Case
A 75-year-old male with a known history of hypertension, chronic kidney
disease IIIb and hyperuricemia underwent aortic valve replacement with a
25-mm bioprosthesis and mitral valve repair with a 30-mm ring via median
sternotomy. On the fourth postoperative day, a surgical mediastinal
revision due to deep sternal wound infection was needed.
Given the patient’s frailty and the recent cardiac surgery, an awake
cardiac operation with subxiphoid access using a Pectoralis-Intercostal
Rectus Sheath (PIRS) plane block (Figure 1 A, B) was planned.
In the operating room intraoperative monitoring was provided by ECG,
peripheral oxygen saturation, non-invasive blood pressure and end-tidal
CO2. The patient was warmed with an active warm touch and received
midazolam 2 mg intravenous as preoperative anxiolytic prior to the
administration of the ultrasound-guided PIRS.
Once analgesia of the xiphoid region was achieved, surgery was initiated
using a subxiphoid access approximately 8 cm long and 6 cm deep (Figure
2).
During the procedure, vital parameters remained stable, and the patient
never reported pain. At the end of the procedure, the patient was
transferred to the intensive care unit (ICU) with a scheduled infusion
of paracetamol (1 g every 8 hours) for 48 hours. No implementation of
the analgesic plan was required during the ICU stay and no major effects
directly attributable to analgesic technique were observed. On the
second postoperative day, the patient was discharged from ICU without
any rescue analgesia administration.