To identify superior pain-control procedures for postoperative patients who undergo cardiac surgeries.
Methods
Literature searches were conducted in globally recognized databases, including MEDLINE, EMBASE and Cochrane Central, to identify randomized controlled trials (RCTs) investigating pain-control procedures after cardiac surgeries. The parameters evaluating analgesic efficacy and postoperative recovery, namely, the pain score and ICU stay, were quantitatively pooled and estimated using Bayesian methods. The values of the surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated to enable the ranking of various pain-control procedures. Node-splitting analysis was performed to test the inconsistency of the main results, and the publication bias was assessed by examining the funnel-plot symmetry.
Results
After a detailed review, 13 RCTs containing 7 different procedures were included in the network meta-analysis. After pooling the results together, an erector spinae plane block (ESPB) and a local parasternal block (LPB) plus target-controlled infusion (TCI) presented the best analgesic effects for reducing pain at rest (SUCRA, .47) and during movement (SUCRA, .52), respectively, while the former also achieved the shortest ICU stay (SUCRA, .48). Moreover, the funnel-plot symmetries showed no inconsistencies or obvious publication bias in the current study.
Conclusions
The current evidence indicates that ESPB is a potential superior analgesic strategy for post-cardiac surgery patients. To verify this conclusion further, it is imperative to obtain more high-quality evidence and conduct relevant investigations in the future.
PerkinsFMKehletH. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93(4):1123-1133.
2.
GottschalkACohenSPYangSOchrochEA. Preventing and treating pain after thoracic surgery. Anesthesiology. 2006;104(3):594-600.
3.
ChoinièreMWatt-WatsonJVictorJC, et al.Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study. CMAJ (Can Med Assoc J). 2014;186(7):E213-E223.
4.
KehletHJensenTSWoolfCJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-1625.
5.
GlarePAubreyKRMylesPS. Transition from acute to chronic pain after surgery. Lancet. 2019;393(10180):1537-1546.
6.
BjørnnesAKParryMLieI, et al.The impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery. Eur J Cardiovasc. 2017;16(01):18-27.
7.
WuCLRajaSN. Treatment of acute postoperative pain. Lancet. 2011;377(9784):2215-2225.
8.
DunkmanWJManningMW. Enhanced recovery after surgery and multimodal strategies for analgesia. Surg Clin. 2018;98(6):1171-1184.
BigeleisenPEGoehnerN. Novel approaches in pain management in cardiac surgery. Curr Opin Anaesthesiol. 2015;28(1):89-94.
11.
NgCSWanSYimAPArifiAA. Pulmonary dysfunction after cardiac surgery. Chest. 2002;121(4):1269-1277.
12.
RawalN. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33(3):160-171.
13.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int J Surg. 2021;88:105906.
14.
SheaBJReevesBCWellsG, et al.AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008.
15.
HigginsJPAltmanDGGøtzschePC, et al.The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
16.
AtkinsDBestDBrissPA, et al.Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490.
17.
PuhanMASchünemannHJMuradMH, et al.A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis. BMJ. 2014;349:g5630.
18.
JansenJPCrawfordBBergmanGStamW. Bayesian meta-analysis of multiple treatment comparisons: an introduction to mixed treatment comparisons. Value Health. 2008;11(5):956-964.
19.
SalantiGHigginsJPAdesAEIoannidisJP. Evaluation of networks of randomized trials. Stat Methods Med Res. 2008;17(3):279-301.
20.
HozoSPDjulbegovicBHozoI. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13.
21.
LuoDWanXLiuJTongT. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res. 2018;27(6):1785-1805.
22.
KrishnaSNChauhanSBhoiD, et al.Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: a randomized controlled trial. J Cardiothorac Vasc Anesth. 2019;33(2):368-375.
23.
El ShoraHAEl BeleehyAAAbdelwahabAA, et al.Bilateral paravertebral block versus thoracic epidural analgesia for pain control post-cardiac surgery: a randomized controlled trial. Thorac Cardiovasc Surg. 2020;68(5):410-416.
24.
EljeziVImhoffEBourdeauxD, et al.Bilateral sternal infusion of ropivacaine and length of stay in ICU after cardiac surgery with increased respiratory risk: A randomised controlled trial. Eur J Anaesthesiol. 2017;34(2):56-65.
25.
NagarajaPSRagavendranSSinghNG, et al.Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. 2018;21(3):323-327.
26.
FlorkiewiczPMusialowiczTHippeläinenMLahtinenP. Continuous Ropivacaine Infusion Offers No Benefit in Treating Postoperative Pain After Cardiac Surgery. J Cardiothorac Vasc Anesth. 2019;33(2):378-384.
27.
ChiuKMWuCCWangMJ, et al.Local infusion of bupivacaine combined with intravenous patient-controlled analgesia provides better pain relief than intravenous patient-controlled analgesia alone in patients undergoing minimally invasive cardiac surgery. J Thorac Cardiovasc Surg. 2008;135(6):1348-1352.
28.
NasrDAAbdelhamidHMMohsenMAlyAH. The analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after cardiac surgery. Ann Card Anaesth. 2015;18(1):15-20.
29.
McDonaldSBJacobsohnEKopaczDJ, et al.Parasternal Block and Local Anesthetic Infiltration with Levobupivacaine After Cardiac Surgery with Desflurane: The Effect on Postoperative Pain, Pulmonary Function, and Tracheal Extubation Times. Anesth Analg. 2005;100(1):25-32.
30.
