Fast-Track Anesthesia in Minimally Invasive Cardiac Surgery: Dexmedetomidine and Erector Spinae Plane Block vs Opioid-Based Anesthesia

Summary

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized perioperative management by implementing evidence-based, patient-centered strategies that improve clinical outcomes, shorten hospital length of stay, and reduce healthcare costs. In cardiac surgery, ERAS has facilitated the adoption of fast-track cardiac anesthesia (FTCA), which aims to achieve early extubation within 6-8 hours after surgery while maintaining patient safety. Compared with conventional high-dose opioid anesthesia, FTCA has been associated with shorter intensive care unit (ICU) stays, earlier mobilization, faster recovery, and comparable rates of mortality and major postoperative complications.

Despite these advantages, opioids remain the cornerstone of perioperative analgesia in cardiac surgery. Their use is associated with respiratory depression, delayed extubation, postoperative nausea and vomiting, ileus, urinary retention, delirium, opioid-induced hyperalgesia, and increased healthcare costs, highlighting the need for opioid-sparing anesthetic strategies.

Dexmedetomidine, a highly selective α2-adrenergic agonist, provides sedation, analgesia, and sympatholysis without clinically significant respiratory depression. In cardiac surgery, it improves hemodynamic stability, reduces perioperative opioid requirements, preserves spontaneous ventilation, and may decrease postoperative delirium, making it particularly suitable for fast-track extubation protocols.

Ultrasound-guided erector spinae plane block (ESPB) has emerged as a safe and effective regional analgesic technique. Compared with thoracic epidural and paravertebral blocks, ESPB offers a lower risk of complications, is technically straightforward, and provides effective bilateral analgesia for cardiac surgery. Randomized studies have demonstrated substantial reductions in intraoperative opioid consumption, improved postoperative pain control, and prolonged opioid-free analgesia.

Minimally invasive cardiac surgery (MICS), characterized by reduced surgical trauma and faster recovery compared with conventional sternotomy, provides an ideal setting to evaluate opioid-sparing anesthetic strategies. Combining dexmedetomidine with ultrasound-guided bilateral ESPB may optimize perioperative analgesia, facilitate early extubation, reduce opioid-related adverse effects, and enhance postoperative recovery, supporting ERAS principles in contemporary cardiac surgery.

Conditions

• Cardiac Disease Minimally Invasive Cardiac Surgery Postoperative Pain

Interventions

DRUG

Dexmedetomidine

Intravenous dexmedetomidine administered as part of a fast-track anesthesia protocol. Patients receive a loading dose of 0.5-1.0 µg/kg over 10 minutes before intubation, followed by an intraoperative infusion of 0.2-0.7 µg/kg/h, adjusted according to hemodynamic response. During cardiopulmonary bypass, the infusion is reduced to 0.2 µg/kg/h. Rescue fentanyl (0.5 µg/kg IV) is permitted only if predefined hemodynamic criteria are met.

PROCEDURE

Ultrasound-Guided Bilateral Erector Spinae Plane Block (ESPB)

Ultrasound-guided bilateral erector spinae plane block performed after induction of anesthesia and before surgical incision. A total of 20 mL of 0.25% bupivacaine is injected into the erector spinae plane on each side at the T5 level using an in-plane ultrasound-guided technique. The procedure is performed as part of an opioid-sparing multimodal analgesia strategy.

DRUG

Fentanyl

Conventional opioid-based general anesthesia using intravenous fentanyl. A dose of 5 µg/kg is administered during induction followed by an intraoperative infusion of 1-3 µg/kg/h, titrated according to hemodynamic parameters and institutional practice. Standardized perioperative management is otherwise identical to the experimental group.

Sponsors & Collaborators

• Assiut University

  lead OTHER

Study Design

Allocation

RANDOMIZED

Purpose

SCREENING

Masking

DOUBLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Max Age

65 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2026-09-01

Primary Completion

2028-09-01

Completion

2028-11-01

Countries

• Egypt

Study Locations