Assessment of Total Ropivacaine Concentration in Blood after Bilateral Pecto-Intercostal Fascial Block Combined with Rectus Sheath Block in Cardiac Surgery Patients


  • Lu Wang Department of Anesthesiology, Peking University People's Hospital, 100044 Beijing, China; Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 100037 Beijing, China
  • Bailin Jiang Department of Anesthesiology, Peking University People's Hospital, 100044 Beijing, China
  • Yi Shi Department of Cardiac Surgery, Peking University People’s Hospital, 100044 Beijing, China
  • Boyu Liu Department of Pharmacy, Peking University People’s Hospital, 100044 Beijing, China
  • Luyang Jiang Department of Anesthesiology, Peking University People's Hospital, 100044 Beijing, China
  • Yi FENG Department of Anesthesiology, Peking University People's Hospital, 100044 Beijing, China



pecto-intercostal fascial block, ropivacaine, rectus sheath block, cardiac


Objectives: Pecto-intercostal fascial block (PIFB) and rectus sheath block (RSB) have been combined to offer better analgesia for cardiac surgery patients, but safety of the analgesic protocol with a large volume of ropivacaine is uncertain. Methods: This is a prospective observational study at Peking University People's Hospital to investigate the pharmacokinetic profile of ropivacaine after combined regional blocks. Patients undergoing elective cardiac surgery by a median sternotomy were enrolled to receive bilateral PIFB and RSB with 70 mL 0.3% ropivacaine (total dose 210 mg). Blood was sampled at 5, 10, 15, 30, 60, 90 and 120 mins after blocks. Total blood concentration of ropivacaine for patients were measured. Results: Ten patients were enrolled and analyzed. The peak total ropivacaine concentration varied from 0.67 to 2.42 µg/mL. Time to reach the peak values mainly located between 10 and 30 mins after the performance. No patients had ropivacaine concentration values above toxic threshold (4.3 µg/mL), and there were no systemic toxicity symptoms during the perioperative period. Conclusions: PIFB combined with RSB in a general injection of 70 mL 0.3% ropivacaine does not give rise to toxic levels, and it is an effective and safe analgesic protocol for cardiac surgery patients.


Lahtinen P, Kokki H, Hynynen M. Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity. Anesthesiology. 2006; 105: 794–800.

Jones J, Murin PJ, Tsui JH. Combined Pectoral-Intercostal Fascial Plane and Rectus Sheath Blocks for Opioid-Sparing Pain Control After Extended Sternotomy for Traumatic Nail Gun Injury. Journal of Cardiothoracic and Vascular Anesthesia. 2021; 35: 1551–1553.

Toscano A, Balzani E, Capuano P, Vaninetti A, Perrucci C, Simonato E, et al. Awake cardiac surgery using the novel pectoralis-intercostal-rectus sheath (PIRS) plane block and subxiphoid approach. Journal of Cardiac Surgery. 2022; 37: 2923–2926.

Kelava M, Alfirevic A, Bustamante S, Hargrave J, Marciniak D. Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks. Anesthesia and Analgesia. 2020; 131: 127–135.

Plakhotnik J, Zhang L, Estrada M, Coles JG, Lonnqvist PA, Maynes JT. Local Anesthetic Cardiac Toxicity Is Mediated by Cardiomyocyte Calcium Dynamics. Anesthesiology. 2022; 137: 687–703.

Breindahl T, Simonsen O, Andreasen K. Column-switching HPLC-MS/MS analysis of ropivacaine in serum, ultrafiltrate and drainage blood for validating the safety of blood reinfusion. Journal of Chromatography. B, Analytical Technologies in the Biomedical and Life Sciences. 2010; 878: 76–82.

Li M, Wan L, Mei W, Tian Y. Update on the clinical utility and practical use of ropivacaine in Chinese patients. Drug Design, Development and Therapy. 2014; 8: 1269–1276.

Wu G, Sun B, Liu LI, Zhou J, Mo L, Ren C, et al. Lipid emulsion mitigates local anesthesia-induced central nervous system toxicity in rats. Experimental and Therapeutic Medicine. 2015; 10: 1133–1138.

Schwoerer AP, Scheel H, Friederich P. A Comparative Analysis of Bupivacaine and Ropivacaine Effects on Human Cardiac SCN5A Channels. Anesthesia and Analgesia. 2015; 120: 1226–1234.

Zausig YA, Zink W, Keil M, Sinner B, Barwing J, Wiese CHR, et al. Lipid emulsion improves recovery from bupivacaine-induced cardiac arrest, but not from ropivacaine- or mepivacaine-induced cardiac arrest. Anesthesia and Analgesia. 2009; 109: 1323–1326.

Knudsen K, Beckman Suurküla M, Blomberg S, Sjövall J, Edvardsson N. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. British Journal of Anaesthesia. 1997; 78: 507–514.

Bianconi M, Ferraro L, Traina GC, Zanoli G, Antonelli T, Guberti A, et al. Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery. British Journal of Anaesthesia. 2003; 91: 830–835.

Torup H, Mitchell AU, Breindahl T, Hansen EG, Rosenberg J, Møller AM. Potentially toxic concentrations in blood of total ropivacaine after bilateral transversus abdominis plane blocks; a pharmacokinetic study. European Journal of Anaesthesiology. 2012; 29: 235–238.

Wiedemann D, Mühlnickel B, Staroske E, Neumann W, Röse W. Ropivacaine plasma concentrations during 120-hour epidural infusion. British Journal of Anaesthesia. 2000; 85: 830–835.

Burm AG, Stienstra R, Brouwer RP, Emanuelsson BM, van Kleef JW. Epidural infusion of ropivacaine for postoperative analgesia after major orthopedic surgery: pharmacokinetic evaluation. Anesthesiology. 2000; 93: 395–403.

Zaballos M, Varela O, Fernández I, Rodríguez L, García S, Quintela O, et al. Assessment of cardiotoxicity and plasma ropivacaine concentrations after serratus intercostal fascial plane block in an experimental model. Scientific Reports. 2023; 13: 47.

Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Regional Anesthesia and Pain Medicine. 2004; 29: 564–575; discussion 524.

Cogan J, André M, Ariano-Lortie G, Nozza A, Raymond M, Rochon A, et al. Injection of Bupivacaine into the Pleural and Mediastinal Drains: A Novel Approach for Decreasing Incident Pain After Cardiac Surgery - Montreal Heart Institute Experience. Journal of Pain Research. 2020; 13: 3409–3413.

Kang H, Chung YS, Choe JW, Woo YC, Kim SW, Park SJ, et al. Application of lidocaine jelly on chest tubes to reduce pain caused by drainage catheter after coronary artery bypass surgery. Journal of Korean Medical Science. 2014; 29: 1398–1403.

Jagadeesan J, Kannan R, Dujon D. Ventricular standstill: a complication of intrapleural anesthesia using bupivacaine in a patient with free transverse rectus abdominus myocutaneous flap breast reconstruction. Annals of Plastic Surgery. 2007; 59: 445–446.



How to Cite

Wang, L., Jiang, B., Shi, Y., Liu, B., Jiang, L., & FENG, Y. (2023). Assessment of Total Ropivacaine Concentration in Blood after Bilateral Pecto-Intercostal Fascial Block Combined with Rectus Sheath Block in Cardiac Surgery Patients. The Heart Surgery Forum, 26(5), E519-E524.