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\begin{document}

\title{Effects of ultrasound-guided regional anesthesia in cardiac surgery: A
systematic review and network meta-analysis}



\author[1]{Burhan Dost}%
\author[2]{Alessandro De Cassai}%
\author[3]{Eleonora Balzani}%
\author[4]{Serkan Tulgar}%
\author[5]{Ali Ahiskalioglu}%
\affil[1]{Ondokuz Mayis Universitesi Tip Fakultesi}%
\affil[2]{Azienda Ospedale Universita Padova}%
\affil[3]{Universita degli Studi di Torino Dipartimento di Scienze Chirurgiche}%
\affil[4]{Samsun Egitim ve Arastirma Hastanesi}%
\affil[5]{Ataturk Universitesi Tip Fakultesi}%


\vspace{-1em}



  
  \date{May 18, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
\textbf{Background and aim} The objective of this systematic review and
network meta-analysis was to compare the effects of single-shot
ultrasound-guided regional anesthesia techniques on postoperative opioid
consumption in patients undergoing open cardiac surgery.
\textbf{Methods} This systematic review and network meta-analysis
involved cardiac surgical patients (age \textgreater{}18 y) requiring
median sternotomy. We searched PubMed, EMBASE, The Cochrane Central
Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The
effects of the single-shot ultrasound-guided regional anesthesia
technique were compared with those of placebo and no intervention.
\textbf{Results} The primary outcome was opioid consumption during the
first 24 h after surgery. The secondary outcomes were pain after
extubation at 12 and 24 h, postoperative nausea and vomiting, extubation
time, intensive care unit discharge time, and length of hospital stay.
Fifteen studies with 849 patients were included. The regional anesthesia
techniques included pecto-intercostal fascial block, transversus
thoracis muscle plane block, erector spinae plane (ESP) block, and
pectoralis nerve block I. All the regional anesthesia techniques
included significantly reduced postoperative opioid consumption at 24
hours, expressed as morphine milligram equivalents (MME). The ESP block
was the most effective treatment (-22.93 MME {[}-34.29;-11.56{]}).
\textbf{Conclusions} In this meta-analysis, we concluded that fascial
plane blocks were better than placebo when evaluating 24 hr MMEs.
However, it is still challenging to determine which is better, given the
paucity of studies available in the literature. More randomized
controlled trials are required to determine which regional anesthesia
technique is better.%
\end{abstract}%



\sloppy


\textbf{Effects of ultrasound-guided regional anesthesia in cardiac
surgery: A systematic}

\textbf{review and network meta-analysis}

\textbf{Running title:} Regional anesthesia in cardiac surgery

Burhan Dost \textsuperscript{1}, Alessandro De
Cassai\textsuperscript{2}, Eleonora Balzani *\textsuperscript{3}, Serkan
Tulgar \textsuperscript{4}, Ali Ahiskalioglu \textsuperscript{5,6}

1 Department of Anesthesiology and Reanimation, Ondokuz Mayis University
Faculty of Medicine, Samsun, Turkey

2 UOC Anesthesia and Intensive Care Unit, University Hospital of Padua,
Padua, Italy

3 Department of Surgical Science, University of Turin, Torino, Italy

4 Department of Anesthesiology and Reanimation, Samsun Training and
Research Hospital, Samsun University Faculty of Medicine, Samsun,
Turkey.

5 Department of Anesthesiology and Reanimation, Ataturk University
School of Medicine, Erzurum, Turkey.

6 Clinical Research, Development and Design Application and Research
Center, Ataturk University School of Medicine, Erzurum, Turkey.

\textbf{Corresponding author}

Eleonora Balzani, MD, Department of Medicine and Surgery, University of
Turin, Via Verdi, 8 - 10124 Torino, Italy (e-mail:
eleonora.balzani2@gmail.com)

Phone: + 39 011 633 5500

Email: eleonora.balzani2@gmail.com

\textbf{Author contributions}

Author Contributions: Conceptualization, B.D. and A.A.; methodology,
A.D.C, and E.B.; software, A.D.C..; validation, S.T. and A.A.;formal
analysis, A.D.C. and E.B.; investigation, B.D. and A.A.; resources,
B.D.; data curation, B.D. and A.A.; writing---original draft
preparation, B.D., A.D.C., E.B., S.T.; writing---review and editing,
B.D., A.D.C., E.B., S.T., and A.A.; project administration, B.D. All
authors have read and agreed to the published version of the manuscript.

\textbf{Data availability statement}

N/A

\textbf{Funding statement}

None

\textbf{Conflict of interest disclosure}

None

\textbf{Institutional Review Board approval or waiver}

N/A

\textbf{Patient consent statement}

N/A

\textbf{Permission to reproduce material from other sources}

N/A

\textbf{Acknowledgments}

None

\textbf{Registiration}

PROSPERO; CRD42022315497.

\textbf{ABSTRACT}

\textbf{Background and aim}

The objective of this systematic review and network meta-analysis was to
compare the effects of single-shot ultrasound-guided regional anesthesia
techniques on postoperative opioid consumption in patients undergoing
open cardiac surgery.

