Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Practice Advisory for Postoperative Pain Management of Thoracic Surgical Patients: A Report from the Society of Cardiovascular Anesthesiologists

Pain after thoracic surgery is often significant, which can disrupt normal respiratory mechanics and impair the clearance of secretions, thus increasing the risk of postoperative respiratory complications. Poorly controlled acute pain can lead to persistent post-thoracotomy pain and continued opioid use that can affect quality of life. With the increased awareness of opioid-associated adverse effects and recent emphasis on enhanced recovery, opioid-sparing multimodal analgesia has been used widely for acute pain management after thoracic surgery. This practice advisory reviews, evaluates, and summarizes the recent literature related to pharmacological therapies and non-pharmacological therapies used for postoperative pain management after thoracic surgery and offers guidance to providers in making appropriate pain management decisions for their patients.

Pain Intensity After Cardiac Surgery and its Association With Kinesiophobia: A Descriptive Study

PURPOSE

Severe pain and fear of pain may decrease physical activity and restrict movements after cardiac surgery. This study aimed to determine pain intensity after cardiac surgery and its association with kinesiophobia.

DESIGN

This was a descriptive and correlational study.

METHODS

The study was conducted with cardiac surgery patients (n = 170). The sample size was calculated by using the G*POWER 3.1 program. According to the power analysis, the sample size was calculated as 170, taking into account the dependent variable with the largest sample size (kinesiophobia) and 20% loss. The outcome measures were pain and kinesiophobia collected using the Visual Analog Scale and Tampa Kinesiophobia Scale.

FINDINGS

Married patients were at the greatest risk for kinesiophobia, higher than that for single patients (β = -3.765, β = -3.609; P < .05). Obese patients were at the greatest risk for kinesiophobia higher when compared to patients of normal weight (β = -2.907, P < .05). No statistically significant correlation was found between the pain intensity and kinesiophobia scores (P > 0.05).

CONCLUSIONS

Kinesiophobia was higher in patients after cardiac surgery. Married and obese patients were predictors of kinesiophobia; however, pain was not associated with kinesiophobia.

Practice Advisory for Postoperative Pain Management of Thoracic Surgical Patients: Executive Summary: A Report From the Society of Cardiovascular Anesthesiologists

Patients after thoracic surgery experience significant pain that can disrupt normal respiratory mechanics, increase the risk of respiratory complications, and impair recovery. Poorly controlled postoperative pain can develop into persistent postoperative pain. In addition, using opioids for pain control in the thoracic surgical population makes them more susceptible to opioid-related side effects due to their pre-existing comorbidities. The lack of consensus on how to effectively attain pain control after thoracic surgery has resulted in variability in the analgesic regimens utilized by providers across institutions and practices. The overall goal of this practice advisory is to identify opportunities for improvement in the postoperative pain management of thoracic surgical patients and provide guidance to perioperative providers through the provision of evidence-based recommendations.

Advances in Anesthesia Techniques for Postoperative Pain Management in Minimally Invasive Cardiac Surgery: An Expert Opinion

Minimally invasive cardiac surgery (MICS) often leads to severe postoperative pain. At present, multimodal analgesia schemes for MICS have attracted much attention, and the application of various chest wall analgesia techniques is becoming increasingly widespread. However, research on anesthesia techniques for postoperative pain management in MICS remains relatively limited at present. We searched for relevant literature and summarized recent related research in eight MICS techniques, including thoracic epidural anesthesia, spinal anesthesia, thoracic paravertebral plane block, erector spinae plane block, serratus anterior plane block, pectoral nerve block, intercostal nerve block, and parasternal block. This article provides an overview of the anatomy and procedures involved in these analgesic techniques, their mechanisms of action, and the latest clinical trial evidence. It also evaluates their progress in MICS, compares their advantages and disadvantages, and discusses practical challenges.

