OBJECTIVE Lately introduced cardiosurgical procedures such as MIDCAB enable an early extubation immediately after surgery. This also requires an adequate anesthesia regime and especially a sufficient postoperative analgesia. Patient controlled analgesia (PCA) and intercostal nerve blockade (ICB) were evaluated for their suitability for postoperative pain relief in patients undergoing a MIDCAB procedure. METHODS After approval by the local ethic committee and obtaining written informed consent 43 patients were included in this study. Anesthesia was induced and maintained in a total intravenous standardised manner with propofol, remifentanil, cisatracurium and additionally glyceroltrinitrate, clonidine and esmolol were given as needed. After revascularisation patients were randomly assigned to one of two groups receiving either 7.5 mg piritramid i.v. before extubation and continuing a PCA with 2 mg boli and a 10 min lockout, or an ICB with ropivacaine 1% (4 times 5 ml). Additionally all patients received 1 g paracetamol rectally before induction of anesthesia and 1 g metamizol i.v. at the end of surgery. A rescue medication of 3.75 mg piritramid i.v. was allowed. A pain score (NRS 0-10), the Aldrete score (AS 0-12) and oxygen saturation were obtained 1, 4, and 8 h after extubation. RESULTS The ICB group showed a significantly greater pain reduction in the first (5.8 +/- 1.8 vs. 7.3 +/- 1.9; P < 0.02) and fourth h (3.6 +/- 1.3 vs. 4.6 +/- 1.4; P < 0.02), respectively. Transfer to an intermediate care ward one hr after extubation was achieved more often in the ICB group according to the AS (ICB 9.6 +/- 1.5 vs. PCA 8.9 +/- 1.2; P < 0.05), too. There was no difference with respect to the oxygen saturation. The additional piritramid demand was 9.3 mg in the ICP group and 5 mg in the PCA group in the first 8 hours postoperative. CONCLUSIONS ICB gives a better pain relief in the early postoperative phase after MIDCAB procedures compared to a PCA. Both regimes are adequate in order to provide a sufficient pain relief and help to avoid prolonged postoperative mechanical ventilation. These will enable an early transfer of patients to an intermediate care station and save ICU capacity.