Thoracic Ultrasound-Guided Regional Nerve Blockade for Pain Management Following Open Heart Surgery in Children: A Systematic Review and Network Meta-analysis of Analgesic Efficacy and Impact on Postoperative Opioid Requirements.

A new era of multimodal opioid-sparing pain management strategies has begun, aiming to control pain while limiting the use of opioids and their associated adverse effects. Peripheral nerve blockade, either single-shot or continuous catheter techniques, constitute an important cornerstone of these strategies. This systematic review and network meta-analysis aimed to compare and evaluate the effects of different single-shot ultrasound-guided regional anesthetic techniques on pain control following open cardiac surgical procedures in pediatric patients. A systematic review and comprehensive search were conducted to retrieve available randomized clinical trials focusing on the use of ultrasound-guided regional anesthesia nerve blockade as part of a multimodal analgesia approach in pediatric patients undergoing open cardiac surgery through median sternotomy. Our search was conducted in major databases, including MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials. The main outcomes of interest were perioperative opioid consumption and postoperative pain scores. A total of 1,511 articles were retrieved for the initial screening of titles, with 16 RCTs deemed eligible and included after full-text screening. Eleven different regional nerve blocks were assessed in the studies, including erector spinae plane block (ESPB), thoracic paravertebral block (PVB), deep parasternal block (DPB), superficial parasternal block (SPB), thoracic retrolaminar paravertebral block (TRLB), pectoral nerve block type II (PECS II), and multiple injection costotransverse block (MICB). Compared to no intervention, parasternal blocks particularly DPB and SPB were associated with a significant reduction in both intraoperative and 24-h postoperative fentanyl consumption. Postoperatively, fentanyl consumption was reduced by -4.92 µg/kg (95% CI: [-6.58 to -3.26]) with DPB, -2.54 µg/kg (95% CI: [-4.16 to -0.91]) with SPB, and -5.6 µg/kg (95% CI: [-8.31 to -2.89]) with TRLB. Intraoperatively, SPB reduced fentanyl use by -5.12 µg/kg (95% CI: [-6.8 to -3.43]) and DPB by -4.31 µg/kg (95% CI: [-5.9 to -2.71]). No significant postoperative opioid-sparing effect was observed with other blocks, such as ESPB, PVB, MICB, or PECS II. The pooled estimates showed considerable heterogeneity, with I2 values of 90.9% for intraoperative and 94.7% for postoperative fentanyl consumption. Ultrasound-guided regional anesthesia-particularly parasternal blocks-may offer superior opioid-sparing effects and enhanced recovery in children undergoing open-heart surgery, making them promising adjuncts to multimodal analgesia. In contrast, blocks such as ESPB, PVB, and MICB showed limited benefit for median sternotomy pain. Given the substantial heterogeneity in the current evidence, the routine use of these techniques should be guided by institutional experience and individualized patient factors.