Regional Analgesia in Pediatric Cardiothoracic Surgery: A Bayesian Network Meta-Analysis.

Summary

Across 24 RCTs (n=1602), all 13 regional techniques reduced 24-hour opioid consumption after pediatric cardiothoracic surgery. Thoracic retrolaminar block had the largest opioid-sparing effect; time to first rescue was longest with pectoral nerve blocks, and PONV incidence was lowest with epidural and transversus thoracis muscle plane blocks. Heterogeneity limits indirect comparisons.

Key Findings

• Network meta-analysis of 24 RCTs (n=1602) across 13 regional techniques showed universal reduction in 24-hour opioid use.
• Thoracic retrolaminar block ranked best for opioid consumption reduction; pain score advantages were modest except immediately postoperative.
• Time to first rescue analgesic was longest with pectoral nerve blocks; PONV incidence was lowest with epidural and transversus thoracis muscle plane blocks.
• Indirect comparisons were limited by heterogeneity across studies.

Clinical Implications

Consider thoracic retrolaminar block for maximal opioid-sparing and pectoral nerve blocks for prolonged analgesia; epidural and transversus thoracis muscle plane blocks may lower PONV. Individualize technique based on surgical approach, expertise, and risk profile, and standardize outcome tracking.

Limitations

• Heterogeneity in block techniques, dosing, and outcome measures limits precision of indirect comparisons.
• Sparse head-to-head trials between certain blocks; safety outcomes variably reported.

Future Directions

Conduct adequately powered head-to-head RCTs with standardized dosing, sedation, and safety outcomes; evaluate long-term recovery metrics and enhanced recovery pathways.