Practice Advisory for Postoperative Pain Management of Cardiac Surgical Patients: A Report by Society of Cardiovascular Anesthesiologists

Moderate to severe pain after cardiac surgery is relatively common, which increases the risk of postoperative cardiopulmonary complications and delays hospital discharge. Opioids have been useful agents for postoperative pain control after cardiac surgery, but are associated with serious adverse effects. As a result, multimodal analgesia has been adopted widely to decrease reliance on opioids for treating postoperative pain, reduce opioid-related adverse effects, and promote early recovery. The advent of fascial plane blocks has expanded the use of regional analgesia for pain management after cardiac surgery that was otherwise limited due to the fear of devastating neurological sequelae in the setting of systemic anticoagulation. This practice advisory reviews and evaluates the recent literature related to the use of pharmacological and non-pharmacological therapies to treat pain after cardiac surgery to help providers with the selection of appropriate pain management interventions for their patients.

Perioperative pain management for cardiac surgery

PURPOSE OF REVIEW

Acute postsurgical pain after cardiac surgery is challenging to treat. Adverse effects related to the high dose opioids which have traditionally been used perioperatively in cardiac surgery have led to the adoption of alternative analgesic strategies. This review aims to highlight current evidence-based approaches to managing pain after cardiac surgery.

RECENT FINDINGS

Current evidence and international guidelines support the use of multimodal analgesics for managing perioperative pain after cardiac surgery. Regional anaesthesia in the form of fascial plane blocks, such as the erector spinae plane and parasternal intercostal plane blocks, are effective and safe techniques for anticoagulated cardiac surgery patients. Transitional pain services are multidisciplinary programmes that bridge the gap between inpatient and outpatient care for these patients.

SUMMARY

This paper reviews advancements in perioperative pain management for cardiac surgery patients, emphasising the shift from high-dose opioids to multimodal analgesia and regional anaesthetic techniques, and highlighting the role of multidisciplinary transitional pain services.

State-of-the-art anesthesia practices: a comprehensive review on optimizing patient safety and recovery

OBJECTIVE

This review explores recent advancements in anesthesia care, focusing on the integration of innovative practices to enhance patient outcomes across the perioperative period.

METHODS

Following the framework of Whitmore and Knafl, we systematically searched six databases (PubMed, Google Scholar, EMBASE, CINAHL, OVID, and Cochrane Library) for studies published from January 2020 to January 2024, relating to advancements in anesthesia care, best practice implementation, and patient outcomes. After independent screening and data extraction by two reviewers, the review focuses on innovations in anesthetic drugs, monitoring technologies, anesthesia techniques, and evidence-based practices in anesthesia and clinical guidelines.

RESULTS

Of the 25,984 studies retrieved, 26 met inclusion criteria. Recent developments in anesthetic drugs have improved safety and efficacy, reducing complications. Advanced monitoring devices, such as multiparameter and brain function monitors, have enhanced patient safety through real-time assessments. Innovations in regional anesthesia and ultrasound-guided nerve blocks have led to better pain management, reduced recovery time, and minimized morbidity. Additionally, evidence-based practices like comprehensive preoperative assessment, patient education, and multidisciplinary teamwork significantly improved patient outcomes.

CONCLUSION

Integrating the latest innovations and best practices in anesthesia care is essential for optimizing patient outcomes. Ongoing research and adoption of advanced technologies are crucial to addressing current challenges and enhancing anesthesia quality. This review emphasizes the importance of a holistic approach from preoperative preparation to postoperative recovery to achieve optimal patient outcomes.

The Role of Regional Anesthesia in ICU Pain Management

PURPOSE OF REVIEW

The purpose of this review is to provide the most recent update and summary on the consideration, benefits and application of regional anesthesia in the ICU setting, as it pertains to the management of perioperative pain.

