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Molecular Psychiatry Mar 2024To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive episode (MDE).
METHODS
PubMed/MEDLINE, Cochrane Library, Embase, GoogleScholar, and US and European trial registries were searched from inception through May 23, 2023, with no language limits. We included RCTs with (1) a diagnosis of MDE; (2) ECT intervention with ketamine and/or other anesthetic agents; and (3) measures included: depressive symptoms, cognitive performance, remission or response rates, and serious adverse events. Network meta-analysis (NMA) was performed to compare ketamine and 7 other anesthetic agents. Hedges' g standardized mean differences (SMDs) were used for continuous measures, and relative risks (RRs) were used for other binary outcomes using random-effects models.
RESULTS
Twenty-two studies were included in the systematic review. A total of 2322 patients from 17 RCTs were included in the NMA. The overall pooled SMD of ketamine, as compared with propofol as a reference group, was -2.21 (95% confidence interval [CI], -3.79 to -0.64) in depressive symptoms, indicating that ketamine had better antidepressant efficacy than propofol. In a sensitivity analysis, however, ketamine-treated patients had a worse outcome in cognitive performance than propofol-treated patients (SMD, -0.18; 95% CI, -0.28 to -0.09). No other statistically significant differences were found.
CONCLUSIONS
Ketamine-assisted ECT is tolerable and may be efficacious in improving depressive symptoms, but a relative adverse impact on cognition may be an important clinical consideration. Anesthetic agents should be considered based on patient profiles and/or preferences to improve effectiveness and safety of ECT use.
Topics: Ketamine; Electroconvulsive Therapy; Humans; Depressive Disorder, Major; Network Meta-Analysis; Treatment Outcome; Propofol; Randomized Controlled Trials as Topic; Anesthetics; Female; Male
PubMed: 38123725
DOI: 10.1038/s41380-023-02366-8 -
The Cochrane Database of Systematic... Aug 2023Despite potential analgesic benefits from topical ophthalmic amides and esters, their outpatient use has become of concern because of the potential for abuse and... (Review)
Review
BACKGROUND
Despite potential analgesic benefits from topical ophthalmic amides and esters, their outpatient use has become of concern because of the potential for abuse and ophthalmic complications.
OBJECTIVES
To assess the effectiveness and safety of topical ophthalmic anesthetics compared with placebo or other treatments in persons with corneal abrasions.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase.com; Latin American and Caribbean Health Sciences (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), without restriction on language or year of publication. The search was performed on 10 February 2023.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) of topical ophthalmic anesthetics alone or in combination with another treatment (e.g. nonsteroidal anti-inflammatory drugs (NSAIDs)) versus a non-anesthetic control group (e.g. placebo, non-treatment, or alternative treatment). We included trials that enrolled participants of all ages who had corneal abrasions within 48 hours of presentation.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methodology.
MAIN RESULTS
We included nine parallel-group RCTs with a total of 556 participants (median number of participants per study: 45, interquartile range (IQR) 44 to 74), conducted in eight countries: Australia, Canada, France, South Korea, Turkey, New Zealand, UK, and USA. Study characteristics and risk of bias Four RCTs (314 participants) investigated post-traumatic corneal abrasions diagnosed in the emergency department setting. Five trials described 242 participants from ophthalmology surgery centers with post-surgical corneal defects: four from photorefractive keratectomy (PRK) and one from pterygium surgery. Study duration ranged from two days to six months, the most common being one week (four RCTs). Treatment duration ranged from three hours to one week (nine RCTs); the majority were between 24 and 48 hours (five RCTs). The age of participants was reported in eight studies, ranging from 17 to 74 years of age. Only one participant in one trial was under 18 years of age. Of four studies that reported funding sources, none was industry-sponsored. We judged a high risk of bias in one trial with respect to