\textbf{Methods}

This systematic review and network meta-analysis involved cardiac
surgical patients (age \textgreater{}18 y) requiring median sternotomy.
We searched PubMed, EMBASE, The Cochrane Central Register of Controlled
Trials (CENTRAL), Scopus, and Web of Science. The effects of the
single-shot ultrasound-guided regional anesthesia technique were
compared with those of placebo and no intervention.

\textbf{Results}

The primary outcome was opioid consumption during the first 24 h after
surgery. The secondary outcomes were pain after extubation at 12 and 24
h, postoperative nausea and vomiting, extubation time, intensive care
unit discharge time, and length of hospital stay. Fifteen studies with
849 patients were included. The regional anesthesia techniques included
pecto-intercostal fascial block, transversus thoracis muscle plane
block, erector spinae plane (ESP) block, and pectoralis nerve block I.
All the regional anesthesia techniques included significantly reduced
postoperative opioid consumption at 24 hours, expressed as morphine
milligram equivalents (MME). The ESP block was the most effective
treatment (-22.93 MME {[}-34.29;-11.56{]}).

\textbf{Conclusions}

In this meta-analysis, we concluded that fascial plane blocks were
better than placebo when

evaluating 24 hr MMEs. However, it is still challenging to determine
which is better, given the paucity of studies available in the
literature. More randomized controlled trials are required to determine
which regional anesthesia technique is better.

\textbf{Keywords:} Cardiac surgery, Meta-analysis, Regional Anesthesia,
Ultrasound

\textbf{INTRODUCTION}

Cardiovascular diseases are prevalent in the general population globally
and affect most of the older adult population. With the increase in
longevity in recent years, there has been a considerable increase in
surgical procedures related to cardiovascular
diseases.\textsuperscript{1} The Society for Enhanced Recovery after
Cardiac Surgery (ERAS\selectlanguage{ngerman}® Cardiac) recommends effective perioperative pain
control to improve patient outcomes. The goals of pain management are to
alleviate suffering, gain early mobilization after surgery, reduce
hospital stay, and improve patient satisfaction and functional
recovery.\textsuperscript{2}

The pain was most intense during the first two days after cardiac
surgery and subsequently decreased. Inadequate acute postoperative pain
control after cardiac surgery may result in chronic pain, which affects
the quality of life. Seventeen percent of patients report chronic pain
one year after cardiac surgery.\textsuperscript{3} Inadequate acute
postoperative pain control can also increase pulmonary complications due
to the inability to breathe, cough, and clear
secretions.\textsuperscript{4} The leading causes of pain in cardiac
surgery procedures are sternotomy/thoracotomy incisions, chest
retraction, internal mammary artery harvesting, chest tubes, sternal
wires, and visceral pain.\textsuperscript{5} Sternal pain is transmitted
by the intercostal nerves raised from the T2-T6 spinal nerve
roots.\textsuperscript{6} The mechanism of cardiovascular surgical pain
can be represented as neuropathic and somatic pain, as it is commonly
identical to postoperative pain.

The use of multimodal perioperative pain management strategies in
current anesthesia practices is recommended instead of systemic
analgesics or opioids only. In addition to pharmacological therapies,
regional anesthesia (RA) interventions should be considered for every
patient. The limited use of neuraxial procedures or paravertebral block
in cardiac surgery with potential hemodynamic instability, full
heparinization, and hemodilution is challenging for
anesthesiologists.\textsuperscript{7} Chest wall fascial plane blocks
are increasingly used to provide postoperative pain relief and decrease
opioid consumption in patients undergoing cardiac surgery and show good
results with fewer side effects when compared to central blocks, such as
thoracic epidural analgesia or systemic analgesia, considering patients
at high cardiovascular risk. In recent years, the development of new RA
techniques, due to the role of ultrasonography, has enabled several new
fascial plane blocks.\textsuperscript{8} Fascial plane blocks are often
technically more accessible and less invasive than neuraxial analgesia
for cardiac surgery. Several randomized controlled trials have compared
the associations between regional anesthesia techniques and
postoperative opioid consumption, pain scores, and complications, but
the results are inconsistent for cardiac surgery.\textsuperscript{9} In
addition, there are not enough studies comparing the effects of
different fascial plane blocks in this subset of patients; hence, it
would be of relevance to examine this aspect.

We hypothesized that the use of single-shot RA techniques would be
associated with superior pain control and reductions in 24-h
postoperative opioid consumption compared with placebo or systemic
analgesics alone. This systematic review and network meta-analysis (NMA)
aimed to compare the effects of single-shot ultrasound-guided RA
techniques on open cardiac surgery.

\textbf{METHODS}

We pre-registered the protocol on a register (PROSPERO; CRD42022315497),
and the manuscript was prepared according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement
Guidelines.\textsuperscript{10}

\textbf{Eligibility Criteria}

To determine study eligibility, we used the following PICOS criteria:
cardiac surgical patients (age \textgreater{}18 y) requiring median
sternotomy (P), single-shot ultrasound-guided RA technique (I), placebo
or no intervention (C), 24-h postoperative opioid consumption, pain
after extubation 12 h, pain after extubation 24 h, postoperative nausea
and vomiting (PONV), extubation time, intensive care unit discharge
time, hospital length of stay (LOS) (O), and randomized controlled
trials (RCTs) (S).

