Analgesic Effects of Regional Analgesic Techniques in Pediatric Inguinal Surgeries: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Various regional analgesic techniques have been used in pediatric inguinal surgery to facilitate postoperative recovery. However, each technique's relative performance was undetermined owing to the lack of quantitative analysis.

METHODS

We systematically searched MEDLINE, Cochrane Library, EMBASE, and Web of Science for randomized controlled trials that compared regional analgesia in pediatric inguinal surgeries. After critical study screening and selection, a random-effects network meta-analysis was performed. The primary outcome was the time to the first rescue analgesic after surgery, and the secondary outcomes were the number of patients requiring rescue analgesics after surgery, postoperative pain scores, incidence of postoperative nausea and vomiting, and other adverse events.

RESULTS

This network meta-analysis included 69 randomized controlled trials (4636 patients) that compared 10 regional analgesic techniques. Our study revealed that the quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic after pediatric inguinal surgeries, by 7.7 hours (95% confidence interval [CI], 5.0-10.3) and 6.0 hours (95% CI, 3.9-8.2) when compared with the control group, respectively. In the subgroup involving only inguinal hernia repair, the quadratus lumborum block significantly prolonged the time to the first rescue analgesic than all other regional analgesics. In contrast, in the subgroup involving orchidopexies, only the caudal block significantly prolonged the time to the first rescue analgesic when compared with the control group (4.1 hours; 95% CI, 0.7-7.5). Wound infiltration and landmark-based ilioinguinal-iliohypogastric block had relatively poor analgesic effects than other regional analgesics. No serious adverse effects related to the regional analgesic techniques were reported in any of the included studies.

CONCLUSIONS

The quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic and the least rescue analgesic requirement for pediatric inguinal surgeries. Specifically, the quadratus lumborum block had the longest analgesic duration in inguinal hernia repair, and the caudal block was found to be the only regional analgesia that extended the time to the first rescue analgesic in pediatric orchidopexy. Most included randomized controlled trials had some concern or a high risk of bias, and future studies should focus on providing high-quality evidence to further clarify the analgesic effects of regional analgesia for pediatric inguinal surgeries.

Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice

BACKGROUND

Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia.

MATERIAL/METHOD

A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records.

RESULTS

Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge.

CONCLUSION

There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Ultrasound-guided retrolaminar block versus ilioinguinal nerve block for postoperative analgesia in children undergoing inguinal herniotomy: A randomized controlled trial

STUDY OBJECTIVE

Ultrasound-guided retrolaminar block (RLB) is a new, safe and technically easy nerve block. To our knowledge, no studies have evaluated its analgesic efficacy in pediatric patients. This study aimed to compare the postoperative analgesic efficacy of RLB and ilioinguinal nerve block (INB) in pediatric patients undergoing unilateral inguinal herniotomy.

DESIGN

Superiority, prospective, randomized, double-blinded, controlled study.

SETTING

Operating rooms and wards of Mansoura University Children's Hospital, Egypt.

PATIENTS

Sixty-five patients aged 2 to 6 years undergoing unilateral inguinal herniotomy were enrolled.

INTERVENTIONS

In the ultrasound-guided RLB group (n = 30), we injected 0.5 mL/kg bupivacaine 0.25% into the retrolaminar space between the lamina of T12 and the paraspinal muscles and in ultrasound-guided INB group (n = 30), 0.5 mL/kg bupivacaine 0.25% was injected for INB.

MEASUREMENTS

The primary outcome measure was the number of patients requiring ibuprofen as rescue analgesia and the secondary outcome measures were intraoperative hemodynamic changes and the postoperative FLACC (Face, Legs, Activity, Cry, Consolability) score.

MAIN RESULTS

The number of patients who needed rescue analgesia in the first postoperative 24 h was significantly lower (P = 0.023) in the RLB group [5 (16%)] than the INB group [13 (43%)]. The mean (SD) arterial blood pressure and heart rate were significantly higher (P < 0.001) during sac traction in the INB group [74.07 (2.99), 97.33 (6.98)] than the RLB group [67.73 (3.55), 90.79 (5.13)]. The postoperative FLACC scores at 4, 6, 12, and 24 h were significantly lower (P < 0.05) in the RLB group than in the INB group.

CONCLUSION

Retrolaminar block is superior to ilioinguinal nerve block in providing postoperative analgesia in pediatric patients undergoing unilateral inguinal herniotomy.

Effects of Ultrasound-Guided Thoracic Paravertebral Block on Postoperative Pain in Children Undergoing Percutaneous Nephrolithotomy

Objective

To compare the effects of ultrasound-guided thoracic paravertebral block (PVB) and intravenous paracetamol on postoperative pain control in paediatric patients undergoing percutaneous nephrolithotomy (PNL).

Methods

Forty patients aged 1-5 years, with an American Society of Anesthesiologists physical status I-II, scheduled for PNL were enrolled into this prospective randomised controlled trial. After arrival in the operating room, all patients were administered standardised general anaesthesia. Patients in Group PVB received ultrasound-guided PVB using bupivacaine 0.5% at a total volume of 0.5 mL kg^-1 at the vertebral levels T11, T12 and L1. Patients in Group P were administered paracetamol intravenously (15 mg kg^-1) before the beginning of surgery. Patients in both groups were given tramadol (1 mg kg^-1) for supplemental analgesia. Patient demographics, haemodynamic parameters, peripheral oxygen saturation and sevoflurane concentration were recorded. The Face, Legs, Activity, Cry and Consolability pain scores; satisfaction of parents; the number of patients requiring supplemental analgesia; and complications were evaluated during the postoperative period.

