<scp>PROSPECT</scp> guideline for elective caesarean section: an update
Eva Roofthooft, G. P. Joshi, Narinder Rawal, Marc Van de Velde, the PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy
Abstract
In 2021, the PROSPECT working group published evidence-based recommendations for the management of post-caesarean section pain [1]. To update the recommendations, the PROSPECT group performed a literature search on 13 February 2023 to include studies that were published from 15 October 2020 to 12 February 2023 and identified 287 trials. Following removal of duplicates and after careful assessment of titles, abstracts and full manuscripts, 36 randomised controlled trials and seven meta-analyses remained. Following critical analysis of the included trials, most recommendations from the 2021 publication remained unaltered. However, we felt it necessary to emphasise a few important analgesic interventions. First, the recommendation on the benefits of dexamethasone is reinforced. Indeed, a systematic review [2] confirm our recommendation of administering a single dose of dexamethasone. Intravenous dexamethasone was associated with reduced pain scores, longer times to first analgesic request and reduced rescue opioid consumption. Second, the analgesic effects of wound infiltration were also reinforced. Two meta-analyses compared wound infiltration with other regional techniques and showed that wound infiltration was equally effective [3, 4]. In addition, a network meta-analysis comparing wound infiltration with other regional techniques provided strong evidence of similar pain score reductions and opioid-sparing effects [5]. Third, there is now evidence from a meta-analysis and trial sequential analysis that the ilioinguinal iliohypogastric block is effective in reducing postoperative opioid consumption [6]. Finally, the PROSPECT group now recommends erector spinae plane block for analgesia after caesarean section, as an alternative to long-acting neuraxial opioids. Erector spinae plane block is recommended based on new randomised controlled trials and a systematic review [7], as are transversus abdominis plane block, quadratus lumborum block and continuous wound infiltration. The updated recommendations are listed in Box 1.