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Regional Analgesia Added to General Anesthesia Compared With General Anesthesia Plus Systemic Analgesia for Cardiac
Ann Monahan1, Joanne Guay2,3,4, John Hajduk1
1From the Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
Insights
Regional analgesia (RA) effectively reduces postoperative pain for up to 24 hours in pediatric cardiac surgery patients. This systematic review found no significant impact of RA on major morbidity or mortality, though further research is recommended.
Area of Science:
- Pediatric Anesthesiology
- Cardiovascular Surgery
- Pain Management
Background:
- Postoperative pain management in children undergoing cardiac surgery is critical.
- Systemic analgesia is the standard, but regional analgesic (RA) techniques offer an alternative.
- Comparing RA and systemic analgesia is essential for optimizing pediatric cardiac surgical care.
Purpose of the Study:
- To systematically review and compare the efficacy and safety of regional analgesic (RA) techniques versus systemic analgesia.
- To evaluate effects on postoperative pain, nausea, vomiting, resource utilization, and complications in pediatric cardiac surgery.
- To assess the impact on reoperation, mortality, and analgesic technique-specific complications.
Main Methods:
- A comprehensive search of PubMed, Embase, and Cochrane Central Register of Controlled Trials was conducted in May 2018.
- Included were randomized controlled trials comparing RA techniques with systemic analgesia in pediatric cardiac surgery.
- Data were analyzed using fixed- or random-effects models, with evidence quality graded by the GRADE scale.
Main Results:
- Regional analgesia (RA) significantly reduced postoperative pain up to 24 hours (SMD -0.81, low-quality evidence).
- No significant differences were found for nausea/vomiting, intubation duration, ICU/hospital length of stay, reoperation, or death.
- No evidence of local anesthetic toxicity or lasting neurological/infectious complications; one case of transient diaphragmatic paralysis reported.
Conclusions:
- Regional analgesic (RA) techniques are effective in reducing postoperative pain for up to 24 hours in pediatric cardiac surgery.
- Current evidence suggests RA does not impact major morbidity or mortality in this population.
- Results should be interpreted cautiously due to the small, heterogeneous nature of the included studies; further research is warranted.
Background:
The aim of this systematic review was to compare the effects of regional analgesic (RA) techniques with systemic analgesia on postoperative pain, nausea and vomiting, resources utilization, reoperation, death, and complications of the analgesic techniques in children undergoing cardiac surgery.
Methods:
A search was done in May 2018 in PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials comparing RA techniques with systemic analgesia. Risks of bias of included trials were judged with the Cochrane tool. Data were analyzed with fixed- (I(2) < 25%) or random-effects models (I(2) ≥ 25%). The quality of evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation working group scale.
Results:
We included 14 randomized controlled trials with 605 participants (312 to RA and 293 to the comparator). RA reduces pain up to 24 hours after surgery. At 6-8 hours after surgery, the standardized mean difference was -0.81 (95% confidence interval [CI], -1.22 to -0.40; low-quality evidence). We did not find a difference for nausea and vomiting (risk ratio [RR], 0.89; 95% CI, 0.61-1.31; very low-quality evidence), duration of tracheal intubation (standardized mean difference, -0.18; 95% CI, -0.40 to 0.05; low-quality evidence), intensive care unit length of stay (mean difference, -0.10 hours; 95% CI, -1.31 to 1.12 hours; low-quality evidence), hospital length of stay (mean difference, -0.02 days; 95% CI, -1.16 to 1.12 days; low-quality evidence), reoperation (RR, 0.76; 95% CI, 0.17-3.28; low-quality evidence), death (RR, 0.50; 95% CI, 0.05-4.94; low-quality evidence), and respiratory depression (RR, 2.06; 95% CI, 0.20-21.68; very low-quality evidence). No trial reported signs of local anesthetic toxicity or lasting neurological or infectious complications related to the RA techniques. One trial reported 1 transient ipsilateral episode of diaphragmatic paralysis with intrapleural analgesia that resolved with cessation of local anesthetic administration.
Conclusions:
Compared to systemic analgesia, RA techniques reduce postoperative pain up to 24 hours in children undergoing cardiac surgery. Currently, there is no evidence that RA for pediatric cardiac surgery has any impact on major morbidity and mortality. These results should be interpreted cautiously because they represent a meta-analysis of small and heterogeneous studies. Further studies are needed.
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