Continuous peripheral nerve blocks compared to thoracic epidurals or multimodal analgesia for midline laparotomy: a systematic review and meta-analysis

Abstract

Background: Continuous peripheral nerve blocks (CPNBs) have been investigated to control pain for abdominal surgery via midline laparotomy while avoiding the adverse events of opioid or epidural analgesia. The review compiles the evidence comparing CPNBs to multimodal and epidural analgesia. Methods: We conducted a systematic review using broad search terms in Medline, EMBASE, Cochrane. Primary outcomes were pain scores and cumulative opioid consumption at 48 hours. Secondary outcomes were length of stay and postoperative nausea and vomiting (PONV). We rated the quality of the evidence using Cochrane and GRADE recommendations. The results were synthesized by metaanalysis using Revman. Results: Our final selection included 26 studies (1,646 patients). There was no statistically significant difference in pain control comparing CPNBs to either multimodal or epidural analgesia (low quality evidence). Less opioids were consumed when receiving epidural analgesia than CPNBs (mean difference (MD)-16.13 [95% CI-32.36,-0.10], low quality evidence) and less when receiving CPNBs than multimodal analgesia (MD-31.52 [95% CI-42.81,-20.22], low quality evidence). The length of hospital stay was shorter when receiving epidural analgesia than CPNBs (MD-0.78 days [95% CI-1.29,-0.27], low quality evidence) and shorter when receiving CPNBs than multimodal analgesia (MD-1.41 days [95% CI-2.45,-0.36], low quality evidence). There was no statistically significant difference in PONV comparing CPNBs to multimodal (high quality evidence) or epidural analgesia (moderate quality evidence).

Explanation of trial sequential analysis: using a post-hoc analysis of meta-analyses published in Korean Journal of Anesthesiology

“…We identified 11 [6][7][8][9][10][11][12][13][14][15][16] papers in our initial search, however, four of them were excluded [6][7][8][9] because they were statistical rounds, while seven were clinical meta-analyses. However, one of them [10] did not have sufficient information to perform TSA and was therefore excluded, leaving six papers for the final analysis [11][12][13][14][15][16] (Fig. 2).…”

“…The considered meta-analyses topics were mixed and distributed in the following way: curare side effects [11], regional anesthesia [12,16], postoperative efficacy of ibuprofen [14], postoperative shivering [13], postoperative nausea and vomiting [15]. Notably only two of them had a pre registered protocol [12,14]. Four papers [11][12][13][14] had two main outcomes and for this reason a total of 10 TSA were performed.. Choi et al [11] evaluated both lidocaine and opioids pretreatment on the incidence of rocuroniuminduced withdrawal movements.…”

“…Notably only two of them had a pre registered protocol [12,14]. Four papers [11][12][13][14] had two main outcomes and for this reason a total of 10 TSA were performed.. Choi et al [11] evaluated both lidocaine and opioids pretreatment on the incidence of rocuroniuminduced withdrawal movements. For both outcomes the cumulative z-score line crossed the line for benefit reaching the required sample size in both the 90% and 99% analysis (Fig 3 and 4).…”

“…The topics of the meta-analyses were as follows: curare side effects [ 11 ], regional anesthesia [ 12 , 16 ], postoperative efficacy of ibuprofen [ 14 ], postoperative shivering [ 13 ], and postoperative nausea and vomiting [ 15 ]. Notably, only two of them had a pre-registered protocol [ 12 , 14 ].…”

“…The topics of the meta-analyses were as follows: curare side effects [ 11 ], regional anesthesia [ 12 , 16 ], postoperative efficacy of ibuprofen [ 14 ], postoperative shivering [ 13 ], and postoperative nausea and vomiting [ 15 ]. Notably, only two of them had a pre-registered protocol [ 12 , 14 ]. Four papers [ 11 - 14 ] had two main outcomes, and for this reason, a total of 10 TSAs were performed.…”