Pecs ii block as part of multimodal analgesia for minimally invasive cardiac surgery with cardiopulmonary bypass – a triple-blinded, randomized, controlled trial

Introduction Minimally-invasive, on-bypass cardiac surgery (MIC) through a unilateral mini-thoracotomy is increasingly popular but associated with high levels of postoperative pain, opioid consumption and opioid-associated side effects. Enhanced Recovery After Surgery (ERAS) protocols as multimodal, multidisciplinary perioperative care approaches are aimed to improveme clinical outcomes and cost savings.1 Opioid-sparing pain management by additional regional analgesia is a cornerstone of ERAS, but the evidence for its usage in cardiac surgery is scarce.2 The PECS II block a interfascial plane block, provides good analgesia to the hemithorax, by depositing involves depositing local anesthetics between (1) pectoralis major and pectoralis minor muscles and (2) pectoralis minor and serratus anterior muscles, at the levels of the third rib.3 This study aimed to elucidate whether adding a PECS II block to conventional multimodal analgesia improves opioid consumption, pain, and quality of recovery, and could therefore be part of an ERAS. Methods After approval by the ethics committee, patients scheduled for MIC were randomized between ultrasound-guided, preoperative unilateral PECS II block with ropivacaine 0.5% vs. placebo (saline). Patients, practitioners and data collectors were blinded to the intervention drug; a standardized multimodal analgesic protocol was applied to all patients. Numerical rating scores (NRS), analgesic consumption and the Overall Benefit of Analgesia Score (OBAS) were collected at different time points up to 24 hours postoperatively, and compared between groups. Results 57 patients were included (ropivacaine n=28, vs. placebo n=29). Block performance (after central venous access) took 5±2.5 minutes. Patients in the ropivacaine group had significantly lower morphine milligram equivalents (MME) during the first 24 hours after extubation (median (interquartile range): 4.2 (2.1-7.6) vs 8.3 (4.2-15.7) mg, p=0.016). NRS at extubation was lower in the ropivacaine group (0.0 (0.0-2.0) vs 1.5 (0.3-3.0), p=0.041). Non-opioid analgesic consumption was similar. The OBAS was, by trend, improved in the ropivacaine group (4.0 (3.0-6.0) vs. 7.0 (3.0-9.0), p=0.082). (Table 1) Discussion The addition of PECS II block to conventional, opioid-based multimodal analgesia protocols is a simple, yet effective measure to optimize opioid consumption, pain relief and side effect profile in patients undergoing minimal invasive cardiac surgery.