Lancet regional health. Americas · 2026
Superficial parasternal intercostal plane block with ropivacaine versus placebo for opioid exposure after cardiac surgery (EPOCH CardioLink-10): a multicentre, double-blind, randomised trial.
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Alli Ahmad, Mazer C David, Dennis Fallon, Teoh Hwee, Chin Kyle, Quan Adrian, Hassan S M Ali, Szarek Michael, Tran John D, Dhingra Nitish K, Ghiringhelli Juan P, de Vasconcelos Papa Fábio, Lee Youngseo, Ricci Michael J, Verma Raj, Derry Kendra L, George Thomas, Krishnaraj Aishwarya, Hess David A, Rotstein Ori D, Cook Richard C, Hassan Ansar, Yau Terrence M, Spence Jessica D, Martinka Pawel M, Sutherland Korey, Gregory Alexander J, Noss Christopher D, de Jager Pieter, Dougherty James L, Arora Rakesh C, Verma Subodh
Аннотация
BACKGROUND: Cardiac surgery performed through a midline chest incision (median sternotomy) is associated with substantial postoperative pain and opioid use, the latter of which remains the dominant modality of analgesia. Contemporary international guidelines prioritise opioid-sparing, multimodal strategies; however, robust randomised evidence to support specific opioid-sparing analgesic approaches in cardiac surgery is lacking.
METHODS: EPOCH CardioLink-10 was a pan-Canadian, multicentre, randomised, double-blind, placebo-controlled trial in adults undergoing cardiac surgery via median sternotomy. Participants were assigned to receive bilateral superficial parasternal intercostal plane (SPIP) blocks with either 0.2% ropivacaine or placebo (0.9% sodium chloride), delivered via indwelling catheters. Study interventions were delivered at a basal infusion rate (0.1-1 mL/h) after a 20 mL bolus post-insertion. Bolus dosing of 5 mL every 3-4 h was continued for 48 h. In the ropivacaine arm, this resulted in a maximum total ropivacaine dose of 592 mg over the infusion period. The primary outcome was cumulative opioid consumption over 72 h following catheter insertion, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included subjective pain scores, cumulative use of opioid to discharge, rates of delirium, and participant-reported Quality of Recovery-15 score (ClinicalTrials.govNCT06028126).
FINDINGS: Between Aug 16, 2023, and Dec 22, 2025, 650 patients were screened, and 318 included in the modified intention-to-treat population (164 in the ropivacaine group, 154 in the placebo group). Median age was 67 years (IQR 61-72), 72 (23%) participants were female, 178 (56%) were White, and 69 (22%) were South Asian. Over 72 h, ropivacaine reduced opioid consumption compared with placebo (least-squares mean difference -20.7 MMEs [95% CI -39.0 to -2.3]; p = 0.027). Pain scores and other secondary outcomes were similar between groups. There were no serious block-related complications and there was no pre-specified analysis of adverse events.
INTERPRETATION: The findings of this multicentre, randomised trial suggest that bilateral SPIP blockade with ropivacaine may be a pragmatic option to manage sternotomy pain with lower opioid consumption post-cardiac surgery.
FUNDING: Grants from the Canadian Institutes of Health Research (CIHR) [Principal Applicant: C D Mazer], the Dr. Timothy & Mrs. Linda Tang Anesthesia Research Fund at the University of Calgary, Calgary, AB [A J Gregory and C D Noss], and the CardioLink Research Trial Platform at St. Michael's Hospital, Toronto, ON. In-kind support from the Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS [P de Jager and J L Dougherty].
METHODS: EPOCH CardioLink-10 was a pan-Canadian, multicentre, randomised, double-blind, placebo-controlled trial in adults undergoing cardiac surgery via median sternotomy. Participants were assigned to receive bilateral superficial parasternal intercostal plane (SPIP) blocks with either 0.2% ropivacaine or placebo (0.9% sodium chloride), delivered via indwelling catheters. Study interventions were delivered at a basal infusion rate (0.1-1 mL/h) after a 20 mL bolus post-insertion. Bolus dosing of 5 mL every 3-4 h was continued for 48 h. In the ropivacaine arm, this resulted in a maximum total ropivacaine dose of 592 mg over the infusion period. The primary outcome was cumulative opioid consumption over 72 h following catheter insertion, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included subjective pain scores, cumulative use of opioid to discharge, rates of delirium, and participant-reported Quality of Recovery-15 score (ClinicalTrials.govNCT06028126).
FINDINGS: Between Aug 16, 2023, and Dec 22, 2025, 650 patients were screened, and 318 included in the modified intention-to-treat population (164 in the ropivacaine group, 154 in the placebo group). Median age was 67 years (IQR 61-72), 72 (23%) participants were female, 178 (56%) were White, and 69 (22%) were South Asian. Over 72 h, ropivacaine reduced opioid consumption compared with placebo (least-squares mean difference -20.7 MMEs [95% CI -39.0 to -2.3]; p = 0.027). Pain scores and other secondary outcomes were similar between groups. There were no serious block-related complications and there was no pre-specified analysis of adverse events.
INTERPRETATION: The findings of this multicentre, randomised trial suggest that bilateral SPIP blockade with ropivacaine may be a pragmatic option to manage sternotomy pain with lower opioid consumption post-cardiac surgery.
FUNDING: Grants from the Canadian Institutes of Health Research (CIHR) [Principal Applicant: C D Mazer], the Dr. Timothy & Mrs. Linda Tang Anesthesia Research Fund at the University of Calgary, Calgary, AB [A J Gregory and C D Noss], and the CardioLink Research Trial Platform at St. Michael's Hospital, Toronto, ON. In-kind support from the Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS [P de Jager and J L Dougherty].