Studies were excluded if they met the following additional criteria: 1)
the use of RA techniques in combination, 2) the use of continuous RA
techniques, 3) minimally invasive cardiac surgery, and 4) off-pump
cardiac surgery.

\textbf{Search strategy}

We performed a systematic search of the medical literature for the
identification, screening, and inclusion of articles in the following
databases: PubMed, EMBASE, The Cochrane Central Register of Controlled
Trials (CENTRAL), Scopus, and Web of Science (last search update April
15, 2022) by two authors (BD and EB) without any restrictions on the
language, status, and year of publication. The snowball method was used
to review the references included in other studies. Specific information
regarding our search strategy is provided in the Supplementary Material
(Supplementary Material, file 1).

\textbf{Study selection}

Initial screening of titles and abstracts was independently performed by
two authors (AA and ST) to select relevant and irrelevant manuscripts,
and in case of disagreement, a third author (BD) mediated the
discussion.

\textbf{Data extraction and data retrieval}

After identifying the studies that met the inclusion criteria, all the
authors manually reviewed and assessed each of the included studies;
however, all the extracted data were manually checked by at least two
authors.

All opioids were converted to intravenous morphine using the GlobalRPh
morphine equivalent calculator, considering a 0\% cross-tolerance
modifier (http://www.globalrph.com/narcotic).

\textbf{Quality assessment and certainty of evidence assessment}

Two researchers independently evaluated the quality of included RCTs by
using the Risk of Bias (RoB) 2 Tool.\textsuperscript{11} The RoB2 tool
uses a three-point scale, including ``low risk of bias,'' ``some
concerns,'' and ``high risk of bias,'' by investigating five domains at
risk of bias. Disagreements were resolved by discussion; if no agreement
was reached after discussion, a third researcher (BD) was involved to
correctly assign the risk of bias.

The grading of recommendations assessment, development, and evaluation
(GRADE) system was used to rate the certainty and, therefore, the
quality of evidence for each outcome.\textsuperscript{12}

\textbf{Statistical methods}

We used R version 4.1 (R Foundation for Statistical Computing, Vienna,
Austria) and the Facenetmeta package to perform the data meta-analysis.

The treatment effect on continuous outcomes was expressed as the mean
difference (MD) with 95\% CI. The treatment effect for dichotomous
outcomes was expressed as an odds ratio (OR) with a 95\% confidence
interval (CI). The methods were ranked based on the frequentist analog
of the surface under the cumulative ranking curve
(SUCRA).\textsuperscript{13} The SUCRA assigns numbers ranging from 0 to
1 to each treatment. A higher SUCRA indicates a higher likelihood that a
specific treatment is most suitable for the investigated outcome.
Comparing the obtained SUCRA for different treatments permits the
creation of a ranking among treatments. Where necessary, we converted
the reported median and interquartile range to the estimated mean and
standard deviation (SD) using the Hozo method.\textsuperscript{14}

When multiple local anesthetic dosing regimens were employed in the same
study for the same block, the means and standard deviations were
combined.

\textbf{Inconsistency, heterogeneity, and Publication bias analysis}

For assessment of study heterogeneity, the Chi-squared test and
I\textsuperscript{2}-statistic were used (considering
I\textsuperscript{2} values as follows: low: \textless{} 25\%,
moderate:25\% to 50\%, or high: \textgreater{}
50\%).\textsuperscript{15} Within design heterogeneity and between
design inconsistency were evaluated using Cochrane's Q. A random-effects
model was preferred, regardless of both inconsistency and heterogeneity.
Publication bias was evaluated by visual inspection of funnel plots and
Egger's test (p-value \textless{} 0.05, indicating a possible
publication bias) (Supplementary Material, File 2)

\textbf{RESULTS}

\textbf{Study selection and data retrieval}

The search results are shown in the PRISMA diagram (Fig. 1). The initial
screening identified 611 studies. Of these, 584 search results were
excluded during the preliminary screening because they were unrelated or
duplicated. The remaining 27 full-text manuscripts were retrieved, and a
further 12 studies were excluded based on our inclusion and exclusion
criteria. Fifteen studies evaluating four different regional anesthesia
techniques were finally included for quantitative and qualitative
analysis.\textsuperscript{16-30}

The regional and local anesthesia techniques included the
pecto-intercostal fascial (PIF), transversus thoracis muscle plane
(TTMP), erector spinae plane (ESP), and pectoralis nerve (PECS) I blocks
( Fig. 2).

The 15 included studies were randomized to 849 patients. Of these, 405
patients were allocated to placebo or no intervention, 183 to the PIF
block, 148 to the TTMP block, 93 to the ESP block, and 20 to the PECS I
block.

According to the risk of bias evaluation, four studies had a low risk of
bias, two had a high risk of bias, and some concerns arose with the
remaining studies (Supplementary Material, File 2). The criteria that
guided us in assigning the risk of bias judgments are available as
supplementary material (Supplementary Material, File 3).

