Systematic review and meta-analysis of the effect of perineural catheters in major lower limb amputations

Ryan Laloo, Graeme K Ambler, Dafydd Locker, Christopher P Twine, David C Bosanquet*

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

Abstract

Objective
Controlling pain after major lower limb amputation (MLLA) is of critical importance to patients and clinicians. The aim of this systematic review and meta-analysis is to assess the effect of perineural catheters (PNCs) on post-operative pain, post-operative morphine requirement, in-hospital mortality, long-term phantom limb pain and chronic stump pain.

Method
A systematic review using PubMed, EMBASE via OVID and the Cochrane library from database inception (1946) to 20th October 2020 was performed according to PRISMA guidelines. Studies involving patients undergoing MLLA which reported on post-operative morphine requirement, pain scores, in-hospital mortality, phantom limb pain (PLP) and chronic stump pain were included. Studies comparing PNC use to epidural or wound site local anaesthetic infusions were excluded. Outcome data were extracted from individual studies and meta-analysis performed using a random-effects (Mantel-Haenszel) model for dichotomous data using an odds ratio (OR) summary statistic with 95% confidence intervals (CI), and with an inverse-variance random-effects model for continuous data using a standardised mean difference (SMD) summary statistic with 95% CIs. Sensitivity analyses were performed for post-operative pain scores and post-operative morphine requirement. Study quality was assessed using the Downs and Black score, and outcomes assessed using the GRADE tool.

Results
Ten studies reporting on 731 patients were included with 350 patients receiving a PNC and 381 receiving standard care. PNC use is associated with a reduction in post-operative pain (SMD -0.30, 95% CI -0.58 to -0.01, p=.04, I2=54%, GRADE quality of evidence: low) and post-operative morphine requirements (SMD -0.63, 95% CI -1.03 to -0.23, p=.002, I2=75%, GRADE quality of evidence: moderate) although the effect of PNC on reduced post-operative morphine requirements is lost on sensitivity analysis of randomised trials only (p=.40). No demonstrable effect was found on in-hospital mortality, PLP or chronic stump pain (GRADE quality of evidence: low).

Conclusion
PNC usage in amputees is associated with a significant reduction in post-operative pain scores and post-operative morphine requirements although this latter finding is lost on sensitivity analysis of randomised trials only.
Original languageEnglish
JournalEuropean Journal of Vascular and Endovascular Surgery
Publication statusAccepted/In press - 8 Mar 2021

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