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
Ordu University
123 participants
Apr 5, 2026
OBSERVATIONAL
Conditions
Summary
In this randomized trial, we 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.
Eligibility
Inclusion Criteria4
- 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 Criteria12
- 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
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Interventions
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).
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.
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.
Locations(1)
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NCT07557108