\textbf{Outcomes}

The results are graphically depicted in Fig. 2 and 3 for the main
outcome and summarized in Table 1 for all outcomes; these results are
based on the combination of direct and indirect evidence. Direct
evidence is obtained from direct comparisons (e.g., A vs. B), while
indirect evidence arises from indirect comparisons (e.g., A vs. B
indirect evidence is provided by direct comparison of A vs. C and B vs.
C).

\textbf{Primary Outcome}

\textbf{Postoperative opioid consumption at 24 hours}

The postoperative opioid consumption was evaluated in 13 studies. There
was an ESP block group in two studies, a PIF block group in six studies,
and a TTMP block in five studies. No data were available on the PECS I
block for this outcome.

All the RA techniques included were statistically significant in
reducing postoperative opioid consumption at 24 hours, expressed as
morphine milligram equivalents (MME). The ESP block was the most
effective treatment (-22.93 MME {[}-34.29;-11.56{]}). A forest plot of
this outcome is shown in Fig. 3.

Using the GRADE assessment, the quality of evidence was rated low or
very low (Table 2).

\textbf{Secondary Outcomes}

\textbf{Pain at 12 and 24 hours}

All the identified RA techniques were evaluated for this outcome.

Pain at 12 postoperative hours was evaluated for the ESP block in three
studies, PIF block in four studies, TTMP block in five studies, and PECS
I block in one study. Pain at 24 postoperative hours was evaluated in
two studies with an ESP block group, in four studies with a PIF block
group, in six studies with a TTMP block group, and one study with a PECS
I block group. However, there were no statistically significant
differences in any of these comparisons.

\textbf{Time to extubation}

This outcome was evaluated in nine studies. There was an ESP block group
in two studies, a PIF block group in three studies, and a TTMP block in
five studies. No data were available on the PECS I block for this
outcome.

The PIF block was the only RA technique with statistically significant
results; however, surprisingly, the required time to extubate the
patient was longer for patients receiving this block 2.14 h (0.22 h to
4.06 h) when compared to placebo or no intervention.

\textbf{Intensive care unit length of stay}

Nine studies reported results for this outcome; two studies reported
data for the ESP block, four studies for the PIF block, five studies for
the TTMP block, and no data for the PECS I block.

Regarding ICU LOS, only the ESP block was significantly associated with
a reduction in the LOS of -1.10 days (-2.01 -0.18)

\textbf{Hospital length of stay}

We only retrieved data for the PIF and TTMP blocks for hospital length
of stay in comparison with placebo/no intervention. However, none of the
RA techniques showed statistically significant differences.

\textbf{Postoperative nausea and vomiting}

Postoperative nausea and vomiting were evaluated for only six studies,
and two studies reported this outcome for each block (ESP, PIF, and
TTMP) but not the PECS I block. However, none of these RA techniques had
a statistically significant result when compared with placebo.

\textbf{DISCUSSION}

In this systematic review and NMA, we aimed to evaluate the effects of
single-shot ultrasound-guided RA techniques on 24-hr MME consumption in
patients undergoing open cardiac surgery. Our NMA showed a statistically
significant reduction in MMEs for the ESP, TTMP, and PIF blocks compared
with placebo. No evidence was found for the PECS I block.

The efficacy of the ESP block in cardiac surgery has been extensively
proven.\textsuperscript{21,31} There is evidence in the literature that
this block has good analgesic effects in sternotomy cardiac surgery. In
our NMA, we can infer that the ESP block has greater efficacy than
placebo; compared with other blocks, it seems to be more effective than
the PIF block. No differences were found between the ESP and TTMP blocks
(Table 3). As in other fascial plane block studies, dermatomal analysis
is not performed in studies evaluating the effectiveness of the ESP
block, and the component of pain that is blocked has not been
established. As mentioned before, pain in cardiac surgery may be caused
by several factors, and the effectiveness of the ESP block may be due to
blocking of the median sternotomy incision pain or acting in other ways.
In future studies, questioning the exact location of pain and revealing
the source by dermatome analysis will shed light on the blocks to be
preferred and the combinations may provide postsurgical analgesia in
cardiac sternotomy surgery.

The PIF and TTMP blocks are two new truncal fascial plane blocks that
aim to anesthetize the anterior cutaneous branches of the thoracic
intercostal nerves (Th2-6). Although these blocks have only recently
been discovered, a 2021 ASRA-ESRA consensus renamed them superficial and
deep parasternal intercostal plane blocks, respectively, to better
define them anatomically.\textsuperscript{32} It was shown to be
effective in postoperative pain management in the context of cardiac
sternotomy surgery.\textsuperscript{26} The TTMP block in our NMA would
seem to have a benefit in terms of 24-hr MME consumption compared with
placebo, not so evident is the benefit when compared directly to PIF
block and indirectly to ESP block (Table 3). The PIF block is the first
among these blocks to be described as effective in the literature
regarding the use of sternotomy cardiac surgery.\textsuperscript{33} In
this NMA, its use seems to be the most questioned, as there does not
appear to be a clear benefit in terms of reduction in MMEs when compared
to placebo (Table 3).

