The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Can Erector Spinae Plane Block Replace Intrathecal Morphine in Cesarean Section? A Prospective Randomized Controlled Study on Opioid Consumption

OBJECTIVES

After cesarean, optimal analgesia is important for early mobilization, mitigating thromboembolic risks, and mother-infant communication. Our study compared the postoperative analgesic effects of intrathecal morphine (ITM) and erector spinae plane block (ESPB) in elective cesarean section under spinal anesthesia.

METHODS

Eighty-two patients were randomized into ESPB and ITM groups. Both groups received spinal anesthesia with 10 mg of heavy bupivacaine. In the ITM group, ITM (100 mcg) was added. The ESPB group received bilateral T10 level ESPB with 20 mL 0.25% bupivacaine postoperatively. Postoperative pain control included intravenous paracetamol 4x1 g, intravenous patient-controlled analgesia with tramadol, and diclofenac 75 mg for rescue analgesia when Numeric Rating Scale (NRS) >4. NRS, tramadol consumption, and side effects were recorded 24 hours postoperatively. The primary outcome of this study is to compare 24-hour postoperative opioid consumption after cesarean sections. Secondary outcomes include postoperative pain scores, rescue analgesia needs, and side effects.

RESULTS

NRS scores ≤4 at all time intervals and were comparable among groups. The total 24-hour tramadol consumption was significantly higher in the ESPB group (median: 75; Q1, Q3 [40, 140]) compared with ITM (50 [27.5, 60], P = 0.008). Tramadol consumption was similar among groups during 0 to 6 and 6 to 12 hours. In the 12 to 24 hours, tramadol consumption was significantly higher in the ESPB group (22.5 [15, 57.5]) compared with ITM (15 [12.5, 25], P = 0.005). In the ITM group, nausea and vomiting were observed in 3 patients and itching in 1 patient; no adverse effects were observed in the patients in the ESPB group.

CONCLUSION

For patients undergoing cesarean section under spinal anesthesia, ITM reduced opioid consumption more effectively than ESPB. ESPB is not recommended as a primary analgesic option for cesarean sections.

Effect of intraoperative injection of esketamine on postoperative analgesia and postoperative rehabilitation after cesarean section

BACKGROUND

Following cesarean section, a significant number of women encounter moderate to severe pain. Inadequate management of acute pain post-cesarean section can have far-reaching implications, adversely impacting maternal emotional well-being, daily activities, breastfeeding, and neonatal care. It may also impede maternal organ function recovery, leading to escalated opioid usage, heightened risk of postpartum depression, and the development of chronic postoperative pain. Both the Chinese Enhanced Recovery After Surgery (ERAS) guidelines and the American ERAS Society guidelines consistently advocate for the adoption of multimodal analgesia protocols in post-cesarean section pain management. Esketamine, functioning as an antagonist of the N-Methyl-D-Aspartate receptor, has been validated for pain management in surgical patients and has exhibited effectiveness in depression treatment. Research has suggested that incorporating esketamine into postoperative pain management via pain pumps can lead to improvements in short-term depression and pain outcomes. This study aims to assess the efficacy and safety of administering a single dose of esketamine during cesarean section.

AIM

To investigate the effect of intraoperative injection of esketamine on postoperative analgesia and postoperative rehabilitation after cesarean section.

METHODS

A total of 315 women undergoing elective cesarean section under combined spinal-epidural anesthesia were randomized into three groups: low-dose esketamine (0.15 mg/kg), high-dose esketamine (0.25 mg/kg), and control (saline). Postoperative Visual Analog Scale (VAS) scores were recorded at 6 hours, 12 hours, 24 hours, and 48 hours. Edinburgh Postnatal Depression Scale (EPDS) scores were noted on 2 days, 7 days and 42 days. Ramsay sedation scores were assessed at specified intervals post-injection. Postoperative adverse reactions were also recorded.

RESULTS

Low-dose group and high-dose group compared to control group, had significantly lower postoperative VAS pain scores at 6 hours 12 hours, and 24 hours (P < 0.05), with reduced analgesic usage (P < 0.05). EPDS scores and postpartum depression rates were significantly lower on 2 days and 7 days (P < 0.05). No significant differences in first exhaust and defecation times were observed (P > 0.05), but ambulation times were shorter (P < 0.05). Ramsay scores were higher at 5 minutes, 15 minutes, and upon room exit (P < 0.05). Low-dose group and high-dose group had higher incidences of hallucination, lethargy, and diplopia within 2 hours (P < 0.05), and with low-dose group had lower incidences of hallucination, lethargy, and diplopia than high-dose group (P < 0.05).

