Superficial parasternal intercostal plane block with ropivacaine versus placebo for opioid exposure after cardiac surgery (EPOCH CardioLink-10): a multicentre, double-blind, randomised trial.

Abstract

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. 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). 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. 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. 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].