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Anaesthesia Jun 2019Intra-operative remifentanil is associated with increased postoperative analgesic requirements and opioid consumption. Dexmedetomidine has characteristics suggesting it... (Comparative Study)
Comparative Study Meta-Analysis Review
Intra-operative remifentanil is associated with increased postoperative analgesic requirements and opioid consumption. Dexmedetomidine has characteristics suggesting it may substitute for intra-operative remifentanil during general anaesthesia, but existing literature has reported conflicting results. We undertook this meta-analysis to investigate whether general anaesthesia including dexmedetomidine would result in less postoperative pain than general anaesthesia including remifentanil. The MEDLINE and PubMed electronic databases were searched up to October 2018. Only randomised trials including patients receiving general anaesthesia and comparing dexmedetomidine with remifentanil administration were included. Meta-analyses were performed mostly employing a random effects model. The primary outcome was pain score at rest (visual analogue scale, 0-10) at two postoperative hours. The secondary outcomes included: pain score at rest at 24 postoperative hours; opioid consumption at 2 and 24 postoperative hours; and rates of hypotension, bradycardia, shivering and postoperative nausea and vomiting. Twenty-one randomised trials, including 1309 patients, were identified. Pain scores at rest at two postoperative hours were lower in the dexmedetomidine group, with a mean difference (95%CI) of -0.7 (-1.2 to -0.2), I = 85%, p = 0.004, and a moderate quality of evidence. Secondary pain outcomes were also significantly better in the dexmedetomidine group. Rates of hypotension, shivering and postoperative nausea and vomiting were at least twice as frequent in patients who received remifentanil. Time to analgesia request was longer, and use of postoperative morphine and rescue analgesia were less, with dexmedetomidine, whereas episodes of bradycardia were similar between groups. There is moderate evidence that intra-operative dexmedetomidine during general anaesthesia improves pain outcomes during the first 24 postoperative hours, when compared with remifentanil, with fewer side effects.
Topics: Analgesia; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia, General; Dexmedetomidine; Humans; Intraoperative Care; Pain, Postoperative; Remifentanil
PubMed: 30950522
DOI: 10.1111/anae.14657 -
Anaesthesia Jul 2021Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is... (Meta-Analysis)
Meta-Analysis
Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
Topics: Adult; Anesthesia, General; Antiemetics; Female; Humans; Male; Network Meta-Analysis; Postoperative Nausea and Vomiting; Treatment Outcome
PubMed: 33170514
DOI: 10.1111/anae.15295 -
Anaesthesia May 2022Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine... (Review)
Review
Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.
Topics: Anesthesia, Epidural; Anesthesia, General; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Female; Humans; Pregnancy
PubMed: 35064923
DOI: 10.1111/anae.15657 -
The Cochrane Database of Systematic... Jul 2015Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.
OBJECTIVES
To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.
SEARCH METHODS
In this updated review we searched CENTRAL (the Cochrane Library 2012, Issue 12) and searched the following databases from inception to 15 January 2013: MEDLINE, EMBASE, PsycINFO and Web of Science. We reran the search in August 2014. We will deal with the single study found to be of interest when we next update the review.
SELECTION CRITERIA
We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.
DATA COLLECTION AND ANALYSIS
At least two review authors independently extracted data and assessed risk of bias in trials.
MAIN RESULTS
We included 28 trials (2681 children) investigating 17 interventions of interest; all trials were conducted in high-income countries. Overall we judged the trials to be at high risk of bias. Except for parental acupuncture (graded low), all other GRADE assessments of the primary outcomes of comparisons were very low, indicating a high degree of uncertainty about the overall findings. Parental presence: In five trials (557 children), parental presence at induction of anaesthesia did not reduce child anxiety compared with not having a parent present (standardized mean difference (SMD) 0.03, 95% confidence interval (CI) -0.14 to 0.20). In a further three trials (267 children) where we were unable to pool results, we found no clear differences in child anxiety, whether a parent was present or not. In a single trial, child anxiety showed no significant difference whether one or two parents were present, although parental anxiety was significantly reduced when both parents were present at the induction. Parental presence was significantly less effective than sedative premedication in reducing children's anxiety at induction in three trials with 254 children (we could not pool results). Child interventions (passive): When a video of the child's choice was played during induction, children were significantly less anxious than controls (median difference modified Yale Preoperative Anxiety Scale (mYPAS) 31.2, 95% CI 27.1 to 33.3) in a trial of 91 children. In another trial of 120 children, co-operation at induction did not differ significantly