Objective: The deep parasternal intercostal plane (D-PIP) block has been used to relieve pain after cardiac surgery. However, the analgesic efficacy of the D-PIP block in adults undergoing cardiac surgery remains unclear. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing analgesic efficacy of the D-PIP block. PubMed, Embase, CENTRAL, Web of Science, Scopus, ClinicalTrials.gov, and gray literature were searched until February 2026. Trials comparing the D-PIP block with standard or placebo analgesia were pooled using a random-effects model. The primary outcome was 24-h opioid use, expressed as morphine milligram equivalents (MME). Risk of bias was assessed using RoB 2 and certainty using GRADE. Prespecified subgroup analyses, sensitivity analysis, meta-regression for the primary outcome, and trial sequential analysis were performed. Results: Seventeen RCTs (n = 1165) were included. The D-PIP block was associated with a reduction in 24-h opioid consumption versus controls (MD -9.38 mg MME; 95% CI -14.72 to -4.03). Substantial heterogeneity was observed across studies (I2 = 98%). Pain scores at rest and movement were lower at all time points with substantial heterogeneity. Postoperative nausea and vomiting (PONV) incidence was significantly reduced in the D-PIP block group (OR 0.30; 95% CI 0.18-0.52), with no observed between-study heterogeneity (I2 = 0%). Extubation time and ıntensive care unit (ICU) length of stay (LOS) were shorter, while hospital LOS was unchanged. Comparator type explained most heterogeneity. Evidence certainty was low-very low overall and high for PONV. Conclusions: There is very low-certainty evidence supporting a modest reduction in 24-h opioid consumption and early postoperative pain with D-PIP block. In contrast, high-certainty evidence supports a significant reduction in the incidence of PONV. Trial registration: International Prospective Register of Systematic Reviews (PROSPERO: CRD420261298563) on February 1, 2026.
Effects of deep parasternal intercostal plane block on opioid consumption and pain after cardiac surgery: a meta-analysis of randomized controlled trials with meta-regression and trial sequential analysis
De Cassai, Alessandro
2026
Abstract
Objective: The deep parasternal intercostal plane (D-PIP) block has been used to relieve pain after cardiac surgery. However, the analgesic efficacy of the D-PIP block in adults undergoing cardiac surgery remains unclear. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing analgesic efficacy of the D-PIP block. PubMed, Embase, CENTRAL, Web of Science, Scopus, ClinicalTrials.gov, and gray literature were searched until February 2026. Trials comparing the D-PIP block with standard or placebo analgesia were pooled using a random-effects model. The primary outcome was 24-h opioid use, expressed as morphine milligram equivalents (MME). Risk of bias was assessed using RoB 2 and certainty using GRADE. Prespecified subgroup analyses, sensitivity analysis, meta-regression for the primary outcome, and trial sequential analysis were performed. Results: Seventeen RCTs (n = 1165) were included. The D-PIP block was associated with a reduction in 24-h opioid consumption versus controls (MD -9.38 mg MME; 95% CI -14.72 to -4.03). Substantial heterogeneity was observed across studies (I2 = 98%). Pain scores at rest and movement were lower at all time points with substantial heterogeneity. Postoperative nausea and vomiting (PONV) incidence was significantly reduced in the D-PIP block group (OR 0.30; 95% CI 0.18-0.52), with no observed between-study heterogeneity (I2 = 0%). Extubation time and ıntensive care unit (ICU) length of stay (LOS) were shorter, while hospital LOS was unchanged. Comparator type explained most heterogeneity. Evidence certainty was low-very low overall and high for PONV. Conclusions: There is very low-certainty evidence supporting a modest reduction in 24-h opioid consumption and early postoperative pain with D-PIP block. In contrast, high-certainty evidence supports a significant reduction in the incidence of PONV. Trial registration: International Prospective Register of Systematic Reviews (PROSPERO: CRD420261298563) on February 1, 2026.
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