Comparison of postoperative pain in children after maintenance anaesthesia with propofol or sevoflurane
A systematic review and meta-analysis
British Journal of Anaesthesia
Submitted August 2024 by Dr Rory Walsh
Read by 304 Journal Watch subscribers
Study Overview:
This was a systematic review and meta-analysis of 13 randomised controlled trials that compared post-operative pain between sevoflurane and propofol anaesthesia in children.
Methods:
The primary outcome was overall post-operative pain - assessed via the need for rescue analgesia or pain scores.
Secondary outcomes were:
(1) pain scores from pain assessment tools only, and
(2) the requirement of rescue analgesia only
Findings:
For the primary outcome the meta-analysis showed higher odds of post-operative pain in the sevoflurane group vs the propofol group (OR 1.88, 95% confidence interval 1.12 – 3.15).
In studies reporting pain scores only, the sevoflurane group had higher odds of post-operative pain (OR 3.18, 95% CI 1.83 – 5.53).
In studies reporting rescue analgesia requirements the sevoflurane group had higher odds of post-operative pain (OR 1.6, 95% CI 0.89 – 2.88).
Hence the review suggests that children maintained on sevoflurane are at greater risk of post-operative pain than those maintained on propofol. However, the authors recommend that further study is warranted.
Take Home Messages and Commentary
1) Does the study address a relevant and / or important question?
Identifying whether propofol or sevoflurane is associated with superior post-operative pain control would help with agent selection - especially for patients at risk of significant post-operative pain.
2) Is there any recent research, evidence, or study on a similar question?
To date it has been unclear whether post-operative pain is significantly affected by the choice of propofol or sevoflurane anaesthesia.
In 2016 Peng et al published a meta-analysis of adult RCTs. This analysis found that compared to volatile anaesthesia, propofol anaesthesia was associated with reduced post-operative pain. However, due to substantial heterogeneity of the included trials, the authors could not draw firm conclusions and recommended further large RCTs be performed. There have been no prior meta-analyses of paediatric trials where post-operative pain was a primary outcome.
3) What are the strengths of the study?
The main strengths of the current meta-analysis is that it included a large number of studies covering a broad range of surgical procedures.
4) What are the limitations of the study?
The authors acknowledged moderately high heterogeneity among the studies, and that some studies did not report the use of intra-operative analgesia. Controlling for intra-operative analgesia would seem to be fundamental in an RCT assessing post-operative pain.
5) Is the study applicable to our practice or to our population?
The included studies incorporated a broad range of paediatric surgical procedures with patient ages ranging from 2 months to 12 years. However, there is limited information regarding the intraoperative analgesia, regional blocks or local anaesthetic used. This might affect applicability to local practice.
