Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

Choongun Ryu, Geun Joo Choi, Yong Hun Jung, Chong Wha Baek, Choon Kyu Cho, Hyun Kang, Choongun Ryu, Geun Joo Choi, Yong Hun Jung, Chong Wha Baek, Choon Kyu Cho, Hyun Kang

Abstract

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (-7.60 (-12.49, -2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

Keywords: cesarean section; nerve block; network meta-analysis; obstetrical analgesia pain; systematic review.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Figures

Figure 1
Figure 1
PRISMA flow diagram of literature search and selection.
Figure 2
Figure 2
Network plots of direct comparisons for all included studies for outcomes. Each postoperative analgesia strategy is depicted by a node that is weighed based on the number of subjects who were randomized to that intervention. Edges between the nodes show the eligible direct comparisons among those interventions, and their width is weighed based on an inverse of the standard error of effect. (A) Pain at rest 6 h after surgery; (B) Postoperative cumulative 24 h morphine equivalent consumption; (C) Pain at rest 24 h after surgery; (D) Dynamic pain at 6 h after surgery; (E) Dynamic pain at 24 h after surgery; (F) The time to first analgesic request.
Figure 3
Figure 3
The confidence intervals (CI) and predictive intervals (PrI) of all outcomes. Each solid black line represents the CI for each comparison, and the red one shows the respective PrI. The blue line is the line of no effect (odds ratio = 1). (A) Pain at rest 6 h after surgery; (B) Postoperative cumulative 24 h morphine equivalent consumption; (C) Pain at rest 24 h after surgery; (D) Dynamic pain at 6 h after surgery; (E) Dynamic pain at 24 h after surgery; (F) The time to first analgesic request.
Figure 4
Figure 4
The expected mean ranking and surface under the cumulative ranking curve (SUCRA) values from a frequentist and Bayesian model of all outcomes. SUCRA is a numeric presentation of the overall ranking. The higher the SUCRA value and the closer to 100%, the better the rank of the intervention. (A) Pain at rest 6 h after surgery; (B) Postoperative cumulative 24 h morphine equivalent consumption; (C) Pain at rest 24 h after surgery; (D) Dynamic pain at 6 h after surgery; (E) Dynamic pain at 24 h after surgery; (F) The time to first analgesic request.

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