Combined Pecto-intercostal Fascial Plane and Rectus Sheath Blocks Versus Local Infiltration for Pain Management Following Pediatric Cardiac Surgery: A Randomized Clinical Trial.

Abstract

BACKGROUND Previous studies have shown that regional anesthesia (RA) use versus placebo control is associated with less postsurgical opioid requirements and improved pain scores. This trial compared a novel combination of bilateral pecto-intercostal fascial plane and unilateral rectus sheath blocks to an active comparator of surgeon-administered local anesthetic wound infiltration in children undergoing septal defect repair. The study tested the hypothesis that RA use would result in less opioid use and lower pain intensity compared to wound infiltration. METHODS This double-blind, randomized, parallel group, single-center trial included children (<18 years) undergoing primary atrial septal defect (ASD) or ventricular septal defect (VSD) repair. Participants were randomized to RA consisting of ultrasound-guided pecto-intercostal fascial plane and rectus sheath blocks or no-block, consisting of local anesthetic wound infiltration. Both groups received 1.5 mL/kg of ropivacaine 0.2% for the intervention. The primary outcome was opioid use (oral morphine milligram equivalents [MME]/kg) 0-12 hours after surgery. Secondary outcomes were opioid use at additional time points, pain (0-10 scale) between 0 and 48 hours (area under the curve [AUC]), and hospital length of stay (LOS). RESULTS Data analysis included 42 children (24 RA, 18 infiltration), age 3.3 ± 2.7 years (mean ± standard deviation [SD]; median, 3; range, 4 months-10 years). Opioid use (MME/kg mean ± SD) 0-12 hours after surgery was 0.44 ± 0.19 in the RA group compared to 0.83 ± 0.39 in the infiltration group (mean difference -0.39; 95% confidence interval [CI], -0.59 to -0.18; P = .001). Total postoperative opioid use from 0 to 48 hours after surgery was 0.95 ± 0.40 in the RA group compared to 1.57 ± 0.75 in the infiltration group (mean difference -0.64; 95% CI, -1.02 to -0.22, P = .004). Pain intensity AUC (0-48 hours) was 45.0 ± 26.8 in the RA group compared to 94.5 ± 55.7 in the infiltration group (mean difference -49.5 [-78.9 to -20.1]; P = .002). Opioid use between 12 and 48 hours and hospital LOS was not different between groups. CONCLUSIONS This single-center study showed that the combined pecto-intercostal fascial plane and rectus sheath blocks were opioid-sparing and provided superior pain control compared to contemporary practice of local anesthetic infiltration in children following septal defect repair. This investigation strengthens the evidence to support RA use to improve postoperative pain in this population.