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.
Inclusion Criteria:
Scheduled for elective minimally invasive cardiac surgery (MICS), including:
Minimally invasive mitral valve repair or replacement. Minimally invasive aortic valve replacement. Atrial septal defect (ASD) closure. Minimally invasive direct coronary artery bypass (MIDCAB). Left ventricular ejection fraction (LVEF) ≥45%. EuroSCORE II <4%. American Society of Anesthesiologists (ASA) physical status II or III. Body mass index (BMI) 18-35 kg/m². Ability to understand the study procedures and provide written informed consent.
Exclusion Criteria:
Obstructive sleep apnea or anticipated difficult airway. Preoperative intubation, cardiogenic shock, or need for preoperative inotropic/vasopressor support.
Known allergy or contraindication to dexmedetomidine, fentanyl, bupivacaine, propofol, or other study medications.
Severe hepatic impairment or renal failure requiring dialysis (creatinine clearance <30 mL/min).
Chronic opioid use (>3 months) or chronic pain requiring long-term analgesics. Contraindications to erector spinae plane block (coagulopathy, platelet count <100,000/µL, INR >1.5, anticoagulant therapy, infection at the injection site, or patient refusal).
Baseline bradycardia (heart rate <50 beats/min) or second-/third-degree atrioventricular block without a functioning pacemaker.
Known substance abuse disorder
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Participants and outcome assessors will be blinded to treatment allocation. Randomization will be performed using a concealed allocation sequence. In the intervention group, patients will receive ultrasound-guided bilateral erector spinae plane block (ESPB) with dexmedetomidine-based fast-track anesthesia. To maintain participant blinding, patients in the control group will receive a sham subcutaneous saline injection after induction. The anesthesiologist performing the block and administering anesthesia will not be blinded because of the nature of the interventions. Data analysis will be performed using coded treatment assignments whenever feasible.
participants receive a fast-track anesthesia protocol consisting of intravenous dexmedetomidine combined with ultrasound-guided bilateral erector spinae plane block (ESPB), with opioid-sparing intraoperative anesthesia and standardized perioperative care.
Participants receive conventional general anesthesia using fentanyl-based opioid analgesia according to the institutional standard protocol, together with standardized perioperative and postoperative care.
Dexmedetomidine Combined With Bupivacaine in Ultrasound-guided Pecto-Intercostal Fascial Block in Cardiac Surgery
Opioid-free Anesthesia for Open Cardiac Surgery: A Prospective Randomized Controlled Trial
Addition of Dexmedetomidine to Ropivacaine in Bilateral Erector Spinae Plane Block in Patients Undergoing Coronary Artery Bypass Surgery
Medical Records Investigation of Whether Perioperative Dexmedetomidine Will Reduce the Duration of Mechanical Ventilation or Hospital Length of Stay in Patients Undergoing Minimally Invasive Cardiac Surgery