A Randomised controlled study for efficacy of bilateral transverse thoracis muscle plane block on perioperative requirement of fentanyl in patients undergoing cardiac surgery

At the time of pre-operative visit, patients will be familiarised with the procedure, a 11 point Numeric

Rating Scale (NRS) for pain assessment (0 = no pain at all, 10 = worst imaginable pain) and use of PCA

pump.On arrival to the operation theatre, fasting status, written informed consent and PAC will be checked.

All routine monitors will be attached; HR, SBP, DBP, MAP, ECG and Spo2 will be noted. Intravenous line

with 18G cannula will be secured and i.v. fluid RL will be started at 5ml/kg/hour.

Internal jugular vein (IJV) and femoral arterial cannulation will be done under local anesthesia.

Patient will be induced with Inj. Midazolam i.v. (0.05mg/kg), Inj. Fentanyl i.v. (3/ μgkg), Inj.Etomidate i.v.

(0.3mg/kg), Inj. Rocuronium i.v. (0.9mg/kg) will be given as a muscle relaxant to facilitate endotracheal

intubation. Patient will be ventilated with 100% oxygen for 3 minutes and under direct laryngoscopy patient

will be intubated with the appropriate size E.T.T. Bilateral air entry will be checked and tube will be fixed.

ULTRASOUND GUIDED BLOCKS: TTMPB will be performed in supine position under sterile conditions after patient is anaesthetised before the commencement of the surgical procedure. A high

frequency 12 MHz linear ultrasound probe with a sterile sheath placed 1 cm lateral to the sternal border, T4-T5 intercostal space identified under ultrasound guidance in a parasagittal view and needle inserted in plane to the probe.

Transversus Thoracis Muscle Plane block will be performed in patients of Group A at T4-T5 intercostal space bilaterally with a 22G atraumatic spinal needle using 40ml 0.5% Ropivacaine with adjuvant Fentanyl 20 mcg (20 ml each side) 10 ml of 0.5 % Ropivacaine is infilterated around the pleural chest tube sites in both the groups . Heart rate, Systolic, Diastolic and mean Blood pressure and CVP will be recorded preoperatively as baseline, just after block, 5 min after block, just after intubation, 5 min after intubation and every 15 min thereafter.

The surgery will be allowed to commence and anesthesia will be maintained will 100% oxygen, 1%

sevoflurane and intermittent Inj. Vecuronium i.v. (0.01mg/kg/half an hourly), injection midazolam 0.01mg/kg hourly , The BIS guided monitoring will be used to evaluate intraoperative pain, BIS monitoring measures the depth of anesthesia and facilitates anesthetic titration, BIS will be maintained 40-60 during surgery if score more than 60 injection Fentanyl 1mcg/kg IV dose will be repeated .

Total intraoperative Fentanyl will be noted.

Patient will be shifted to ICU with IPPV and taken on ventilator. As per protocol of our hospital injection paracetamol 1 gm IV will be given before patient is shifted to ICU.

When patient is conscious, hemodynamically stable and fulfills the criteria of extubation, the patient will be, the time of extubation will be noted.

After extubation, NRS (Numeric Rating Scale) pain score will be noted.

In ICU, Patient Controlled Analgesia (PCA) pump will be started with Fentanyl (5 mcg/ml) at a basal infusion rate of 2 ml/hr and a bolus 2ml (10 mcg) whenever needed by the patient him/herself with a lockout

interval of 15 mins upto 48 hours after extubation. If patient needs rescue analgesia within lockout interval Inj Tramadol (50mg) IV bolus will be given.

H0 (NULL HYPOTHESIS):

There is no significant difference in the mean of total dose requirement of Fentanyl in 48 hours with Transverse Thoracis Muscle Plane Block (TTMPB) as compared to the control group.

H1 (ALTERNATE HYPOTHESIS):

There is a significant difference in the mean of total dose requirement of Fentanyl in 48 hours with TTMPB as compared to the control group.