CONCLUSION

Esketamine enhances analgesia and postpartum recovery; a 0.15 mg/kg dose is optimal for cesarean sections, balancing efficacy with minimized adverse effects.

Efficacy and safety of ketamine wound infiltration for postoperative pain management: a systematic review, meta-analysis, and trial sequential analysis

Background

Postoperative pain has a huge impact on the patients, families, healthcare practitioners, and healthcare delivery. Pain management with opioid-based analgesics and blind techniques have certain limitations, and ultrasound-based regional analgesia necessitates resources and experience, but ketamine wound infiltration is innovative with few side effects. However, its effectiveness is still uncertain.

Methods

A thorough search was carried out across various databases including PubMed/Medline, Cochrane, ScienceDirect, CINAHL, and LILACS, with no limitations on date or language. Only randomized trials comparing the effectiveness of ketamine wound infiltration for managing postoperative pain were considered for inclusion. Two authors independently conducted data extraction, and the quality of evidence was assessed using GRADEpro software. Trial sequential analysis (TSA) was utilized to ascertain the conclusiveness of the findings.

Results

The review showed that the first analgesic request was higher in the control group as compared to ketamine standard mean difference (SMD)=1.68 (95% CI: 0.95-2.41). The TSA revealed that the cumulative Z-curve crosses both alpha-spending boundaries and reaches the required information size threshold, revealing strong power for current evidence. However, the quality of evidence was moderate.

Conclusion

Despite available evidence, the provision of a firm conclusion is less optimal with current evidence as the included studies were unpowered with low to very low quality of evidence.

Application of ultrasound-guided anterior quadratus lumborum block approach at the lateral supra-arcuate ligament in elderly patients undergoing colorectal cancer surgery

OBJECTIVE

To investigate the anesthetic and analgesic effects of combining general anesthesia with an anterior quadratus lumborum block at the lateral supra-arcuate ligament (SA-AQLB) in elderly patients undergoing laparoscopic radical resection for colorectal cancer (CRC).

METHODS

In this prospective study, 92 elderly patients scheduled for radical CRC resection were randomly divided into three groups: ultrasound-guided SA-AQLB group (SA group, n=31), ultrasound-guided subcostal AQLB (SC-AQLB) group (SC group, n=31), and a general anesthesia-only group (GA group, n=30). Measurements included mean arterial pressure (MAP) and heart rate (HR) at predefined time points, ranging from pre-operation to the end of surgery. Visual analog scale (VAS) pain scores were recorded at multiple postoperative time points up to 48 hours. Additional data collected included intraoperative drug dosages, anesthetic recovery times, patient-controlled intravenous analgesia (PCIA) usage, Lovett muscle strength scores, and early postoperative recovery indicators.

RESULTS

The SA group consistently showed lower MAP and HR compared to the SC group, which in turn was lower than the GA group during the monitored time points (all P<0.05). Sensory block levels were significantly higher in the SA group than that in the SC group (P<0.05). Postoperative VAS scores were also significantly lower in the SA group compared to the other groups at all recorded times (all P<0.05). The SA group required lower doses of propofol, remifentanil, and sufentanil, but higher doses of ephedrine compared to the SC and GA groups (all P<0.05). Anesthesia recovery time was shorter in the SA group, and the total number of PCIA pump presses was least in the SA group (P<0.05). Early ambulation was achieved sooner in the SA and SC groups (P<0.05), and the incidence of nausea and vomiting was reduced in these groups compared to the GA group (P<0.05).

CONCLUSION

General anesthesia combined with ultrasound-guided SA-AQLB provides superior outcomes to general anesthesia alone in elderly patients undergoing laparoscopic CRC surgery. This approach significantly reduces general anesthesia drug dosage, decreases postoperative pain, minimizes perioperative adverse events, and accelerates patient recovery.

Incidence and predictors of postoperative severe acute pain within 24 hours after cesarean section performed under spinal anesthesia at public hospitals in West Shoa, Ethiopia, 2022 prospective cohort study

Background

Acute postoperative pain is common after a caesarean section; the mother suffers severe pain in the first 24 h after the caesarean section compared to spontaneous birth. Failure to discover predictors of pain leads to maternal dissatisfaction, increased expenses, and restricted movement; it increases the risk of deep vein thrombosis, lengthens hospital stays, and decreases social intimacy.