When we evaluated the other outcomes, the PIF block seemed to be the
only one to increase extubation time with a statistically significant
result by increasing the time. This result is highly influenced by one
study\textsuperscript{16} that showed a high difference among the
groups. Therefore, further evidence for this outcome is warranted.

The impact of the ESP and TTMP blocks on ICU LOS is significant and
favorable. Another NMA that evaluates the effects of fascial blocks in
cardiac surgery can be found in the literature, but this one does not
discriminate between sternotomy and non-sternotomy procedures, and this
is a major limitation, as these are quite different procedures in terms
of postoperative pain compared to each
other.\textsuperscript{34}In-hospital LOS is assessed only for PIF and
TTMP blocks and is not statistically significant.

While there are no clear data to define the minimal clinically important
difference (MCID) for 24-h opioid consumption in the literature
referring to sternotomy cardiac surgery procedures, it is difficult to
determine the magnitude of the analgesic effect of fascial blocks in
this population. Hussain et al. evaluated breast cancer operations and
considered reductions equivalent to 10 mg i.v. morphine reduction to be
clinically important.\textsuperscript{35} Aware of the differences in
the analgesic setting, considering the different structures involved in
the surgical procedure, and comparing this to our results, we can assume
that the ESP and TTMP blocks are effective.

This study has several limitations. First, the included studies are few,
and most of them compared the blocks with placebo, making indirect
comparison essential. In addition, publication bias assumed by Egger's
test makes indirect comparison possible for 24 hr MMEs, which is more
difficult to estimate for other outcomes. Therefore, there is reduced
consistency for untestable assumptions. Second, the heterogeneity in our
analysis was very high. We attribute this to the fact that these blocks
are relatively new, have been used in clinical settings in the last five
years, and are being developed daily. Third, it should be specified that
a placebo is often defined as an injection of saline instead of a local
anesthetic, but sometimes studies represent placebo as no injection or
medication. Fourth, the volume, type, and concentration of the local
anesthetic administered varied. In some trials, adjuncts were added to
the local anesthetic.

\textbf{Conclusions}

Ultrasound-guided regional anesthesia is certainly a key analgesic
technique in the context of cardiac surgery, as it spares opioids,
reducing their neurological and hemodynamic impact but without
interfering with the coagulative status of the patient, allowing its use
in non-elective procedures. Although there are several fascial blocks,
no single technique is better than the others. In this meta-analysis, we
concluded that ESP, PIF, and TTMP blocks were better than placebo when
evaluating 24-hr MMEs. However, it is still challenging to determine
which is better, given the lack of studies available in the literature.
More high-quality RCTs are required to determine which regional
anesthesia technique is better. An MCID should also be determined in
cardiac surgery to quantify the effect of individual blocks compared
with the standard of care.

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Block (PIFB) as a Novel Technique for Postoperative Pain Management in
Patients Undergoing Cardiac Surgery. \emph{J Cardiothorac Vasc
Anesth.}2021;35(1):116-122.

19. Khera T, Murugappan KR, Leibowitz A, et al. Ultrasound-Guided
Pecto-Intercostal Fascial Block for Postoperative Pain Management in
Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled
Trial.\emph{J Cardiothorac Vasc Anesth.} 2021;35(3):896-903.

20. Aydin ME, Ahiskalioglu A, Ates I, et al. Efficacy of
Ultrasound-Guided Transversus Thoracic Muscle Plane Block on
Postoperative Opioid Consumption After Cardiac Surgery: A Prospective,
Randomized, Double-Blind Study. \emph{J Cardiothorac Vasc
Anesth.}2020;34(11):2996-3003.

21. Krishna SN, Chauhan S, Bhoi D, et al. Bilateral Erector Spinae Plane
Block for Acute Post-Surgical Pain in Adult Cardiac Surgical Patients: A
Randomized Controlled Trial. \emph{J Cardiothorac Vasc
Anesth.}2019;33(2):368-375.

22. Chen H, Song W, Wang W, et al. Ultrasound-guided parasternal
intercostal nerve block for postoperative analgesia in mediastinal mass
resection by median sternotomy: a randomized, double-blind,
placebo-controlled trial. \emph{BMC Anesthesiol.} 2021;21(1):98.

23. Hamed MA, Abdelhady MA, Hassan A, Boules ML. The Analgesic Effect of
Ultrasound-guided Bilateral Pectointercostal Fascial Plane Block on
Sternal Wound Pain After Open Heart Surgeries: A Randomized Controlled
Study. \emph{Clin J Pain.} 2022;38(4):279-284.

24. Kaya C, Dost B, Dokmeci O, Yucel SM, Karakaya D. Comparison of
Ultrasound-Guided Pectointercostal Fascial Block and Transversus
Thoracic Muscle Plane Block for Acute Poststernotomy Pain Management
After Cardiac Surgery: A Prospective, Randomized, Double-Blind Pilot
Study. \emph{J Cardiothorac Vasc Anesth.} 2021.

25. Shokri H, Ali I, Kasem AA. Evaluation of the Analgesic Efficacy of
Bilateral Ultrasound-Guided Transversus Thoracic Muscle Plane Block on
Post-Sternotomy Pain: A Randomized Controlled Trial. \emph{Local Reg
Anesth.} 2021;14:145-152.

