Efficacy of pecto-intercostal fascial plane block in patients undergoing cardiac surgeries with midline sternotomy

G Pravin Kumar1*, Balakrishnan N2, Murshid Ahamed3, Deepak4

Department of Cardiac Anaesthesia, Kauvery Hospital, Heart City, Trichy

Abstract

Background: Postoperative pain management after midline sternotomy remains a clinical challenge, with up to 78% of patients experiencing severe pain during coughing. The Pecto-Intercostal Fascial Plane Block (PIFB) offers a targeted regional analgesic technique by blocking the anterior cutaneous branches of the intercostal nerves. This study aimed to evaluate the efficacy of PIFB in reducing opioid requirements and postoperative pain in patients undergoing cardiac surgery.

Methods: A prospective observational study was conducted over two months including 50 adult patients undergoing cardiac surgery via midline sternotomy. Patients were assigned to either conventional analgesia (n=25) or bilateral ultrasound-guided PIFB using 0.25% bupivacaine with dexamethasone (n=25). Primary outcome was total fentanyl consumption within 24 hours postoperatively. Secondary outcomes included Numeric Rating Scale (NRS) pain scores at 8, 12, and 24 hours post-extubation, extubation time, and ICU length of stay.

Results: The PIFB group showed a significant reduction in 24-hour fentanyl use (mean 263 ± 60 mcg) compared to the conventional group (389 ± 143 mcg; p=0.0001). NRS pain scores were consistently lower at 8 and 12 hours post-extubation in the PIFB group (p=0.01 and 0.001, respectively). Extubation times were also significantly shorter in the PIFB group. No adverse events related to local anesthetic toxicity or block complications were observed.

Conclusion: Ultrasound-guided PIFB provides superior analgesia with reduced opioid consumption and facilitates early extubation in cardiac surgery patients undergoing midline sternotomy, making it a valuable component of multimodal analgesia.

Introduction

Postoperative pain after cardiac surgery with midline sternotomy is multifactorial, originating from sternotomy, rib and intercostal nerve injury, pleural irritation, pericardial manipulation, and chest drain placement. [1][2] Effective pain control enhances recovery, reduces pulmonary complications, and improves patient satisfaction.[3] Traditional regional anesthesia techniques such as central neuraxial and paravertebral blocks are effective but carry risks like hemodynamic instability and potential for epidural hematoma or pneumothorax.[4] Recently, inter-fascial plane blocks under ultrasound guidance, including Pecto-Intercostal Fascial Plane Block (PIFB), have emerged as safer alternatives that specifically target anterior cutaneous branches of intercostal nerves by depositing local anesthetic in the fascial plane between the pectoralis major and external intercostal muscles.[5] This study investigates the analgesic efficacy and safety of PIFB in adult patients undergoing cardiac surgery requiring median sternotomy.

Materials and Methods

A prospective observational study conducted in a tertiary cardiac surgery hospital (Kauvery Heart City, Trichy) over two months. Fifty adult patients (>18 years, ASA 3/4) scheduled for coronary artery bypass graft (CABG) or isolated valve surgeries via median sternotomy were recruited after informed consent. Exclusion criteria included allergy to local anaesthetics, emergency or redo surgeries, perioperative cardiac arrest, preoperative mechanical circulatory support (IABP), infections, coagulopathy (INR ≥2), renal or liver dysfunction, and refusal of consent. Patients were assigned to Group A (Conventional analgesia, n=25) receiving standard opioid-based perioperative analgesia, Group B (PIFB, n=25) receiving bilateral ultrasound-guided Pecto-Intercostal Fascial Plane Block in addition to conventional care. Standard monitoring (pulse oximetry, ECG, invasive BP, central venous pressure) was applied. Induction and maintenance followed institutional protocols. In supine position under aseptic conditions, ultrasound guidance was used to identify fascial plane between pectoralis major and external intercostal muscles at T2-T3 and T4-T5 levels bilaterally. At each site, 10 mL of 0.25% bupivacaine with 2 mg dexamethasone was injected, totalling 40 mL. Warming blankets and warm fluids were administered to maintain normothermia. The primary outcome was total fentanyl consumption during 24 hours postoperatively. Secondary outcomes were NRS pain scores at rest over sternum at 8, 12, and 24 hours after extubation, time to extubation (time from ICU arrival to extubation), length of ICU stay; adverse events. Pain scores were assessed using the Numeric Rating Scale (0–10). Patients were extubated after regaining of adequate consciousness and muscle strength. Data were analyzed using mean ± SD or median (range) as appropriate. Comparison of continuous variables employed Student’s t-test or Mann-Whitney U test; categorical data used Chi-square test. A p-value less than 0.05 was considered statistically significant.

Fig (1): Administration of PIFB

Results

The two groups were comparable in age and baseline characteristics (Table 1). The PIFB group required significantly lower fentanyl doses within 24 hr postoperatively than the conventional group (Table 2). Patients receiving PIFB demonstrated reduced extubation time compared to conventional analgesia (mean 4.96 ± 0.71 hours vs. 6.08 ± 0.69 hours; p=0.005). PIFB group reported significantly lower NRS scores at 8 hours (0.92 ± 0.86 vs. 1.48 ± 0.65; p=0.01) and 12 hr (1.0 ± 0.91 vs. 1.76 ± 0.59; p=0.001) post-extubation Figure 2). Differences at 24 hr were not statistically significant. None of the patients in either group experienced local anesthetic systemic toxicity, hemodynamic instability, pneumothorax, or respiratory depression. 4 patients in conventional group and 1 patient in PIFB group had paralytic ileus which is responsible for increase in ICU stay.

Table 1: Demographic parameters

ParameterConventionalPIFBP value
Age58.48±12.0657.62±11.830.98
Sex (M/F)20/1022/80.88
Height (cms)161.62±9.94161±8.840.792
Weight (kgs)64.72±11.3464±11.90.805
BSA1.68±0.1911.67±0.1580.816
Weight (kgs)24.54±3.3524.7±4.160.866

Table 2: Intraoperative and post-operative parameters

ParametersConventionalPIFBP value
Intraoperative Fentanyl usage407.03±146.63270.16±70.24<0.0001
Extubation time in minutes456.36±95.4338.82±82.40.005
Total post operative fentanyl usage389±52.4263.93±36.40.0001

Fig (2): NRS sternum pain scores post extubation

Discussion

This study demonstrates that ultrasound-guided PIFB is an effective adjunct to conventional analgesia for cardiac surgery via sternotomy, significantly reducing opioid requirements and pain scores within the initial 24 postoperative hours. Our findings align with previous randomized studies and meta-analyses indicating the superiority of fascial plane blocks over systemic analgesics in managing poststernotomy pain. Early extubation facilitated by improved analgesia may contribute to reduced pulmonary complications and shorter ICU stays, ultimately enhancing recovery trajectories and lowering healthcare costs. The absence of block-related complications underscores the safety of PIFB when performed under ultrasound guidance. Limitations include the observational design, small sample size, and single-center setting, suggesting the need for larger randomized controlled trials to confirm long-term outcomes and optimal dosing strategies.

Conclusion

Pecto-Intercostal Fascial Plane Block provides superior perioperative analgesia with significant opioid sparing and facilitates earlier extubation following cardiac surgery with median sternotomy. It represents a safe and effective regional anesthesia technique worthy of incorporation into multimodal postoperative pain management protocols.

References

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