Open heart surgery is defined as surgery performed on the heart valves, arteries, and
other heart structures by cutting the sternum with a median sternotomy. Cardiovascular
diseases are prevalent in the general global population and affect most of the older
adult population. With the increase in life expectancy in recent years, there has been a
significant increase in surgical procedures for cardiovascular diseases. ERAS recommends
effective perioperative pain control to improve outcomes after Cardiac Surgery.
Inadequate pain control after open heart surgery causes decreased mobilization, increased
respiratory complications, prolonged hospital stays, and chronic pain.
Post-heart surgery pain is most intense during the first two days and then decreases.
Considering that 17% of patients report chronic pain after cardiac surgery, it is crucial
to provide effective analgesia in the early postoperative period.
Failure to adequately relieve post-operative pain may lead to increased pulmonary
complications as a result of inability to breathe deeply, coughing due to fear of pain,
and consequent inability to clear bronchial secretions. Moreover, increased endogenous
catecholamines due to surgery and pain increase the heart's oxygen consumption by causing
tachycardia and hypertension. This situation causes ischemia, heart failure, and
arrhythmias in patients who have undergone cardiac surgery.
In general, postoperative pain is reduced with opioids, which can cause various
complications. Although the use of opioids is recommended in cardiac surgery due to their
ischemic effects, multimodal perioperative pain management strategies are recommended in
current anesthesia. The use of regional anesthesia as part of multimodal strategies is
steadily increasing in cardiac surgeries performed through median sternotomy. Despite
multimodal analgesia strategies using regional techniques, post-operative pain still
emerges as an important problem in open heart surgery with median sternotomy.
The leading causes of pain after cardiac surgery are; sternotomy incisions, chest
retraction, dissection of the internal mammary artery, thoracic tubes, sternal wires, and
visceral pain. Sternal pain is transmitted through intercostal nerves originating from
T2-T6 spinal nerve roots, whereas various regional techniques are used for analgesia in
parasternal region surgeries. Amongst these techniques, while parasternal blocks can be
preferred as fascial plane blocks, these aim to block the anterior cutaneous branches of
the T2-T6 thoracic nerves. Pectointercostal fascial block (PIFB) is an effective
technique for controlling sternal pain in heart surgeries where median sternotomy is
performed.
In cardiac surgeries performed with median sternotomy, mediastinal and thoracic tube
placement sites are outside the area of effect of parasternal blocks, and sometimes the
sternotomy incision extends below the T6 dermatome. Recto intercostal fascial plane block
(RIFPB) has been defined as a complementary block for analgesia of this region. This
study aims to evaluate the effectiveness of the combination of ultrasound-guided
recto-intercostal fascial plane block and pectointercostal fascial block for
postoperative analgesia management after open heart surgery (coronary artery bypass) with
median sternotomy.