RECENT FINDINGS

Regional anesthesia and analgesia have become ubiquitous in the perioperative setting, with numerous indications and benefits. As integral part of the multimodal analgesia approach, various regional blocks have been increasingly utilized in critically ill patients. We focus this review on various regional techniques employed for critically ill patients after cardiac, thoracic, and major abdominal surgery, including neuraxial and novel truncal blocks. Effective pain management in critically ill patients poses many challenges and is extremely important. Regional anesthesia, in combination with other analgesia modalities, while still under-utilized, can help reduce acute perioperative pain, stress response, opioid use and related side effects and expedite recovery and improve clinical outcomes.

Comparison between thoracic epidural analgesia VS patient controlled analgesia on chronic postoperative pain after video-assisted thoracoscopic surgery: A prospective randomized controlled study

STUDY OBJECTIVE

To test the hypothesis that thoracic epidural anesthesia and analgesia (TEA) reduces the incidence of chronic postoperative pain (CPSP) after video-assisted thoracoscopic surgery (VATS).

DESIGN

A single-center, single-blind, randomized controlled trial was conducted.

SETTING

The study was conducted in the operating room, with follow-up assessments performed in the ward. Telephone was used to follow the long-term outcomes.

PATIENTS

231 patients ≥18 years of age and scheduled for VATS.

INTERVENTIONS

Patients were randomized into two groups, including an epidural block (EPI) group (general anesthesia with patient-controlled epidural analgesia) and a general anesthesia with patient-controlled intravenous analgesia (PCIA) group.

MEASUREMENTS

The primary endpoint was the incidence of CPSP at 3 months postoperatively. CPSP data, including acute pain, neuropathic pain, depression, and side effects, were collected at 3 and 6 months postoperatively through telephone follow-up.

MAIN RESULTS

A total of 231 patients were analyzed, including 114 in the PCIA group and 117 in the EPI group. Sixty-six patients (56.4 %) in the PCIA group and 33 patients (28.9 %) in the EPI group experienced chronic pain at 3 months postoperatively. The odds ratio (OR) was 0.31 (95 % confidence interval [CI], 0.18 to 0.54; P < 0.0001). After adjusting for confounding factors, the adjusted OR was 0.28 (95 % CI, 0.16 to 0.50, P < 0.001). Six months postoperatively, 50 (42.7 %) and 17 (14.9 %) patients in the PCIA and EPI groups, respectively, were diagnosed with CPSP (P < 0.0001).

Practice Advisory for Postoperative Pain Management of Cardiac Surgical Patients: Executive Summary. A Report From the Society of Cardiovascular Anesthesiologists

Cardiac surgery is associated with significant postoperative pain that can affect patients' recovery and quality of life. Optimal analgesia after cardiac surgery can be challenging due to patients' coexisting morbidities and frequently observed adverse effects when opioids are used to treat postoperative pain. In this current era of enhanced recovery and fast track extubation, multimodal analgesia is increasingly being utilized for pain management after cardiac surgery. Regional analgesia is an integral part of multimodal analgesia and has garnered more attention since the development of fascial plane blocks. There is considerable variability among individuals, institutions, and practices in the analgesic approaches used to treat postoperative pain in cardiac surgical patients because of lack of consensus or guidelines. This practice advisory was developed with the overall goal of identifying opportunities for improving postoperative pain relief and pain-related outcomes after cardiac surgery and guiding perioperative providers through the provision of clinically relevant evidence-based recommendations.

Predictive Scores for Identifying Chronic Opioid Dependence After General Anesthesia Surgery

Purpose

To address the prevalence and risk factors of postoperative chronic opioid dependence, focusing on the development of a predictive scoring system to identify high-risk populations.

Methods

We analyzed data from the Taiwan Health Insurance Research Database spanning January 2016 to December 2018, encompassing adults undergoing major elective surgeries with general anesthesia. Patient demographics, surgical details, comorbidities, and preoperative medication use were scrutinized. Wu and Zhang's scores, a predictive system, were developed through a stepwise multivariate model, incorporating factors significantly linked to chronic opioid dependence. Internal validation was executed using bootstrap sampling.

