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Introduction: Cesarean section is one of the most commonly performed surgical procedures. Postoperative pain after cesarean section is moderate to severe, though it has been neglected due to several reasons. Systemic opoids, local wound infiltration, and abdominal nerve blocks are among popular techniques used for postoperative pain after cesarean section in an area where epidural analgesia is barely practiced. Thus, this study aimed to assess the analgesic effectiveness of II-IH nerve block and wound site infiltration for pain management after cesarean section. Method: An institutional based prospective cohort study was conducted on 72 parturient scheduled for elective cesarean section. The parturients grouped based on whether they took II-IH, WSI or non-exposed groups. Data collection methods include preoperative chart review, intraoperative observation and postoperative patient interview starting from recovery room for 24 h. Time to first analgesic request, NRS score and total analgesic consumption were used as outcome variables. Continuous data were analyzed using one-way analysis of variance (ANOVA) or kuruska-walih H rank test depending on normality whereas categorical data analyzed by Pearson chi-square test. Result: Time to first analgesic request was significantly prolonged in II-IH groups compared to WSI and Non-exposed groups with p-value 0.01. Similarly, NRS score within 24 h was significantly lower in II-IH groups compared to Non-exposed Group at all follow up periods except at 2 and 24 h. However, WSI reduced NRS score, in a comparison with non-exposed group, only at 4 and 6 h with p-value of 0.04 and 0.02 respectively. In addition, the post hoc comparison of total tramadol consumption revealed significant difference between all the possible three comparisons. Conclusion and Recommendation: Although II-IH nerve block provides better and prolonged pain relief, WSI was also effective analgesic technique for post cesarean section pain. Therefore, we recommend use of either II-IH or WSI as a part of post-operative pain management for cesarean section. Further Randomized controlled trial studies were also recommended on similar area. Highlights:
Introduction: Cesarean section is one of the most commonly performed surgical procedures. Postoperative pain after cesarean section is moderate to severe, though it has been neglected due to several reasons. Systemic opoids, local wound infiltration, and abdominal nerve blocks are among popular techniques used for postoperative pain after cesarean section in an area where epidural analgesia is barely practiced. Thus, this study aimed to assess the analgesic effectiveness of II-IH nerve block and wound site infiltration for pain management after cesarean section. Method: An institutional based prospective cohort study was conducted on 72 parturient scheduled for elective cesarean section. The parturients grouped based on whether they took II-IH, WSI or non-exposed groups. Data collection methods include preoperative chart review, intraoperative observation and postoperative patient interview starting from recovery room for 24 h. Time to first analgesic request, NRS score and total analgesic consumption were used as outcome variables. Continuous data were analyzed using one-way analysis of variance (ANOVA) or kuruska-walih H rank test depending on normality whereas categorical data analyzed by Pearson chi-square test. Result: Time to first analgesic request was significantly prolonged in II-IH groups compared to WSI and Non-exposed groups with p-value 0.01. Similarly, NRS score within 24 h was significantly lower in II-IH groups compared to Non-exposed Group at all follow up periods except at 2 and 24 h. However, WSI reduced NRS score, in a comparison with non-exposed group, only at 4 and 6 h with p-value of 0.04 and 0.02 respectively. In addition, the post hoc comparison of total tramadol consumption revealed significant difference between all the possible three comparisons. Conclusion and Recommendation: Although II-IH nerve block provides better and prolonged pain relief, WSI was also effective analgesic technique for post cesarean section pain. Therefore, we recommend use of either II-IH or WSI as a part of post-operative pain management for cesarean section. Further Randomized controlled trial studies were also recommended on similar area. Highlights:
BACKGROUND An effective analgesia strategy following caesarean delivery should be designed to improve fetomaternal outcomes. Much recent research has focused on the efficacy of ilioinguinal-iliohypogastric (II-IH) block for providing such analgesia. DESIGN A systematic review and meta-analysis of randomised controlled trials. OBJECTIVES To investigate the effectiveness of II-IH block in patients undergoing caesarean delivery. The primary outcome was the cumulative parenteral morphine equivalents at 24 h. Pain scores at 4 to 6 and 24 h postsurgery, time to first rescue analgesia and adverse effects were the secondary outcomes analysed. DATA SOURCES Two reviewers searched independently PubMed, Embase, Google Scholar and the Cochrane central registers of a controlled trial from their inception until June 2020. METHODOLOGY Prospective randomised control trials comparing II-IH block with either systemic analgesia alone or a placebo block (non-active controls) were eligible for inclusion. Only trials that reported their methods comprehensibly and transparently were included. Cochrane methodology was used to assess the risk of bias. Data are presented as mean difference with 95% confidence interval (CI). RESULTS Thirteen trials comprising a total of 858 patients were included. Opioid (intravenous morphine equivalents) consumption was reduced by 15.57 mg (95% CI −19.87 to −11.28; P < 0.00001; I 2 = 95%) during the first 24 h in patients receiving II-IH block when compared with placebo or no block. Patients receiving general anaesthesia showed a greater reduction in morphine requirement at 24 h than those receiving neuraxial anaesthesia. Adequate ‘information size’ for the above outcome was confirmed with trial sequential analysis to rule out the possibility of a false-positive result. II-IH also significantly reduced pain scores at rest more so at 4 to 6 h than at 24 h. CONCLUSIONS Our study suggests that the use of II-IH blocks is associated with a lower 24 h requirement for intravenous morphine equivalents in patients undergoing caesarean delivery. However, given the methodological limitations, data should be interpreted with caution until more studies are available.
Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilioinguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention À4 (À10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (À0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinaliliohypogastric 0.6 (À0.5 to 1.8); transverse abdominis 0.6 (À0.1 to 1.2); wound infiltration 0.5 (À0.3 to 1.3); transversalis fascia À0.8 (À3.4 to 1.9); ilio-inguinal À0.9 (À3.6 to 1.7); and no intervention À0.8 (À1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.
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