Combined Superficial Parasternal Intercostal Plane and Rectus Sheath Blocks for Enhanced Recovery After Cardiac Surgery: A Randomized Controlled Trial

Abstract Background Pain after cardiac surgery via median sternotomy, arising from both the sternal incision and upper abdominal drains, impedes recovery. While the superficial parasternal intercostal plane (SPIP) block effectively addresses sternotomy pain, analgesia for the abdominal region remains challenging. We hypothesized that combining the SPIP block with a rectus sheath block (RSB) would provide comprehensive analgesia, thereby enhancing early recovery quality. Methods : In this randomized controlled trial, 234 patients scheduled for median sternotomy cardiac surgery were randomly assigned to receive either bilateral SPIP and RSB with 0.3% ropivacaine or sham blocks with saline, both groups received the usual analgesic protocol. The primary outcome was the 48-hour postoperative quality of recovery, assessed using the QoR-15 scale. Secondary outcomes included QoR-15 scores at 72 hours postoperatively, postoperative pain scores, opioid consumption, ICU and hospital length of stay, time to extubation, time to first incentive spirometer use, time to first ambulation, and 6-minute walk test (6MWT) performance at discharge. Results : The SPIP + RSB group exhibited significantly higher QoR-15 scores at 48 hours (89.2 ± 7.3 vs. 95.6 ± 7.5, respectively; 95% CI, -8.7 to -4.2, P < 0.001) and 72 hours (103.8 ± 7.9 vs. 110.7 ± 9.4, respectively; 95% CI, -9.6 to -4.3, P < 0.001) postoperatively compared to the control group. Patients receiving SPIP + RSB also reported significantly lower NRS pain scores at all assessed time points ( P < 0.05), consumed less opioid analgesia within the first 48 hours, and experienced shorter time to exhaust, shorter ICU stay, and shorter hospital stay (all P < 0.05). Additionally, the SPIP + RSB group demonstrated earlier achievement of key recovery milestones, including earlier first ambulation and incentive spirometer exercises, as well as improved 6MWT performance at discharge (all P < 0.05). The incidence of postoperative delirium was similar between groups ( P = 0.496), and no block-related adverse events were observed in either group. Conclusions: Compared with sham block, the combination of ultrasound‑guided SPIP and RSB significantly enhanced postoperative recovery quality, provided superior analgesic efficacy, and reduced opioid consumption following cardiac surgery.