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| 21KF-029 |
Postoperative analgesic effectiveness of peripheral nerve blocks in cesarean delivery: A systematic review
Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
Study objective: To determine the analgesic effectiveness of peripheral nerve blocks including each anatomical approaches with or without intrathecal morphine (ITMP) in cesarean delivery (CD).
Design: Systematic review and network meta-analysis.
Patients: All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until 22 December 2020.
Interventions: PNBs with or without ITMP.
Measurements: The two co-primary outcomes were designated as (1) pain at rest 6-h after surgery and (2) postoperative cumulative 24- h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24-h, and dynamic pain 6 and 24-h after surgery. Data are presented as mean difference [95% confidence interval] or surface under the cumulative ranking curve (SUCRA) value.
Main results: Seventy six studies (6,278 women) were analyzed. Combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA values in postoperative rest pain at 6-h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia showed significant reduction in two co-primary outcomes, too. Only II-aTAP block has statistically significant additional analgesic effect compared to ITMP alone in rest pain at 6 h after surgery (-7.60 [-12.49,-2.70]).
Conclusions: Combined II-aTAP block in conjunction with ITMP is the most effective postcesarean analgesic strategy with lower rest pain at 6-h and cumulative 24-h morphine consumption. It is considered reasonable to use the six analgesic strategies described in the results section for postoperative pain management after CD. Lateral TAP block, WI and WC below the fascia may be useful alternatives if the patient reports history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.
Design: Systematic review and network meta-analysis.
Patients: All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until 22 December 2020.
Interventions: PNBs with or without ITMP.
Measurements: The two co-primary outcomes were designated as (1) pain at rest 6-h after surgery and (2) postoperative cumulative 24- h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24-h, and dynamic pain 6 and 24-h after surgery. Data are presented as mean difference [95% confidence interval] or surface under the cumulative ranking curve (SUCRA) value.
Main results: Seventy six studies (6,278 women) were analyzed. Combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA values in postoperative rest pain at 6-h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia showed significant reduction in two co-primary outcomes, too. Only II-aTAP block has statistically significant additional analgesic effect compared to ITMP alone in rest pain at 6 h after surgery (-7.60 [-12.49,-2.70]).
Conclusions: Combined II-aTAP block in conjunction with ITMP is the most effective postcesarean analgesic strategy with lower rest pain at 6-h and cumulative 24-h morphine consumption. It is considered reasonable to use the six analgesic strategies described in the results section for postoperative pain management after CD. Lateral TAP block, WI and WC below the fascia may be useful alternatives if the patient reports history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.
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