BarrAMTutungiEAlmeidaAA. Parasternal intercostal block with ropivacaine for pain management after cardiac surgery: a double-blind, randomized, controlled trial. J Cardiothorac Vasc Anesth. 2007;21(4):547-553.
31.
AnwarSCooperJRahmanJSharmaCLangfordR. Prolonged perioperative use of pregabalin and ketamine to prevent persistent pain after cardiac surgery. Anesthesiology. 2019;131(1):119-131.
32.
EljeziVDualéCAzarnoushK, et al.The Analgesic Effects of a Bilateral Sternal Infusion of Ropivacaine After Cardiac Surgery. Reg Anesth Pain Med. 2012;37(2):166-174.
33.
AmourJCholleyBOuattaraA, et al.The effect of local anesthetic continuous wound infusion for the prevention of postoperative pneumonia after on-pump cardiac surgery with sternotomy: the STERNOCAT randomized clinical trial. Intensive Care Med. 2019;45(1):33-43.
34.
FujiiSRocheMJonesPMVissaDBainbridgeDZhouJR. Transversus thoracis muscle plane block in cardiac surgery: a pilot feasibility study. Reg Anesth Pain Med. 2019;44(5):556-560.
35.
KehletHDahlJB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362(9399):1921-1928.
36.
AlazawiWPirmadjidNLahiriRBhattacharyaS. Inflammatory and Immune Responses to Surgery and Their Clinical Impact. Ann Surg. 2016;264(1):73-80.
37.
KuwataTShibasakiIOgataK, et al.Lung-diffusing capacity for carbon monoxide predicts early complications after cardiac surgery. Surg Today. 2019;49(7):571-579.
38.
The LancetL. Best practice in managing postoperative pain. Lancet. 2019;393(10180):1478.
39.
KehletH. Postoperative pain, analgesia, and recovery-bedfellows that cannot be ignored. Pain. 2018;159(suppl 1):S11-S16.
40.
HollmannMWRathmellJPLirkP. Optimal postoperative pain management: redefining the role for opioids. Lancet. 2019;393(10180):1483-1485.
41.
HuangAPSakataRK. [Pain after sternotomy - review]. Rev Bras Anestesiol. 2016;66(4):395-401.
42.
BradyKTMcCauleyJLBackSE. Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update. Am J Psychiatr. 2016;173(1):18-26.
43.
Maxam-MooreVAWilkieDJWoodsSL. Analgesics for cardiac surgery patients in critical care: describing current practice. Am J Crit Care. 1994;3(1):31-39.
44.
WilliamsJBMcConnellGAllenderJE, et al.One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program. J Thorac Cardiovasc Surg. 2019;157(5):1881-1888.
45.
SimpsonJCBaoXAgarwalaA. Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clin Colon Rectal Surg. 2019;32(2):121-128.
46.
GilronICarrDBDesjardinsPJKehletH. Current methods and challenges for acute pain clinical trials. Pain Rep. 2018;4(3):e647.
47.
ForeroMAdhikarySDLopezHTsuiCChinKJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016;41(5):621-627.
ForeroMRajarathinamMAdhikarySChinKJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure: a case report. A A Case Rep. 2017;8(10):254-256.
50.
AdhikarySDPruettAForeroMThiruvenkatarajanV. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth. 2018;62(1):75-78.
51.
Luis-NavarroJCSeda-GuzmánMLuis-MorenoCChinKJ. Erector spinae plane block in abdominal surgery: Case series. Indian J Anaesth. 2018;62(7):549-554.
52.
AdhikarySDLiuWMFullerECruz-EngHChinKJ. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia. 2019;74(5):585-593.
53.
TulgarSSenturkO. Ultrasound guided Erector Spinae Plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. J Clin Anesth. 2018;44:68.
54.
GürkanYAksuCKuşAYörükoğluUHKılıçCT. Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: A randomized controlled study. J Clin Anesth. 2018;50:65-68.
55.
DowlingRThielmeierKGhalyABarberDBoiceTDineA. Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial. J Thorac Cardiovasc Surg. 2003;126(5):1271-1278.
56.
WhitePFRawalSLathamP, et al.Use of a continuous local anesthetic infusion for pain management after median sternotomy. Anesthesiology. 2003;99(4):918-923.
57.
AgarwalSNuttallGAJohnsonMEHansonACOliverWC. A prospective, randomized, blinded study of continuous ropivacaine infusion in the median sternotomy incision following cardiac surgery. Reg Anesth Pain Med. 2013;38(2):145-150.
58.
DrageM. Caution in the use of lidocaine infusion in the surgical patient. Anesth Analg. 1998;87(5):1212-1213.
59.
BrowerMCJohnsonME. Adverse effects of local anesthetic infiltration on wound healing. Reg Anesth Pain Med. 2003;28(3):233-240.
ScarfeAJSchuhmann-HingelSDuncanJKMaNAtukoraleYNCameronAL. Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis. Eur J Cardio Thorac Surg. 2016;50(6):1010-1018.
62.
LubenowTRFaberLPMcCarthyRJHopkinsEMWarrenWHIvankovichAD. Postthoracotomy pain management using continuous epidural analgesia in 1,324 patients. Ann Thorac Surg. 1994;58(4):924-930.
63.
RosenDAHawkinberryDWRosenKRGustafsonRAHoggJPBroadmanLM. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg. 2004;98(4):966.
64.
Rodriguez-AldreteDCandiottiKAJanakiramanRRodriguez-BlancoYF. Trends and New Evidence in the Management of Acute and Chronic Post-Thoracotomy Pain-An Overview of the Literature from 2005 to 2015. J Cardiothorac Vasc Anesth. 2016;30(3):762-772.
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