Results

Among 111,069 patients, 1.6% developed chronic opioid dependence postoperatively. Significant risk factors included age, gender, surgical type, anesthesia duration, preoperative opioid use, and comorbidities. Wu and Zhang's scores demonstrated good predictive accuracy (AUC=0.83), with risk categories (low, moderate, high) showing varying susceptibility (0.7%, 1.4%, 3.5%, respectively). Internal validation confirmed the model's stability and potential applicability to external populations.

Conclusion

This study provides a comprehensive understanding of postoperative chronic opioid dependence and introduces an effective predictive scoring system. The identified risk factors and risk stratification allow for early detection and targeted interventions, aligning with the broader initiative to enhance patient outcomes, minimize societal burdens, and contribute to the nuanced management of postoperative pain.

Enhanced Recovery After Surgery (ERAS) cardiac turnkey order set for perioperative pain management in cardiac surgery: Proceedings from the American Association for Thoracic Surgery (AATS) ERAS Conclave 2023

Objective

Optimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management.

Methods

Subject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type.

Results

Opioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery.

Conclusions

There has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.

Effects of Serratus Anterior Plane Block on Early Recovery from Thoracoscopic Lung Resection: A Randomized, Blinded, Placebo-controlled Trial

BACKGROUND

The efficacy of serratus anterior plane block for treatment of pain after minimally invasive thoracic surgery remains unclear. This trial assesses the impact of serratus anterior plane block on postoperative opioid consumption and on measures of early recovery after thoracoscopic lung resection.

METHODS

Patients undergoing minimally invasive anatomic lung resection at a single center were randomized to undergo serratus anterior plane block with 40 ml injectate containing bupivacaine 0.25%, clonidine 100 μg, and dexamethasone 4 mg (serratus anterior plane block group) or sham block with 40 ml normal saline (placebo group) at the conclusion of surgery. The primary outcome was cumulative intravenous morphine equivalents during the first 24 h postoperatively. Secondary outcomes were intravenous morphine equivalents, pain scores at rest and with cough, inspiratory volume on incentive spirometry, incidence of nausea or vomiting during the first 48 h postoperatively, Quality of Recovery-15 score on postoperative day 7, and length of stay.

RESULTS

Using the protocol-specified intention-to-treat analysis, the median (interquartile range) intravenous morphine equivalents was 10.6 (5.0 to 27.1) mg in serratus anterior plane block patients (n = 46) versus 18.8 (9.9 to 29.6) mg in placebo patients (n = 46; 32% reduction; ratio, 0.68 [95% CI, 0.44 to 1.06]; P = 0.085). Of the secondary outcomes, only the composite pain with cough scores differed significantly in the serratus anterior plane block group by a coefficient of -0.41 (95% CI, -0.81 to -0.01; P = 0.044). A sensitivity as-treated analysis reported median (interquartile range) intravenous morphine equivalents of 10.0 (5.0 to 27.2) mg in serratus anterior plane block patients (n = 44) versus 19.9 (10.4 to 29.0) mg in placebo patients (n = 48; 36% reduction; ratio, 0.64 [95% CI, 0.41 to 1.00]; P = 0.048).

CONCLUSIONS

The protocol-specified intention-to-treat analysis demonstrated that serratus anterior plane block did not result in a significant reduction in opioid consumption when added to a multimodal analgesic regimen after thoracoscopic anatomic lung resection. The sensitivity as-treated analysis showed a significant and modest clinical reduction in the primary outcome that warrants further investigation.

EDITOR’S PERSPECTIVE

Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

The efficacy of loco-regional ropivacaine analgesia via intercostal catheters after lung resection: a randomized, double-blind, placebo-controlled, superiority study

OBJECTIVES

Postoperative pain remains a burden for patients after minimally invasive anatomic lung resection. Current guidelines recommend the intraoperative placement of intercostal catheters to promote faster recovery. This trial aimed to determine the analgesic efficacy of continuous loco-regional ropivacaine application via intercostal catheter and establish this method as a possible standard of care.

