Dexmedetomidine-enhanced chest wall fascial plane blocks in ultra-fast-track minimally invasive heart valve surgery: a randomized controlled trial

Abstract

Background: Injury to the sternocostal joint during minimally invasive cardiac surgery frequently results in severe pain, yet there is no established standard for perioperative analgesia. This randomized controlled trial evaluated whether adding 1 μg/kg dexmedetomidine to 0.375% ropivacaine for chest wall fascial plane blocks enhances opioid sparing in ultra-fast-track (UFT) minimally invasive heart valve surgery.

Methods: Seventy-six elective patients were randomized (1:1) in a double-blind manner. The control group received 60 mL of 0.375% ropivacaine, while the DEX group was administered 60 mL of 1 μg/kg dexmedetomidine plus 0.375% ropivacaine. The primary outcomes were intraoperative remifentanil use and 24-h postoperative sufentanil consumption, which served as co-primary endpoints to evaluate opioid-sparing effects. Secondary outcomes included 24-h postoperative sufentanil consumption, 24-h oxycodone use, patient-controlled analgesia (PCA) activations, episodes of Visual Analog Scale (VAS) scores ≥ 3 within 48 h, time to recovery of consciousness, time to extubation, duration of intensive care unit (ICU), and hospital stays, and complications.

Results: The DEX group exhibited significantly reduced intraoperative remifentanil consumption (2.45 ± 0.47 vs. 2.98 ± 0.53 mg, p < 0.001) and 24-h sufentanil use (median with interquartile range (IQR) 57 [54-60] vs. 63 [63-66] μg, p < 0.001). It also demonstrated lower 24-h oxycodone consumption (median [IQR] 5 [0-10] vs. 10 [10-20] mg, p < 0.001), fewer 24-h PCA activations (median [IQR] 3 [2-4] vs. 5 [5-6], p < 0.001), and less frequent VAS ≥ 3 episodes (median [IQR] 3 [2.5-4] vs. 6 [5-6], p < 0.001), alongside shorter lengths of ICU (21.34 ± 3.59 vs. 24.29 ± 4.07 h, p = 0.002) and hospital stays (6.51 ± 1.04 vs. 8.65 ± 1.80 days, p < 0.001). Postoperative complications did not differ significantly between groups, though dexmedetomidine-related hemodynamic effects were not systematically monitored.

Conclusion: The administration of 1 μg/kg dexmedetomidine in combination with ropivacaine for chest wall fascial plane blocks reduces opioid requirements and shortens ICU/hospital stays in UFT cardiac surgery, supporting its safety and efficacy, but limitations include the single-center design, fixed dexmedetomidine dosage, and incomplete complication assessment, warranting multicenter validation with standardized safety monitoring.

Trial registration: ChiCTR2100051182.

Keywords: Dexmedetomidine; Chest wall fascial plane block; Ultra-fast-track; Minimally invasive heart valve surgery.

Fig. 1

Pectoral nerves I block. NOTE, PECS I: Pectoral nerves I block, PM: Pectoral major, Pm: Pectoral minor, PN: Puncture needle, Aa: Acromial artery

Fig. 2

Pectoral nerves II block. NOTE, PECS II: Pectoral nerve block II. SAM: Serratus anterior muscle.PM: Pectoralis major. Pm: Pectoralis minor. PN: Puncture needle

Fig. 3

Serratus anterior plane block. NOTE, SAPB: Serratus anterior plane block. SAM: Serratus anterior muscle. LDM: Latissimus dorsi muscle. PN: Puncture needle. R4: Rib 4

Fig. 4

The flow diagram of the study population. NOTE: ERACS, Enhanced Recovery After Cardiac Surgery. BMI, body mass index. NHYA, New York Heart Association. PASP, pulmonary artery systolic pressure