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Combined SPSP and TTP Blocks for Postoperative Analgesia Post-CABG
Sponsor: Ain Shams University
Summary
After heart bypass surgery (coronary artery bypass grafting, CABG), the breastbone is divided to reach the heart, which causes significant pain. Pain can make deep breathing and coughing difficult and may slow recovery. Strong pain medicines called opioids are the usual treatment, but they can cause side effects such as drowsiness, slowed breathing, nausea, vomiting, and confusion. This study tested whether two nerve blocks given together can reduce the need for opioids after bypass surgery. A nerve block is an injection of local anesthetic, guided by ultrasound, that numbs a specific area of the body. The two blocks are the serratus posterior superior plane (SPSP) block, which numbs the upper side and back of the chest wall, and the transversus thoracic plane (TTP) block, which numbs the front of the chest next to the breastbone. Both were placed on each side of the chest after the patient was asleep under general anesthesia and before surgery began. Adults aged 18 to 75 having planned (non-emergency) bypass surgery were randomly assigned, by chance, to one of two groups. One group received both blocks plus standard pain medicines. The other group received standard pain medicines alone. Patients did not know which group they were in, and the staff who measured outcomes were also unaware of group assignment. The main question was how much opioid medicine patients needed in the first 48 hours after the breathing tube was removed. Other measures included pain scores at rest and with movement, time until first rescue pain medicine, time to breathing-tube removal, oxygen levels, length of ICU and hospital stay, time to first getting out of bed, patient satisfaction, and side effects such as complications from the blocks or from opioids. The results may help doctors decide whether combining these two blocks is a useful way to control pain and reduce opioid use after heart bypass surgery.
Official title: Ultrasound-Guided Serratus Posterior Superior Plane and Transversus Thoracic Plane Blocks for Postoperative Analgesia After Coronary Artery Bypass Grafting: A Randomized Controlled Trial
Key Details
Gender
All
Age Range
18 Years - 75 Years
Study Type
INTERVENTIONAL
Enrollment
100
Start Date
2026-07-01
Completion Date
2026-09-30
Last Updated
2026-11-02
Healthy Volunteers
No
Interventions
Bilateral Posterior Superior Plane Block
With the patient in slight lateral tilt (15-20°), the trapezius (superficial), rhomboid major/minor, and the fascial plane deep to the rhomboids overlying the serratus posterior superior muscle at T2 to T5 were identified. Using a 22-gauge, 50-80 mm echogenic needle (Stimuplex Ultra 360, B. Braun) and an in-plane lateral-to-medial approach, after negative aspiration and a 1 mL test dose, 15 mL of 0.25% bupivacaine per side was deposited incrementally, confirming fascial spread under continuous ultrasound guidance. The procedure was repeated on the contralateral side.
Bilateral Transversus Thoracic Plane
With the patient supine, a parasternal short-axis scan was performed at the second-fourth intercostal space level. The pectoralis major (superficial), internal intercostal muscle, and transversus thoracic muscle (deep) were identified. Using a 22-gauge, 50-80 mm echogenic block needle (Stimuplex Ultra 360, B. Braun) and an in-plane approach, after negative aspiration and a 1 mL test dose, 15 mL of 0.25% bupivacaine per side was deposited in 3-5 mL increments with intermittent aspiration, confirming fascial spread (downward displacement of the pleura). The procedure was repeated on the contralateral side.
Conventional Systemic Analgesia
Standardized multimodal systemic analgesia regimen administered to both groups. Intraoperative: fentanyl 5-10 mcg/kg at induction with supplemental 1-2 mcg/kg boluses as needed. Postoperative: paracetamol 1 g every 6 hours from ICU arrival. A continuous intravenous fentanyl infusion commenced at 0.5 μg/kg/h once the patient emerged from anesthesia and NRS assessment became feasible. The fentanyl infusion weaned by 25% every hour prior to planned extubation and discontinued at extubation. Intravenous morphine was administered in incremental doses of 2-3 mg every 10 minutes when the NRS score was ≥4, with repeated doses until satisfactory analgesia (NRS ≤3) was achieved. Additional rescue doses of 1-2 mg were provided as required based on subsequent pain assessments.
Bupivacaine 0.25%
Local anesthetic administered for regional blocks; total dose up to 2.5 mg/kg (maximum 150 mg for patients ≥65 kg, adjusted for lower weights)
Locations (1)
Ain Shams University Hospitals
Cairo, Cairo Governorate, Egypt