26. Fujii S, Roche M, Jones PM, Vissa D, Bainbridge D, Zhou JR.
Transversus thoracis muscle plane block in cardiac surgery: a pilot
feasibility study. \emph{Reg Anesth Pain Med.} 2019;44(5):556-560.

27. Zhang Y, Li X, Chen S. Bilateral transversus thoracis muscle plane
block provides effective analgesia and enhances recovery after open
cardiac surgery. \emph{J Card Surg.} 2021;36(8):2818-2823.

28. Kumar KN, Kalyane RN, Singh NG, et al. Efficacy of bilateral
pectoralis nerve block for ultrafast tracking and postoperative pain
management in cardiac surgery. \emph{Ann Card
Anaesth.}2018;21(3):333-338.

29. Hamed MA, Boules ML, Sobhy MM, Abdelhady MA. The Analgesic Efficacy
of Ultrasound-Guided Bilateral Transversus Thoracic Muscle Plane Block
After Open-Heart Surgeries: A Randomized Controlled Study. \emph{J Pain
Res.} 2022;15:675-682.

30. Ersoy BBG, Tuna E, Aysin. Postoperative analgesic effectiveness of
bilateral erector spinae plane block for adult cardiac surgery: a
randomized controlled trial. \emph{5.} 2022.

31. Magoon R, Makhija N, Sarkar S. Erector spinae plane block and
cardiac surgery: 'A closer look'. \emph{J Clin Anesth.} 2020;60:8.

32. El-Boghdadly K, Wolmarans M, Stengel AD, et al. Standardizing
nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study
of abdominal wall, paraspinal, and chest wall blocks. \emph{Reg Anesth
Pain Med.} 2021;46(7):571-580.

33. McDonald SB, Jacobsohn E, Kopacz DJ, et al. Parasternal block and
local anesthetic infiltration with levobupivacaine after cardiac surgery
with desflurane: the effect on postoperative pain, pulmonary function,
and tracheal extubation times. \emph{Anesth Analg.} 2005;100(1):25-32.

34. Hu M, Wang Y, Hao B, Gong C, Li Z. Evaluation of Different
Pain-Control Procedures for Post-cardiac Surgery: A Systematic Review
and Network Meta-Analysis. \emph{Surg Innov.} 2022;29(2):269-277.

35. Hussain N, Brull R, Noble J, et al. Statistically significant but
clinically unimportant: a systematic review and meta-analysis of the
analgesic benefits of erector spinae plane block following breast cancer
surgery. \emph{Reg Anesth Pain Med.} 2021;46(1):3-12.