when a video fairytale was played before induction. Children exposed to low sensory stimulation were significantly less anxious than control children on introduction of the anaesthesia mask and more likely to be co-operative during induction in one trial of 70 children. Music therapy did not show a significant effect on children's anxiety in another trial of 51 children. Child interventions (mask introduction): We found no significant differences between a mask exposure intervention and control in a single trial of 103 children for child anxiety (risk ratio (RR) 0.59, 95% CI 0.31 to 1.11) although children did demonstrate significantly better co-operation in the mask exposure group (RR 1.27, 95% CI 1.06 to 1.51). Child interventions (interactive): In a three-arm trial of 168 children, preparation with interactive computer packages (in addition to parental presence) was more effective than verbal preparation, although differences between computer and cartoon preparation were not significant, and neither was cartoon preparation when compared with verbal preparation. Children given video games before induction were significantly less anxious at induction than those in the control group (mYPAS mean difference (MD) -9.80, 95% CI -19.42 to -0.18) and also when compared with children who were sedated with midazolam (mYPAS MD -12.20, 95% CI -21.82 to -2.58) in a trial of 112 children. When compared with parental presence only, clowns or clown doctors significantly lessened children's anxiety in the operating/induction room (mYPAS MD -24.41, 95% CI -38.43 to -10.48; random-effects, I² 75%) in three trials with a total of 133 children. However, we saw no significant differences in child anxiety in the operating room between clowns/clown doctors and sedative premedication (mYPAS MD -9.67, 95% CI -21.14 to 1.80, random-effects, I² 66%; 2 trials of 93 children). In a trial of hypnotherapy versus sedative premedication in 50 children, there were no significant differences in children's anxiety at induction (RR 0.59, 95% CI 0.33 to 1.04). Parental interventions: Children of parents having acupuncture compared with parental sham acupuncture were less anxious during induction (mYPAS MD -17, 95% CI -30.51 to -3.49) and were more co-operative (RR 1.59, 95% CI 1.01 to 2.53) in a single trial of 67 children. Two trials with 191 parents assessed the effects of parental video viewing but did not report any of the review's prespecified primary outcomes.
AUTHORS' CONCLUSIONS
This review shows that the presence of parents during induction of general anaesthesia does not diminish their child's anxiety. Potentially promising non-pharmacological interventions such as parental acupuncture; clowns/clown doctors; playing videos of the child's choice during induction; low sensory stimulation; and hand-held video games need further investigation in larger studies.
Topics: Acupuncture Therapy; Anesthesia, General; Anxiety; Child; Cooperative Behavior; Humans; Hypnosis, Anesthetic; Music Therapy; Noise; Parents; Physician's Role; Preanesthetic Medication; Randomized Controlled Trials as Topic; Stress, Psychological; Video Games
PubMed: 26171895
DOI: 10.1002/14651858.CD006447.pub3 -
Anaesthesia Jan 2021Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now...
Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.
Topics: Adolescent; Anesthesia, Conduction; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Pediatrics
PubMed: 33426659
DOI: 10.1111/anae.15283 -
Anaesthesia Aug 2021Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles... (Meta-Analysis)
Meta-Analysis
Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both the gauge and needle tip design as risk-factors, but failed to provide an unbiased comparison of individual needles. This network meta-analysis compared the odds of post-dural puncture headache with needles of varying gauge and tip design. We searched randomised controlled trials in medical databases. The primary outcome measure of the network meta-analysis was the incidence of post-dural puncture headache. Secondary outcomes were procedural failure, backache and non-specific headache. Overall, we compared 11 different needles in 61 randomised controlled trials including a total of 14,961 participants. The probability of post-dural puncture headache and procedural failure was lowest with 26-G atraumatic needles. The 29-G cutting needle was more likely than three atraumatic needles to have the lowest odds of post-dural puncture headache, although with increased risk of procedural failure. The probability rankings were: 26 atraumatic > 27 atraumatic > 29 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 23 cutting > 22 cutting > 25 cutting > 27 cutting = 26 cutting for post-dural puncture headache; and 26 atraumatic > 25 cutting > 22 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 26 cutting > 29 cutting > 27 atraumatic = 27 cutting for procedural success. Meta-regression by type of surgical population (obstetric/non-obstetric) and participant position (sitting/lateral) did not alter these rank orders. This analysis provides an unbiased comparison of individual needles that does not support the use of simple rules when selecting the optimal needle. The 26-G atraumatic needle is most likely to enable successful insertion while avoiding post-dural puncture headache but, where this is not available, our probability rankings can help clinicians select the best of available options.