Methods and materials

An institution-based prospective cohort study was conducted among 422 women who went to undergo caesarean sections under spinal anaesthesia at public hospitals in West Shoa from 30 July to 30 October. Participants were selected by systematic random sampling. Data were collected by a structured questionnaire, and the collected data were entered into SPSS version 20 and exported into STATA 64 for analysis. The results were presented in tables and figures. Risk factors were assessed by Poisson regression with a robust standard error.

Results

The overall incidence of severe postoperative pain after a caesarean section performed under spinal anaesthesia within 24 h of follow-up was 50.4% [95% confidence interval (CI): 40.7, 60.1]. Preoperative anxiety risk ratio 1.7 (95% CI: 1.4-2.0), preoperative pain risk ratio 1.3 (95% CI: 1.0-1.48), type of incision risk ratio 11.3 (95% CI: 1.1-1.6), spinal anaesthesia without adjuvants risk ratio 4.1 (95% CI: 1.5-10.9), and duration of surgery risk ratio 1.5 (95% CI: 1.3-1.8) were found to be predictors for postoperative severe acute pain after caesarean section performed under spinal anaesthesia.

Conclusion

In this study, the overall incidence of severe acute pain after a caesarean section under spinal anaesthesia was high. Preoperative fear, duration of the operation, preparatory pain, spinal anaesthesia without the use of adjuvants, and the type of incision were risk factors for severe acute postoperative pain after a caesarean section under spinal anaesthesia.

Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis

Background

Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear.

Methods

Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality.

Results

This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques.

Conclusions

TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.

Efficacy of pharmacological therapies for preventing post-dural puncture headaches in obstetric patients: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache (PDPH) is a major complication of neuraxial anesthesia. PDPH usually occurs after Caesarean section in obstetric patients. The efficacy of prophylactic pharmacological therapies remains controversial.

METHODS

Seven pharmacological therapies (aminophylline (AMP), dexamethasone, gabapentin/pregabalin (GBP/PGB), hydrocortisone, magnesium, ondansetron (OND), and propofol (PPF)), were studied in this Bayesian network meta-analysis. The primary outcome was the cumulative incidence of PDPH within 7 days. Secondary outcomes included the incidence of PDPH at 24 and 48 h postoperatively, the severity of headache in PDPH patients (24, 48, and 72 h postoperatively), and postoperative nausea and vomiting (PONV).

RESULTS

Twenty-two randomized controlled trials with 4,921 pregnant women (2,723 parturients received prophylactic pharmacological therapies) were included. The analyses demonstrated that PPF, OND, and AMP were efficient in decreasing the cumulative incidence of PDPH during the follow-up period compared to the placebo group (OR = 0.19, 95% CI: 0.05 to 0.70; OR = 0.37, 95% CI: 0.16 to 0.87; OR = 0.40, 95% CI: 0.18 to 0.84, respectively). PPF and OND had the lower incidence of PONV compared to the placebo group (OR = 0.07, 95% CI: 0.01 to 0.30; and OR = 0.12, 95% CI: 0.02 to 0.63). No significant difference in other outcomes was found among different therapies.

CONCLUSIONS

Based on available data, PPF, OND, and AMP may have better efficacy in decreasing the incidence of PDPH compared to the placebo group. No significant side effects were revealed. Better-designed studies are requested to verify these conclusions.

Efficacy and safety of wound infiltration modalities for postoperative pain management after cesarean section: a systematic review and network meta-analysis protocol

BACKGROUND

Postoperative pain after a cesarean section has negative consequences for the mother during the postoperative period. Over the years, various postoperative pain management strategies have been used following cesarean section. Opioid-based analgesics and landmark approaches have negative side effects, while ultrasound-based regional analgesia necessitates resources and experience, but various wound infiltration adjuvants are innovative with few side effects and are simple to use. The efficacy and safety of each adjuvant, however, are unknown and require further investigation.

OBJECTIVE

This network meta-analysis is intended to provide the most effective wound infiltration drugs for postoperative management after cesarean section.