\textbf{Tables}

Table 1. Summary of findings table\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllll@{}}
\toprule
\begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
Author (Year)\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
Group 1\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
Group 2\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
Country\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
Age\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
ASA\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
LA1\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
LA2\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
GA protocol\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
PO analgesia protocol\strut
\end{minipage} & \begin{minipage}[b]{0.09\columnwidth}\raggedright\strut
Main Outcome\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Zhang Y (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
China\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20-70\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
3-4\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0.4\% ropivacaine 20 ml\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Saline 20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
INDUCTION: MDZ 0.05 - 0.1 mg/kg. SUF 0.8 - 1 \selectlanguage{greek}μ\selectlanguage{english}g/kg.; ETM 0.3 mg/kg and
ROC 0.6 mg/kg MAINTENANCE: SUF. PRP and ROC\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PCA SUF and 20 mg parecoxib iv at 6 h intervals\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Postoperative pain\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Athar M (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
ESPB\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
India\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
18-60\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
0.25\% levobupivacaine 20 ml\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Saline 20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PREMEDICATION: diazepam 0.2 mg/kg INDUCTION: FNT 5 mcg/kg. ETM 0.3-0.6
mg/kg, ROC 0.6-1 mg/kg MAINTENANCE: SEVO 1-2\%. FNT 5-10 mcg/kg/h\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Fentanyl comsumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Kumar AK (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
IV ANALGESIC\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
India\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
18-80\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Ropivacaine 0.25\% 10 ml\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Saline 10 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
INDUCTION: FNT. 2 mg/kg. THP 2-3 mg/kg. ROC 1 mg/kg. MAINTENANCE:
isoflurane, FNT and ROC\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Acetaminophen iv 1 g. and tramadol 50 mg every 6 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Postoperative pain\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Khera T (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
USA\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textgreater{}18\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
0.25\% bupivacaine 20 ml\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Saline 20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Morphine comsumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Aydin ME (2020)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Turkey\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2-3\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20 ml of 0.25\% bupivacaine\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Saline 20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
INDUCTION: MDZ 0.5 mg/kg; THP 5 mg/kg, ROC 0.6 mg/kg, REMI 0.5 mg/kg
bolus MAINTENANCE: REMI 0.15 - 0.35 mg/kg/min\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Tramadol 100 mg if VAS [?] 4\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Fentanyl comsumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Krishna SN (2019)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
ESPB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
IV ANALGESIC\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
India\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20-70\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
3 mg/kg of 0.375\% ropivacaine 20 to 25 ml\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Not given\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
INDUCTION: FNT 1 mg/kg, MDZ 0.05 mg/kg , HP 3 -5 mg/kg , ROC 0.6 mg/kg
MAINTENANCE: isoflurane and boluses of atracurium and FNT\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Tramadol or FNT iv\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Postoperative pain\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Chen H (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
China\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
18-65\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
1-2\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Ropivacaine 0.5\% 10 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Saline 10 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
MAINTENANCE: SEVO and REMI. Cisatracurium\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PCA-SUF 1.5 - 2.5 mcg/h and boluses of 1 mcg 10 min lockout interval
(Max dose: 8 mcg/h)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Cumulative sufentanil consumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Hamed. M. A. (2022)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Egypt\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\textgreater{}18\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Bupivacaine 0.25\% 20 mL plus 5 mcg/mL epinephrine\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Dry needle\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
INDUCTION: MDZ 2 mg, FNT 10 mcg/kg, PRP 2 mg/kg. atracurium 0.5 mg/kg
MAINTENANCE: isoflurane 1\%. atracurium 0.5 mg/kg\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
IV morphine 5-10 mg boluses (required)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Cumulative morphine consumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Kaya C (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Turkey\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
18-80\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
2-3\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Bupivacaine 0.25\% 20 mL plus 1:400000 epinephrine\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Bupivacaine 0.25\% 20 mL plus 1:400000 epinephrine\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
INDUCTION: MDZ 0.05-0.1 mg/kg, FNT 2-5 mcg/kg, pentothal 4-5 mg/kg. ROC
1mg/kg. MAINTENANCE: SEVO 1-2 \%. FNT 2-5 mcg/kg/h\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Acetaminophen 1 g x 4. PCA: 20 mcg/kg morphine lockout time: 6-10 min,
tramadol 100 mg (NRS \textgreater{}3)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Morphine comsumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Shokri H (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Egypt\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
55-74\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
2-3\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Bupivacaine 0.25\% 15 mL\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Bupivacaine 0.25\% 15 mL\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PREMEDICATION: MDZ 1-3 mg INDUCTION: FNT 5-6 mcg/kg, PRP 2 mg/kg. ROC
0.6 mg/kg MAINTENANCE: isoflurane 1-2 \%\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
4x1gr paracetamol. morphine 0.05 mg/kg (VAS\textgreater{}4)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Morphine comsumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Fujii S (2018)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
IV ANALGESIC\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Canada\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
18-90\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Ropivacaine 0.3(weighing\textless{}75 kg) -0.5 ( \textgreater{}75kg) \%
20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Ropivacaine 0.3(weighing\textless{}75 kg) -0.5 ( \textgreater{}75kg) \%
20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
INDUCTION: PRP 0.5-1 mg/kg, MDZ 0.05-1 mg/kg, FNT 2-5 mcg/kg, ROC 0.6-1
mg/kg MAINTENANCE: isoflurane 0.5-1\%\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Hidmorphone, Acetaminophen, NSAID\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Recruitment rate. Adherence rate. Adverse events rate\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Zhang (2021)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
IV ANALGESIC\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
China\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
18-70\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2-3\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Ropivacaine 0.4\% 20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Saline 20 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
INDUCTION: MDZ 0.1 mg/kg, ETM 0.3 mg/kg, cisatracurium 0.15 mg/kg, SUF
0.6-1 mcg/kg MAINTENANCE: PRP and cisatracurium\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Sufentanyl iv additional pain: 4x50 mg flurbiprofen\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Perioperative sufentanil consumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Kumar K (2018)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
IV ANALGES\selectlanguage{polish}İ\selectlanguage{english}C\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PECS I\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
India\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
25-65\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
No block\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Bupivacaine 0.25\% + dexmetedomidine 25 mcg 30 mL and bupivacaine 0.25\%
5 mL\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Paracetamol 1 gr + tramadol 50 mg iv+ fentanyl 1 mcg/kg
(VAS\textgreater{}4 rescue analgesia) and diclofenac 75 mg
(VAS\textgreater{}4 30 min after first rescue analgesia)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Postoperative pain\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Hamed (2022)\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Egypt\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
\textgreater{}18\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
20 mL of 0.25\% bupivacaine\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
20 mL of 0.9\% saline\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
PREMEDICATION: 10mg morphine im INDUCTION: MDZ 2 mg, FNT (10\selectlanguage{greek}μ\selectlanguage{english}g.kg-1),
PRP (3mg.Kg-1), and atracurium (0.5 mg.kg-1). MAINTENANCE: Isoflurane
0.4\% - 1\%, atracurium 0.5 mg/kg/h, PRP 50--100 \selectlanguage{greek}μ/\selectlanguage{english}kg/min\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
IV FNT PCA with (10 \selectlanguage{greek}μ\selectlanguage{english}g/mL, bolus of 15 \selectlanguage{greek}μ\selectlanguage{english}g, lockout 10 minutes - MAX
90\selectlanguage{greek}μ/\selectlanguage{english}hr). Acetaminophene 1 g every 8 hours.\strut
\end{minipage} & \begin{minipage}[t]{0.09\columnwidth}\raggedright\strut
Total fentanyl consumption\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Guven (2022)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
ESPB\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
IV ANALGESIC\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Turkey\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
18-65\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
1-2\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
20 ml of 0.25\% bupivacaine\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
No block\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
PREMEDICATION: MDZ 0.03 mg/kg INDUCTION: FNT 1 \selectlanguage{greek}µ\selectlanguage{english}g/kg, MDZ 0.15 mg/kg,
PRP 1-2 mg/kg, ROC 1 mg/kg. MAINTENANCE: SEVO, ROC infusion (0.01
mg/kg/min) and FNT (2-3 \selectlanguage{greek}µ\selectlanguage{english}g/kg/h).\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Acetaminophen 1 g, 100 mg IV tramadol, IV PCA with morphine (0.5 mg/ml
concentration, 1 mg bolus dose, lockout 10 min)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Total morphine consumption\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2. GRADE assessment, the quality of evidence evaluated considering
direct evidence, indirect evidence, and network meta-analysis evidence.
Network