Results

Pain scores were significantly lower in Group PVB compared with Group P (p=0.001). There were no analgesic requirements in Group PVB; however, all patients needed a supplemental analgesic in Group P. Parental satisfaction was higher in Group PVB than in Group P.

Conclusion

This study demonstrated that ultrasound-guided PVB provides more effective postoperative analgesia with no side effects compared to intravenous paracetamol in children undergoing PNL.

Paravertebral block in paediatric abdominal surgery-a systematic review and meta-analysis of randomized trials

The increased popularity of paravertebral block (PVB) can be attributed to its relative safety and comparable efficacy when compared with epidural analgesia. It has thus been recommended for open cholecystectomy and other less painful surgeries such as inguinal herniorraphy and appendectomy. We performed a systematic review of PVB in paediatric abdominal conditions to assess its clinical efficacy and side effects compared with other analgesic therapies.A search of Medline, Embase, and Web of Science and hand-searching references from inception date to May 2016 was done. Relevant studies were randomized clinical trials in patients 0-18 years old comparing PVB (single shot or continuous catheter) with any comparator and analgesic medication. Pain scores, rescue analgesia and adverse events were compared.The systematic reviews identified six trials enrolling 358 paediatric patients. PVB medications included bupivacaine, ropivacaine, lidocaine, and fentanyl. Surgical procedures included inguinal herniorraphy, cholecystectomy, and appendectomy. The standardized mean difference in early pain scores favoured PVB: 0.85 [95% confidence interval (CI) 0.12-1.58] at 4-6 h and 0.64 (95% CI 0.28-1.00) at 24 h. One study reported a reduced length of stay. Parental [odds ratio (OR) 5.12 (95% CI 2.59-10.1)] and surgeon [OR 6.05 (95% CI 2.25-16.3)] satisfaction were higher in those receiving a PVB. No major complications occurred with a PVB.PVB resulted in minimally improved pain scores for up to 24 h after surgery, reduced rescue analgesia requirements, and increased surgeon and parental satisfaction. PVB is a good alternative to caudal and ilioinguinal block in paediatric abdominal surgery.

Comparison of caudal epidural block with paravertebral block for renal surgeries in pediatric patients: A prospective randomised, blinded clinical trial

STUDY OBJECTIVE

This study was undertaken to compare the analgesic efficacy of ultrasound-guided single-shot caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries.

DESIGN

Randomised, interventional, blinded clinical trial.

SETTING

Operating rooms of All India Institute of Medical Sciences, New Delhi, India.

PATIENTS

50 children aged 2-10 years, of ASA status I/II, posted for elective renal surgeries.

INTERVENTIONS

The children were randomised into two groups (Group C-caudal block, Group P-paravertebral block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline.

MEASUREMENTS

Time to first rescue analgesia, time to perform blocks, intraoperative and post-operative hemodynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded.

MAIN RESULTS

Children in Group P had significantly longer duration of analgesia (p < 0.0004) than Group C. Post-operative FLACC scores (p < 0.005) and analgesic requirements (p < 0.0004) were lower in Group P. The mean fentanyl requirement over 24 h in group P was 0.56 ± 0.82 μg/kg, compared to 1.8 ± 1.2 μg/kg in group C. Parents in Group P reported greater satisfaction (p < 0.02). No complications were seen in either of the groups.

CONCLUSION

This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in children requires adequate expertise and practice.

Regional anesthesia in pediatrics: marching forward

PURPOSE OF REVIEW

This review highlights new data and current trends of well tolerated and effective paediatric regional anesthesia. Historically, the practice of paediatric regional anesthesia was based largely on information from adult studies, but recent literature contains information on paediatric specific risks and benefits of old and new techniques as well as the impact of new ideas and technologies.

RECENT FINDINGS

Excellent pain relief with regional anesthesia is well demonstrated in children. Several databases of paediatric regional anesthesia (over 46,000 regional anesthetics) demonstrate overall safety and lack of major complications. Detailed analysis demonstrates additional safety and decreased failure rates of peripheral compared with neuraxial nerve blocks. Ultrasound technology confers additional safety and efficacy benefits.Increasingly, data support the safety and efficacy of novel peripheral nerve blocks, transversus abdominis plane and ultrasound-guided paravertebral, and the use of perineural catheters for both inpatients and outpatients. Regional anesthesia as a sole agent for surgical anesthesia and the use of regional anesthesia for pain in nonsurgical pain patients remains underutilized.

SUMMARY

Paediatric specific data for regional anesthesia are available to help guide optimal pain management. The paediatric regional anesthesia literature lags behind literature available for adult populations and increased studies are needed for additional information for informed decision-making.

A systematic review and meta-analysis of caudal block as compared to noncaudal regional techniques for inguinal surgeries in children

This systematic review and meta-analysis were designed to compare the analgesic effectiveness and adverse effects with the use of caudal analgesia as compared to noncaudal regional analgesia techniques in children undergoing inguinal surgeries. MEDLINE, EMBASE, and CENTRAL (Cochrane) databases were searched for randomized control trials published in English language from 1946 up to 2013. Use of rescue analgesia and adverse effects were considered as primary and secondary outcomes, respectively. Outcomes were pooled using random effects model and reported as risk ratio (RR) with 95% CI. Out of 3240 hits and 24 reports for final selection, 17 were included in this review. Caudal analgesia was found to be better in both early (RR = 0.81 [0.66, 0.99], P = 0.04) and late (RR = 0.81 [0.69, 0.96], P = 0.01) periods, but with a significant risk of motor block and urinary retention. According to GRADE, the quality of evidence was moderate. Although potentially superior, caudal analgesia increases the chance of motor block and urinary retention. There are limited studies to demonstrate that the technical superiority using ultrasound translates into better clinical success with the inguinal nerve blocks.