METHOD

A comprehensive search will be conducted in PubMed/MEDLINE, Cochrane Library, Science Direct, CINHAL, and LILACS without date and language restrictions. All randomized trials comparing the effectiveness of wound infiltration drugs for postoperative pain management after cesarean section will be included. Data extraction will be conducted independently by two authors. The quality of studies will be evaluated using the Cochrane risk of bias tool, and the overall quality of the evidence will be determined by GRADEpro software.

DISCUSSION

The rate of postoperative acute and chronic pain is very high which has a huge impact on the mother, family, healthcare practitioners, and healthcare delivery. It is a basic human right to give every patient with postoperative pain treatment that is realistic in terms of resources, technique, cost, and adverse event profile.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021268774.

Analgesic effect of ultrasound-guided erector spinae plane block (espb) in general anesthesia for cesarean section: a randomized controlled trial

Background

The analgesic effects of erector spinae plane block in general anesthesia for cesarean section and recovery from puerperae remain unclear.

Methods

Sixty patients with contraindications for spinal anesthesia who required general anesthesia for cesarean section were enrolled and randomly divided into the erector spinal plane block (ESPB) combined with the general anesthesia group (group E) and general anesthesia group (group G). Group E received bilateral ESPB (20 ml of 0.25% ropivacaine on each side) under ultrasound guidance 30 min before general anesthesia. The primary outcomes were the number of patient-controlled intravenous analgesia (PCIA) boluses, and Bruggemann comfort scale (BCS) scores at 2 h, 6 h, 12 h, and 24 h after operation. The second outcome was intraoperative anesthesia dosage, fetal delivery time, puerperae emergence time, visual analog scale (VAS) at 2 h, 6 h, 12 h, and 24 h after operation, and incidence of nausea and vomiting. Heart rate (HR) and mean arterial pressure (MAP) were recorded 10 min before the start of anesthesia (T0), at the induction of anesthesia (T1), at skin incision (T2), and fetal delivery (T3), and immediately after surgery (T4).

Results

The number of PCIA boluses was lower in group E than in group G (P < 0.001). The BCS score increased at 2 h and 6 h after the operation in group E (P < 0.05), while the VAS score significantly decreased in group E at the same time (P < 0.05). Compared with group G, the doses of propofol and remifentanil were significantly decreased in group E (P < 0.001), the emergence time of puerperae was shortened (P = 0.003), and the incidence of nausea and vomiting was significantly decreased (P = 0.014).

Conclusion

Ultrasound-guided ESPB applied to general anesthesia for a cesarean section can significantly reduce the required dose of general anesthetic drugs, shorten the recovery time of the puerperae, and improve postoperative analgesia.

Trial registration:www.clinicaltrials.gov under the number ChiCTR2200056337 (04–02-2022).

Effect of Bilateral Quadratus Lumborum Block Type I on Patient Satisfaction and Incidence of Chronic Postsurgical Pain Following Cesarean Section-A Randomized Controlled Trial

BACKGROUND

Quadratus lumborum block (QLB) provides a reduction in pain scores and opioid consumption after cesarean section (CS). Intrathecal morphine (ITM) is still considered as the gold standard of acute postoperative pain therapy, but it does have some significant side effects. The aim of this clinical study was to evaluate whether performing the quadratus lumborum block type I in patients undergoing CS would be associated with an increased satisfaction of pain therapy and a decreased incidence of chronic postsurgical pain (CPSP).

METHODS

Sixty patients scheduled for elective CS were enrolled. All patients received spinal anesthesia and were randomly allocated to either the QLB group (received bilateral quadratus lumborum block type I with the use of 24 m mL 0.375% ropivacaine) or the control group (received no block). The level of satisfaction was evaluated using a three-step scale and the answers provided in a questionnaire regarding the patients' satisfaction with the method of postoperative pain treatment in the first 48 h. After a 6-month period, all patients were interviewed to evaluate the incidence and possible severity of CPSP.

RESULTS

Satisfaction scores were significantly lower in the QLB group than in the control group (p = 0.0000). There were no significant differences between the QLB and control groups regarding the occurrence of chronic postsurgical pain after 6 months following CS (p = 0.102). No statistical differences between the groups were recorded when we compared the results of the questionnaire after a period of 48 h from CS (the number of participants were limited in number).

CONCLUSIONS

QLB type I is an analgetic option that increased the satisfaction of parturients with pain therapy after CS compared to patients who did not receive the block, and there is a tendency for a lower incidence of CPSP.