ESPB Versus Combined PIPB and RIB for Analgesia in Minimally Invasive Cardiac Surgery

Patients allocated to this group will receive a unilateral ultrasound-guided erector spinae plane block (ESPB) at the T5 vertebral level on the surgical side after induction of general anesthesia and before surgical incision. A total of 30 mL of 0.25% bupivacaine (75 mg) will be administered.

An ultrasound-guided unilateral erector spinae plane block (ESPB) will be performed at the T5 vertebral level on the surgical side after induction of general anesthesia and before surgical incision. A total of 30 mL of 0.25% bupivacaine (75 mg) will be injected into the fascial plane between the erector spinae muscle and the transverse process.

Patients allocated to this group will receive a combination of ultrasound-guided parasternal intercostal plane block (PIPB) and rhomboid intercostal block (RIB) after induction of general anesthesia and before surgical incision. A total of 15 mL of 0.25% bupivacaine will be administered for PIPB and 15 mL of 0.25% bupivacaine for RIB on the surgical side. The total local anesthetic volume will be 30 mL (75 mg).

Following induction of general anesthesia and before surgical incision, patients will receive two ultrasound-guided fascial plane blocks on the surgical side. A parasternal intercostal plane block (PIPB) will be performed with 15 mL of 0.25% bupivacaine, followed by a rhomboid intercostal block (RIB) with 15 mL of 0.25% bupivacaine injected between the rhomboid major and intercostal muscles. The total administered volume will be 30 mL of 0.25% bupivacaine (75 mg).

Postoperative pain intensity at rest will be assessed using the Numeric Rating Scale (NRS), ranging from 0 (no pain) to 10 (worst imaginable pain). Measurements will be obtained at 0, 2, 4, 8, and 12 hours after extubation. The primary outcome will be the group-by-time interaction in resting NRS scores, comparing the erector spinae plane block (ESPB) group with the combined parasternal intercostal plane block and rhomboid intercostal block (PIPB + RIB) group using a repeated-measures statistical approach.

Total tramadol consumption (mg) during the first 24 hours after extubation will be recorded. Postoperative patient-controlled analgesia (PCA) will be provided using tramadol with a 10 mg bolus dose, a 10-minute lockout interval, and no basal infusion. Cumulative tramadol consumption will be compared between the ESPB and combined PIPB + RIB groups. Higher consumption indicates greater postoperative opioid requirements.

Postoperative pain intensity at rest will be assessed using the Numeric Rating Scale (NRS), ranging from 0 (no pain) to 10 (worst imaginable pain). Pain scores will be recorded at 24 hours after extubation and compared between the ESPB and combined PIPB + RIB groups. Higher scores indicate greater pain intensity.

Quality of postoperative recovery will be assessed using the validated Turkish version of the 15-item Quality of Recovery questionnaire (QoR-15T). The questionnaire evaluates five domains: pain, physical comfort, physical independence, psychological support, and emotional state. Each item is scored from 0 to 10, yielding a total score ranging from 0 to 150, with higher scores indicating better recovery quality. The QoR-15T will be administered preoperatively and at 48 hours after extubation. The change in total score from baseline to 48 hours will be compared between the ESPB and combined PIPB + RIB groups.

Patient-reported acceptability of postoperative pain management will be assessed using a five-point Likert scale at 48 hours after extubation. Patients will rate their agreement with the statement, "The level of pain I experienced after surgery was acceptable to me." Responses will be scored as follows: 1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, and 5 = Strongly agree. Higher scores indicate greater acceptability of postoperative pain management. The distribution of responses will be compared between the ESPB and combined PIPB + RIB groups.

Time elapsed from extubation to the first administration of rescue analgesia, measured in minutes.

Number of participants experiencing block-related adverse events, including pneumothorax and local anesthetic systemic toxicity.

Postoperative pain intensity during movement will be assessed using the Numeric Rating Scale (NRS), ranging from 0 (no pain) to 10 (worst imaginable pain). Pain scores will be recorded at 24 hours after extubation and compared between the ESPB and combined PIPB + RIB groups. Higher scores indicate greater pain intensity.