Pecto-Intercostal Fascial Block in Cardiac Surgical Patients

Despite an ever-growing motivation towards minimal invasion in cardiac surgery, the majority of open-heart surgery continues to employ a median sternotomy incision which results in significant acute postoperative pain with subsequently enhanced predisposition to persistent post-sternotomy pain (PSP).^[1-3]

Ultrasound (USG)-guided pecto-intercostal fascial block (PIFB) has been recently proposed to effectively manage the median sternotomy pain wherein García Simón and Fajardo Perez suggest a decreased risk of major complications (including, vascular injury and pneumothorax) with PIFB as opposed to the transversus thoracis muscle plane block.^[1-4]

We often perform a bilateral PIFB for our cardiac surgical patients undergoing median sternotomy, mostly after induction of general anesthesia. With the patient in a supine position, a high-frequency L 12–3 MHz linear USG probe (EPIQ7C, PHILIPS, Holland) is placed 2–3 cm lateral to the corresponding sternal edge in the 4^th intercostal space [Figure 1a]. Using a 21-gauge ×100 mm Stimuplex A block needle (B. Braun, Melsungen, Germany), an in-plane approach is employed to reach the target PIFB between the pectoralis major and external intercostal muscles [Figure 1b]. Following hydro-dissection with saline to confirm the desired plane for local anesthetic (LA) injection [Figure 1c], 20 mL of dilute concentrations of 0.25–0.3% ropivacaine is injected on each side, which tends to be within the safe limits of the LA dose as per the body weight of the patient.

Meanwhile, we practice a single-injection PIFB (akin to research groups like Wang et al.^[2]) and rely on the LA spread visualized under USG-guidance, independent researchers also employ 2–3-injection PIFB technique equally dividing the LA volumes accordingly.^[1,3]

Nonetheless, recent literature on the efficacy-safety of PIFB is encouraging wherein one can achieve adequate post-sternotomy pain relief with an acceptable degree of opioid-sparing closely governed by institutional analgesic practices.^[1-5]

Interestingly, Sahoo et al. report a seminal use of PIFB in a 63-year-old lady suffering from severe persistent PSP following coronary artery bypass grafting, propounding the role of the former in chronic pain settings as well.^[6]