Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

Abstract

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. 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. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for 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 also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

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“…The previous recommendation is based on information obtained from a recent meta-analysis, Champaneria et al [24] state that TAP blocks significantly reduce pain and postoperative morphine consumption at rest both when compared with placebo or no TAP blocks, however, this significance is lost when compared to IT morphine or given in co-administration. Contrary to this, a recent network meta-analysis by Ryu et al [25] concluded that combined IT morphine in conjunction with ilioinguinal-iliohypogastric nerve and anterior transversus abdominis plane block was the most effective post-caesarean analgesic strategy with lower rest pain at 6 hours and cumulative 24-hour morphine consumption. Additionally, other effective options for effective analgesia were IT morphine, ilioinguinal-iliohypogastric nerve block with IT morphine, lateral TAP block, and Perioperative Analgesia in Caesarean Section: What's New?…”

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