meta-analysis evidence are calculated using the Bayesian method.\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
Comparison & Direct evidence & Direct evidence & Indirect evidence &
Indirect evidence & Network meta-anaalysis & Network
meta-anaalysis\tabularnewline
\midrule
\endhead
& \textbf{SMD (95\% CI)} & \textbf{Quality of evidence} & \textbf{SMD
(95\% CI)} & \textbf{Quality of evidence} & \textbf{SMD (95\% CI)} &
\textbf{Quality of evidence}\tabularnewline
ESPB versus placebo & - & - & -22.93(-34.29;-11.57) & [?][?][?][?] \textbf{Low}
& -22.93(-34.29;-11.57) & [?][?][?][?] \textbf{Low}\tabularnewline
PIFB versus placebo & -6.57(-14.52;1.39) & [?][?][?][?] \textbf{Low} &
-11.97(-28.41;4.46) & [?][?][?][?] \textbf{Very Low} & -7.59(-14.75;-0.44) &
[?][?][?][?] \textbf{Low}\tabularnewline
TTMPB versus placebo & -11.47 (-18.36;-4.59) & [?][?][?][?] \textbf{Low} &
-6.07(-22.98;10.84) & [?][?][?][?] \textbf{Very Low} & -10.70(-17.08; -4.32) &
[?][?][?][?] \textbf{Low}\tabularnewline
ESPB versus PIFB & - & - & -15.34(-28.77;-1.91) & [?][?][?][?] \textbf{Very Low}
& -15.34(-28.77;-1.91) & [?][?][?][?] \textbf{Very Low}\tabularnewline
ESPB versus TTMPB & - & - & -12.23(-25.25;0.80) & [?][?][?][?] \textbf{Very Low}
& -12.23(-25.25;0.80) & [?][?][?][?] \textbf{Very Low}\tabularnewline
PIFB versus TTMPB & -0.50 (-15.42;14.42) & [?][?][?][?] \textbf{Low} &
4.90(-5.61;15.42) & [?][?][?][?] \textbf{Very Low} & 3.11(-5.48; 11.70) & [?][?][?][?]
\textbf{Low}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Abbreviations:} GRADE, Grading of recommendations assessment,
development, and evaluation; SMD, standardized mean difference; ESPB,
erector spinae plane block; PIFB, pecto-intercostal fascial block; TTMP,
transversus thoracis muscle plane block.

Table 3. Direct and indirect effects of 24 hours morphine consumption
and postoperative nausea and vomiting and regional anesthesia compared
with placebo\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
ESPB\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
2.37 (0.12;45.07)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
2.29 (0.11;48.51)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
1.22 (0.14;10.72)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-15.34 (-28.77;-1.91)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
PIFB\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.97 (0.05;18.03)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.52 (0.07;3.77)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-12.23 (-25.25;0.80)*\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-0.50 (-15.42;14.42)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
TTMPB\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.53 (0.06;4.56)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-22.93 (-34.29;-11.57)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-6.57 (-14.52;1.39)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-11.47 (-18.36;-4.59)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
PLACEBO\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Note:} (*) Direct and indirect effects. In light blue; mean
difference 24 hrs morphine milligram equivalents. In gray; odds ratio of
postoperative nause and vomiting.

\textbf{Abbreviations:} ESPB, erector spinae plane block; PIFB,
pecto-intercostal fascial block; TTMP, transversus thoracis muscle plane
block.

\textbf{Figure Legends}

Figure 1. PRISMA flow diagram. The diagram shows the study selection
process and provides reasons for exclusion for the records screened.
PRISMA, Preferred Reporting Items for Systematic Reviews and
Meta-Analyses.

Figure 2. Network diagram comparing different regional anesthesia
techniques in terms of intravenous morphine equivalents (mg) in the
first 24 h.

Figure 3. Forest plot for the comparison of intravenous morphine
equivalents (mg) in the first 24 h. Comparison of results expressed in
intravenous morphine equivalents (mg) through meand difference (MD)
between subgroups.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig/Fig}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fih/Fih}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fii/Fii}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

