patients

Exclusion Criteria:

• - Patients undergoing emergency or recurrent surgery
• Patients with left ventricular ejection fraction < 30
• Patients who died per-operatively
• Patients who do not provide informed consent
• Presence of chronic pain
• Presence of allergy to local anesthetics
• Presence of infection in the area where the block will be performed
• Coagulopathy
• Pre-existing neurological deficit
• Mental retardation
• Anatomical deformity

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: GroupASPB + PIPB Group; Patients in this group received ultrasound-guided bilateral anterior serratus plane block combined with bilateral pectoral-intercostal plane block after induction of general anesthesia and before surgical incision as part of the multimodal analgesia protocol.	Procedure: Combined ASPB and PIPB; Ultrasound-guided bilateral anterior serratus plane block combined with bilateral pectoral-intercostal plane block performed after induction of general anesthesia and before surgical incision to provide perioperative multimodal analgesia in patients undergoing cardiopulmonary bypass surgery.
Active Comparator: ASPB Group: Patients assigned to the ASPB group underwent ultrasound-guided bilateral anterior serratus plane block following induction of general anesthesia and prior to skin incision. The block was incorporated into the perioperative multimodal analgesia protocol.	Procedure: Anterior Serratus Plane Block; Ultrasound-guided bilateral anterior serratus plane block performed after induction of general anesthesia and before surgical incision to provide perioperative analgesia in patients undergoing cardiopulmonary bypass surgery.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Postoperative pain intensity	Postoperative pain intensity will be assessed at rest and during coughing using the Visual Analog Scale at extubation (0 hour) and at 4, 8, 12, and 24 hours after surgery. The Visual Analog Scale ranges from 0 to 10 cm, where 0 indicates no pain and 10 indicates the worst imaginable pain. Higher scores indicate greater pain intensity and therefore a worse outcome.	At extubation (0 hour) and at 4, 8, 12, and 24 hours after surgery.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intraoperative fentanyl consumption	Total dose of fentanyl administered from the induction of anesthesia until the end of surgery. Fentanyl consumption will be recorded in micrograms.	From induction of anesthesia until the end of surgery.
Postoperative tramadol consumption	Cumulative dose of tramadol administered for rescue analgesia during the first 24 hours after surgery. Tramadol consumption will be recorded in milligrams.	During the first 24 hours after surgery.
Time to extubation	Time elapsed from the end of surgery until successful removal of the endotracheal tube. Time to extubation will be recorded in hours.	From the end of surgery until extubation, assessed up to 7 days after surgery.
Intensive care unit length of stay	Time elapsed from postoperative admission to the intensive care unit until discharge from the intensive care unit. Length of stay will be recorded in days.	From postoperative intensive care unit admission until intensive care unit discharge, assessed up to 30 days after surgery.
Hospital length of stay	Time elapsed from the date of surgery until discharge from the hospital. Hospital length of stay will be recorded in days.	From the date of surgery until hospital discharge, assessed up to 30 days after surgery.
Incidence of postoperative cardiac arrhythmias	Number of participants who develop a new postoperative cardiac arrhythmia documented by electrocardiography or continuous cardiac monitoring during the index hospitalization. Results will be reported as the number and percentage of participants with at least one cardiac arrhythmia.	From the end of surgery until hospital discharge, assessed up to 30 days after surgery.
Incidence of block-related complications	Number of participants who develop at least one complication related to the regional anesthesia procedure, including local anesthetic systemic toxicity, vascular puncture, hematoma, infection, pneumothorax, or nerve injury. Results will be reported as the number and percentage of participants with at least one block-related complication.	From block administration until hospital discharge, assessed up to 30 days after surgery.
Incidence of postoperative surgical complications	Number of participants who develop at least one postoperative surgical complication during the index hospitalization. Results will be reported as the number and percentage of participants with at least one surgical complication.	From the end of surgery until hospital discharge, assessed up to 30 days after surgery.
Time to thoracic drain removal	Time elapsed from the end of surgery until removal of all thoracic drains. Time to thoracic drain removal will be recorded in hours.	From the end of surgery until removal of all thoracic drains, assessed up to 30 days after surgery.
Time to urinary catheter removal	Time elapsed from the end of surgery until removal of the urinary catheter. Time to urinary catheter removal will be recorded in hours.	From the end of surgery until urinary catheter removal, assessed up to 30 days after surgery.

Collaborators and Investigators

• Sponsor: Sisli Hamidiye Etfal Training and Research Hospital
• Investigators: Study Chair: LEYLA KILINC, şişli etfal eğitim araştırma hastanesi

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2026
• Primary Completion (Estimated): May 30, 2027
• Study Completion (Estimated): June 30, 2027

Study Registration Dates

• First Submitted: June 28, 2026
• First Submitted That Met QC Criteria: July 16, 2026
• First Posted (Actual): July 21, 2026

Study Record Updates

• Last Update Posted (Actual): July 21, 2026
• Last Update Submitted That Met QC Criteria: July 16, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Postoperative Pain; Enhanced Recovery After Surgery; Cardiopulmonary Bypass; Regional Anesthesia
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Postoperative Complications; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Pain, Postoperative
• Other Study ID Numbers: 1025

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

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