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Regional Analgesia Added to General Anesthesia Compared With General Anesthesia Plus Systemic Analgesia for Cardiac Surgery in Children

A Systematic Review and Meta-analysis of Randomized Clinical Trials

Monahan, Ann, MD*; Guay, Joanne, MD†,‡,§; Hajduk, John, BS*; Suresh, Santhanam, MD*

doi: 10.1213/ANE.0000000000003831
Pediatric Anesthesiology: Meta Analysis

BACKGROUND: The aim of this systematic review was to compare the effects of regional analgesic (RA) techniques with systemic analgesia on postoperative pain, nausea and vomiting, resources utilization, reoperation, death, and complications of the analgesic techniques in children undergoing cardiac surgery.

METHODS: A search was done in May 2018 in PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials comparing RA techniques with systemic analgesia. Risks of bias of included trials were judged with the Cochrane tool. Data were analyzed with fixed- (I 2 < 25%) or random-effects models (I 2 ≥ 25%). The quality of evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation working group scale.

RESULTS: We included 14 randomized controlled trials with 605 participants (312 to RA and 293 to the comparator). RA reduces pain up to 24 hours after surgery. At 6–8 hours after surgery, the standardized mean difference was −0.81 (95% confidence interval [CI], −1.22 to −0.40; low-quality evidence). We did not find a difference for nausea and vomiting (risk ratio [RR], 0.89; 95% CI, 0.61–1.31; very low-quality evidence), duration of tracheal intubation (standardized mean difference, −0.18; 95% CI, −0.40 to 0.05; low-quality evidence), intensive care unit length of stay (mean difference, −0.10 hours; 95% CI, −1.31 to 1.12 hours; low-quality evidence), hospital length of stay (mean difference, −0.02 days; 95% CI, −1.16 to 1.12 days; low-quality evidence), reoperation (RR, 0.76; 95% CI, 0.17–3.28; low-quality evidence), death (RR, 0.50; 95% CI, 0.05–4.94; low-quality evidence), and respiratory depression (RR, 2.06; 95% CI, 0.20–21.68; very low-quality evidence). No trial reported signs of local anesthetic toxicity or lasting neurological or infectious complications related to the RA techniques. One trial reported 1 transient ipsilateral episode of diaphragmatic paralysis with intrapleural analgesia that resolved with cessation of local anesthetic administration.

CONCLUSIONS: Compared to systemic analgesia, RA techniques reduce postoperative pain up to 24 hours in children undergoing cardiac surgery. Currently, there is no evidence that RA for pediatric cardiac surgery has any impact on major morbidity and mortality. These results should be interpreted cautiously because they represent a meta-analysis of small and heterogeneous studies. Further studies are needed.

From the *Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois

Department of Anesthesio logy and Critical Care, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada

Department of Anesthesiology, Faculty of Medicine, Univer sity of Sherbrooke, Quebec, Canada

§Teaching and Research Unit, Health Sciences, University of Quebec in Abitibi-Temiscamingue, Quebec, Canada.

Accepted for publication August 24, 2018.

Published ahead of print 24 August 2018.

Funding: University of Sherbrooke, University of Quebec in Abitibi-Temiscam ingue, University Laval, and Northwestern University’s Feinberg School of Medi cine Chicago granted access to electronic databases and major medical journals.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Institutional review board: This is a systematic review: ethics committee approval, informed consents, and original data collection were the responsibility of the authors of each study. Therefore, we can only attest that data are those published by the study authors.

Reprints will not be available from the authors.

Address correspondence to Joanne Guay, MD, Department of Anesthesiology, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1K 2R1, Canada. Address e-mail to joanneguay@bell.net.

© 2019 International Anesthesia Research Society
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