Topics: Anesthesia, Spinal; Humans; Needles; Post-Dural Puncture Headache
PubMed: 33332606
DOI: 10.1111/anae.15320 -
Anaesthesia Jul 2018Combined spinal-epidural and single-shot spinal anaesthesia are both used for caesarean section. It has been claimed in individual trials that combined spinal-epidural... (Meta-Analysis)
Meta-Analysis
Combined spinal-epidural and single-shot spinal anaesthesia are both used for caesarean section. It has been claimed in individual trials that combined spinal-epidural is associated with higher sensory spread and greater cardiovascular stability. We set out to gather all available evidence. We performed: a systematic literature search to identify randomised controlled trials comparing combined spinal-epidural with spinal anaesthesia for caesarean section: conventional meta-analysis; trial-sequential analysis; and assessment of trial quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Fifteen trials with high heterogeneity, including 1015 patients, were analysed. There was no significant difference between combined spinal-epidural and spinal anaesthesia for our primary outcomes maximum sensory height and vasopressor use (mg ephedrine equivalents). However, trial-sequential analysis suggested insufficient data and the GRADE scores showed 'very low' quality of evidence for these outcomes. The secondary outcomes hypotension, time for sensory block to recede to the level of T10, and the combined outcome of nausea and vomiting, did not differ significantly between the interventions. The block times were statistically significantly longer for combined spinal-epidural in individual trials, but only one trial showed a clinically meaningful difference (11 min). Based on this analysis, and taking into consideration all comparisons irrespective of whether drugs had been applied via the epidural route, there is not enough evidence to postulate any advantage compared with the spinal technique. Future analyses and studies need to examine the potential advantages of the combined spinal-epidural technique by using the epidural route intra- and/or postoperatively.
Topics: Adult; Anesthesia, Epidural; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Female; Humans; Pregnancy
PubMed: 29330854
DOI: 10.1111/anae.14210 -
British Journal of Anaesthesia Mar 2022During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes. (Meta-Analysis)
Meta-Analysis
BACKGROUND
During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes.
METHODS
Included clinical trials investigated goal-directed haemodynamic therapy during general anaesthesia in adults undergoing noncardiac surgery and reported at least one patient-centred postoperative outcome. PubMed and Embase were searched for relevant articles on March 8, 2021. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. The primary outcomes were mortality and hospital length of stay, whereas 15 postoperative complications were included based on availability. From a main pool of comparable trials, meta-analyses were performed on trials with homogenous outcome definitions. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).
RESULTS
The main pool consisted of 76 trials with intermediate risk of bias for most outcomes. Overall, goal-directed haemodynamic therapy might reduce mortality (odds ratio=0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference=-0.72 days; 95% CI, -1.10 to -0.35) but with low certainty in the evidence. For both outcomes, larger effects favouring goal-directed haemodynamic therapy were seen in abdominal surgery, very high-risk surgery, and using targets based on preload variation by the respiratory cycle. However, formal tests for subgroup differences were not statistically significant. Goal-directed haemodynamic therapy decreased risk of several postoperative outcomes, but only infectious outcomes and anastomotic leakage reached moderate certainty of evidence.
CONCLUSIONS
Goal-directed haemodynamic therapy during general anaesthesia might decrease mortality, hospital length of stay, and several postoperative complications. Only infectious postoperative complications and anastomotic leakage reached moderate certainty in the evidence.
Topics: Anesthesia, General; General Surgery; Hemodynamics; Humans; Postoperative Complications
PubMed: 34916049
DOI: 10.1016/j.bja.2021.10.046 -
The Cochrane Database of Systematic... Jul 2020Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury).
OBJECTIVES
To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth's Trials Register (9 August 2016) and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study quality and extracted data from eligible studies. We report 'Summary of findings' tables using GRADE.
MAIN RESULTS
We included 125 studies involving 9469 women. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review's primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit. Crystalloid versus control (no fluids) Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence). Colloid versus crystalloid Fewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.69, 95% CI 0.58 to 0.81; 2009 women; 27 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women; very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.98, 95% CI 0.54 to 1.78, 5 studies, 413 women; very low-quality evidence), nausea and/or vomiting (average RR 0.89, 95% CI 0.66 to 1.19, 14 studies, 1058 women, I² = 29%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 10 studies, 730 babies; very low-quality evidence). Ephedrine versus phenylephrine There were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence). Ondansetron versus control Ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence). Lower limb compression versus control Lower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42, 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence). Walking versus lying There was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence). Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections. External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration.
AUTHORS' CONCLUSIONS
While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.
Topics: Anesthesia, Obstetrical; Anesthesia, Spinal; Antiemetics; Cesarean Section; Colloids; Crystalloid Solutions; Ephedrine; Female; Humans; Hypotension; Intraoperative Complications; Isotonic Solutions; Ondansetron; Phenylephrine; Postoperative Nausea and Vomiting; Pregnancy; Randomized Controlled Trials as Topic; Vasoconstrictor Agents; Walking
PubMed: 32619039
DOI: 10.1002/14651858.CD002251.pub4 -
JAMA Network Open Nov 2021The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown.
OBJECTIVE
To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.
DATA SOURCES
A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.
STUDY SELECTION
Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening.
DATA EXTRACTION AND SYNTHESIS
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model.
MAIN OUTCOMES AND MEASURES
The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function.
RESULTS
Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs).
CONCLUSIONS AND RELEVANCE
In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.
Topics: Acute Pain; Analgesia, Epidural; Anesthesia, Epidural; Female; Humans; Intercostal Nerves; Male; Nerve Block; Pain, Postoperative; Thoracic Surgical Procedures
PubMed: 34779845
DOI: 10.1001/jamanetworkopen.2021.33394