Erector spinae plane block versus caudal epidural block in pediatric surgery: a systematic review and meta-analysis of randomized clinical trials
Bloqueio do plano do músculo eretor da espinha versus bloqueio epidural caudal em cirurgia pediátrica: uma revisão sistemática e meta-análise de ensaios clínicos randomizados
Barbara Bombassaro Masiero, Deivyd Cavalcante, Fatemeh Akbarpoor, Capela António Dicazeco Pascoal, Lubna Al-Sharif, Fellipe Feijó Halfeld, Lucas Cael Azevedo Ramos Bendaham, Patricia Viana, Jesslyn N. Haryianto, Maria Luiza de Souza Rasia, Mariana Copetti de Almeida Cunha, Ana Djulia Tesche, Júlia Caletti Roth de Oliveira, Rafael Arsky Lombardi
Abstract
Background
Caudal Epidural Block (CEB) is a well-established regional anesthesia technique for abdominal and sub-abdominal pediatric surgeries. However, it has a short duration, often leading to additional analgesic administration. Erector Spinae Plane Block (ESPB), for instance, is an emerging technique that, like CEB, provides analgesic effect to a specific dermatome of the body during surgery and in the postoperative period. Therefore, we performed this systematic review with meta-analysis to compare both techniques.
Métodos
We searched PubMed, Embase and Cochrane Central for Randomized Controlled Trials (RCTs) comparing ESPB versus CEB in pediatric patients undergoing abdominal and sub-abdominal surgeries. The primary outcome was the time to first analgesic request. Secondary outcomes were I) FLACC score; II) Postoperative nausea and vomiting, and III) Urinary retention.
Resultados
Nine randomized controlled trials encompassing 507 patients were included in this analysis (1‒9). The patients were predominantly male and under 10 years of age. There was an equal distribution between the two groups regarding the number of patients and patients’ baseline characteristics. The main results were: time to first analgesic request (MD = 3.71; 95% CI: -1.88–9.29; I2 = 99%; p = 0.19); FLACC scores at 2 hours (MD = 0.15; 95% CI: -0.30–0.59; I2 = 0%; p = 0.52); FLACC scores at 24 hours (MD = -0.17; 95% CI: -0.39–0.05; I2 = 41%; I2 = 41%; p = 0.13); urinary retention events (RR = 0.12; 95% CI: 0.02–0.94; I2 = 0%; p = 0.04); and Postoperative Nausea and Vomiting (PONV) which was null in both groups in three studies. However, it is important to clarify that some limitations were identified, such as significant heterogeneity in the following outcomes: time to first analgesic request and FLACC score at 24h, possibly due to different age groups, different types of surgeries, different background analgesia administration, and a relatively small sample size. As for the risk of bias, two studies were found to have some concerns in “bias due to deviations from intended interventions” (8,9).
Conclusão
Our findings suggest that the administration of ESPB did not statistically differ from CEB regarding the time to first analgesic request. FLACC scores also did not show a statistically significant difference between groups. The ESPB group, however, experienced minor urinary retention events compared to the CEB group.
Quality of evidence
According to the GRADE assessment, all outcomes evaluated in this study were classified as high-quality evidence. Quality assessment is detailed in Supplementary Table 1.
Keywords
Resumo
Introdução
O CEB é uma técnica de anestesia regional bem estabelecida para cirurgias pediátricas abdominais e subabdominais. No entanto, possui curta duração, frequentemente levando à administração adicional de analgésicos. O ESPB, por exemplo, é uma técnica emergente que, assim como o CEB, proporciona efeito analgésico para um dermátomo específico do corpo durante a cirurgia e no período pós-operatório. Portanto, realizamos esta revisão sistemática com meta-análise para comparar ambas as técnicas.
Métodos
Realizamos buscas no PubMed, Embase e Cochrane Central por RCTs comparando ESPB versus CEB em pacientes pediátricos submetidos a cirurgias abdominais e subabdominais. O desfecho primário foi o tempo até o primeiro pedido de analgésico. Os desfechos secundários foram: I) escore FLACC; II) PONV; e III) retenção urinária.
Resultados
Nove RCTs abrangendo 507 pacientes foram incluídos nesta análise (1‒9). Os pacientes eram predominantemente do sexo masculino e com menos de 10 anos de idade. Houve distribuição equilibrada entre os dois grupos em relação ao número de pacientes e às características basais. Os principais resultados foram: tempo até o primeiro pedido de analgésico (MD = 3,71; IC 95%: -1,88 a 9,29; I² = 99%; p = 0,19); escores FLACC às 2 horas (MD = 0,15; IC 95%: -0,30 a 0,59; I² = 0%; p = 0,52); escores FLACC às 24 horas (MD = -0,17; IC 95%: -0,39 a 0,05; I² = 41%; p = 0,13); eventos de retenção urinária (RR = 0,12; IC 95%: 0,02 a 0,94; I² = 0%; p = 0,04); e PONV, que foi nulo em ambos os grupos em três estudos. Entretanto, é importante esclarecer que foram identificadas algumas limitações, como heterogeneidade significativa nos seguintes desfechos: tempo até o primeiro pedido de analgésico e escore FLACC às 24h, possivelmente devido a diferentes faixas etárias, tipos variados de cirurgias, administração distinta de analgesia basal e tamanho relativamente pequeno da amostra. Quanto ao risco de viés, dois estudos apresentaram algumas preocupações em “viés devido a desvios das intervenções pretendidas” (8,9).
Conclusão
Nossos achados sugerem que a administração de ESPB não difere estatisticamente do CEB em relação ao tempo até o primeiro pedido de analgésico. Os escores FLACC também não mostraram diferença estatisticamente significativa entre os grupos. O grupo ESPB, contudo, apresentou menos eventos de retenção urinária em comparação ao grupo CEB.
Qualidade da evidência
De acordo com a avaliação GRADE, todos os desfechos avaliados neste estudo foram classificados como evidência de alta qualidade. A avaliação da qualidade está detalhada na Tabela Suplementar 1.
Palavras-chave
References
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Submitted date:
10/14/2024
Accepted date:
05/01/2025
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