Effect of ultrasound-guided pectointercostal fascial block on postoperati̇ve pai̇n management in patients undergoing off-pump coronary artery bypass surgery

Off-pump coronary artery by-pass grafting surgery is (CABG) a coronary artery surgery in the beating heart without using a cardiopulmonary bypass (CPB) device. It is usually performed using the median sternotomy method. It is a very painful procedure as it is a major surgery. Postoperative analgesia methods are very important both to reduce pain and to prevent pain-related complications. Multimodal analgesia methods are often preferred. Pectointercostal fascial block is among the preferred thoracic wall fascial blocks with the increasing use of ultrasound in recent years. In this study, we evaluated the effectiveness of ultrasonography-guided pectointercostal fascial block on postoperative pain control and opioid requirement in patients undergoing off-pump coronary artery by-pass grafting surgery. After the approval of the Local Ethics Committee dated 30/03/2021 and numbered 2021/74 and the written consent of the patient, 50 patients at risk of ASA II-III between the ages of 18-70 who were planned for elective off-pump coronary artery by-pass graft surgery were included in the study. The patients were divided into 2 groups as Group P (Pectointercostal) and Group K (Control) by randomized, prospective and closed envelope method before the operation. During the follow-up period, 3 patients were excluded from the study. Postoperative bilateral pectointercostal fascial block was applied to the patients in Group P (Pectointercostal). After the operation was completed and the thorax was closed, the ultrasound probe was placed in the parasagittal plane above the third and fourth ribs in the midclavicular line, and a 50-80 mm sonovisible needle (Stimuplex B. Braun R, Melsungen AG) was advanced in the caudal to cranial direction parallel to the long axis of the probe. The tip was placed between the pectoralis major and intercostal muscles. It was observed that there was no air or blood with aspiration, and a test dose was applied with 2 ml of physiological saline. After the test dose, pectointercostal fascial block was performed by injecting 20ml of 0.25% bupivacaine (Buvasin 0.5% Vem İlaç Istanbul, Turkey) between the pectoralis major and the vii intercostal muscle plane. The same procedure was done to the opposite side. Patients in Group K (Control) were not performed this procedure on postoperatively. In both groups, tramadol HCL (Tramosel 100 mg/2 ml Haver Pharma İlaç A.Ş, Istanbul) was administered with a continuous opioid infusion at a concentration of 4mg/ml at a dose of 2cc/hour, with a maximum dose of 400mg within 24 hours. Doses that could be administered 20 mg of tramadol HCL as IV bolus at each push with a lock-in interval of 20 minutes were adjusted. When the VAS was above 4, 0.05 mg/kg morphine (Morphine HCL® 0.01 g/ml amp Galen İlaç AŞ./ Turkey) in 100 ml physiological saline was administered intravenously as a rescue analgesic. Demographic data of the patients were recorded by evaluating postoperative extubation time, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), visual analog scale (VAS) values at 1st hour, 2nd hour, 4th hour, 8th hour, 12th hour, 18th hour and 24th hour after extubation; and analgesic consumption at 0-1, 1-12, 12-24 hours, nausea, vomiting, total analgesic consumption, and patient satisfaction. In demographic data, no significant difference was found between the groups in the SAP, DAP, MAP, HR and the incidence of side effects. In the VAS evaluation of the patients, it was determined that the VAS values at the 1st, 2nd, 4th, 8th and 12th hours after postoperative extubation were statistically significantly lower in Group P compared to Group K (p<0,05). Tramadol consumption in Group P were found to be statistically significantly lower at 0-1. and 1-12. hours. It was observed that the total amount of tramadol consumption was statistically significantly lower in Group P (p<0,05). As a result; we determined that bilateral pectointercostal fascial block applied after coronary artery by-pass grafting operation reduces analgesic consumption as a part of multimodal analgesia and provides effective postoperative analgesia.