METHODS

Between December 2021 and October 2023, patients were randomly assigned to receive ropivacaine 0.2% or a placebo through an intercostal catheter with a flow rate of 6-8 ml/h for 72 h after surgery. Patients were undergoing anatomic VATS lung resection under general anaesthesia for confirmed or suspected stage I lung cancer (UICC, 8th edition). The sample size was calculated to assess a difference in numerical rating scale associated with pain reduction of 1.5 points.

RESULTS

Fourteen patients were included in the ropivacaine group, whereas the placebo group comprised 18 participants. Patient characteristics and preoperative pain scores were similar in both groups. There was no statistically significant difference in postoperative pain scores and morphine consumption between the 2 groups. The mean numerical rating scale when coughing during the first 24 h postoperatively was 4.9 (SD: 2.2) in the ropivacaine group and 4.3 (SD: 2.4); P = 0.47 in the placebo group. We were unable to determine any effect of administered ropivacaine on the postoperative pulmonary function (FEV1, PEF).

CONCLUSIONS

Our preliminary results suggest that continuous loco-regional ropivacaine administration via surgically placed intercostal catheter has no positive effect on postoperative pain scores or morphine requirements.

CLINICAL REGISTRATION NUMBER

NCT04939545.

Effects of epidural anesthesia and analgesia on the incidence of chronic pain after thoracoscopic lung surgery: A retrospective cohort study

Objective

Chronic postoperative pain (CPSP) is common after thoracic surgery, even after the less invasive video-assisted thoracoscopic surgery (VATS). This study investigated the effect of thoracic epidural anesthesia (TEA) on the development of CPSP.

Materials

We retrospectively analyzed the data of patients who underwent VATS at our center between 2020 and 2022. The enrolled patients were divided into the epidural block (EPI) and patient-controlled intravenous analgesia (PCIA) groups. A telephone questionnaire was used to collect information regarding CPSP, which was defined as a numerical rating scale (VAS) score ≥1 at 3 or 6 months postoperatively. Additionally, statistical analyses were performed to identify the risk factors for CPSP in the two groups.

Results

Overall, 894 patients completed the follow-up interviews at 3 and 6 months, with 325 and 569 patients in the PCIA and EPI groups, respectively. The incidence rates of CPSP in the PCIA group at 3 and 6 months were 16.9 % (95 % confidence interval [CI]: 9.3-32.7 %) and 13.5 % (95 % CI: 8.7-33.4 %), and 10.3 % (95 % CI: 8.1-30.5 %) and 3.6 % (95 % CI: 3.5-21.5 %) in EPI group, respectively. The incidence of CPSP at 3 months (P = 0.0048) and 6 months (P < 0.005) was statistically significant in both groups. Age and lymph node dissection were significantly associated with CPSP.

Conclusions

Compared to PCIA, TEA was associated with a lower incidence of CPSP after VATS, and should be considered an important part of the analgesia regimen for patients with VATS.

Intraoperative Methadone Use Is Associated With Reduced Postoperative Pain and More Rapid Opioid Weaning After Coronary Artery Bypass Grafting

OBJECTIVE

To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery.

DESIGN

Retrospective cohort study.

SETTING

Single academic medical center.

PARTICIPANTS

Patients undergoing isolated CABG over a 5-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01).

CONCLUSIONS

Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.

Superficial parasternal intercostal plane blocks in cardiac surgery: a systematic review and meta-analysis

PURPOSE

Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified.

RESULTS

We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI,  -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks.

CONCLUSION

The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required.

STUDY REGISTRATION

PROSPERO (CRD42022306914); first submitted 22 March 2022.

Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery.

DESIGN

A systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation).

SETTING

Randomized controlled trials (RCTs).

PARTICIPANTS

Adults and children undergoing heart surgery.

INTERVENTIONS

Any kind of PRA compared to no RA or placebo or neuraxial anesthesia.

MEASUREMENTS AND MAIN RESULTS

In total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials.

CONCLUSIONS

Compared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.