the outcome pain control by 48 hours, and in five of seven trials with respect to the outcome complications at the furthest time point. The domain for which we assessed studies to be at the highest risk of bias was missing or selective reporting of outcome data. Findings The treatments investigated included topical anesthetics compared with placebo, topical anesthetic compared with NSAID (post-surgical cases), and topical anesthetics plus NSAID compared with placebo (post-surgical cases). Pain control by 24 hours In all studies, self-reported pain outcomes were on a 10-point scale, where lower numbers represent less pain. In post-surgical trials, topical anesthetics provided a moderate reduction in self-reported pain at 24 hours compared with placebo of 1.28 points on a 10-point scale (mean difference (MD) -1.28, 95% confidence interval (CI) -1.76 to -0.80; 3 RCTs, 119 participants). In the post-trauma participants, there may be little or no difference in effect (MD -0.04, 95% CI -0.10 to 0.02; 1 RCT, 76 participants). Compared with NSAID in post-surgical participants, topical anesthetics resulted in a slight increase in pain at 24 hours (MD 0.82, 95% CI 0.01 to 1.63; 1 RCT, 74 participants). One RCT compared topical anesthetics plus NSAID to placebo. There may be a large reduction in pain at 24 hours with topical anesthetics plus NSAID in post-surgical participants, but the evidence to support this large effect is very uncertain (MD -5.72, 95% CI -7.35 to -4.09; 1 RCT, 30 participants; very low-certainty evidence). Pain control by 48 hours Compared with placebo, topical anesthetics reduced post-trauma pain substantially by 48 hours (MD -5.68, 95% CI -6.38 to -4.98; 1 RCT, 111 participants) but had little to no effect on post-surgical pain (MD 0.41, 95% CI -0.45 to 1.27; 1 RCT, 44 participants), although the evidence is very uncertain. Pain control by 72 hours One post-surgical RCT showed little or no effect of topical anesthetics compared with placebo by 72 hours (MD 0.49, 95% CI -0.06 to 1.04; 44 participants; very low-certainty evidence). Proportion of participants with unresolved epithelial defects When compared with placebo or NSAID, topical anesthetics increased the number of participants without complete resolution of defects in trials of post-trauma participants (risk ratio (RR) 1.37, 95% CI 0.78 to 2.42; 3 RCTs, 221 participants; very low-certainty evidence). The proportion of placebo-treated post-surgical participants with unresolved epithelial defects at 24 to 72 hours was lower when compared with those assigned to topical anesthetics (RR 0.14, 95% CI 0.01 to 2.55; 1 RCT, 30 participants; very low-certainty evidence) or topical anesthetics plus NSAID (RR 0.33, 95% CI 0.04 to 2.85; 1 RCT, 30 participants; very low-certainty evidence). Proportion of participants with complications at the longest follow-up When compared with placebo or NSAID, topical anesthetics resulted in a higher proportion of post-trauma participants with complications at up to two weeks (RR 1.13, 95% CI 0.23 to 5.46; 3 RCTs, 242 participants) and post-surgical participants with complications at up to one week (RR 7.00, 95% CI 0.38 to 128.02; 1 RCT, 44 participants). When topical anesthetic plus NSAID was compared with placebo, no complications were reported in either treatment arm up to one week post-surgery (risk difference (RD) 0.00, 95% CI -0.12 to 0.12; 1 RCT, 30 participants). The evidence is very uncertain for safety outcomes. Quality of life None of the included trials assessed quality of life outcomes.
AUTHORS' CONCLUSIONS
Despite topical anesthetics providing excellent pain control in the intraoperative setting, the currently available evidence provides little or no certainty about their efficacy for reducing ocular pain in the initial 24 to 72 hours after a corneal abrasion, whether from unintentional trauma or surgery. We have very low confidence in this evidence as a basis to recommend topical anesthetics as an efficacious treatment modality to relieve pain from corneal abrasions. We also found no evidence of a substantial effect on epithelial healing up to 72 hours or a reduction in ocular complications when we compared anesthetics alone or with NSAIDs versus placebo.
Topics: Humans; Adolescent; Young Adult; Adult; Middle Aged; Aged; Anesthetics, Local; Anti-Inflammatory Agents, Non-Steroidal; Analgesics; Corneal Injuries; Pain, Postoperative
PubMed: 37555621
DOI: 10.1002/14651858.CD015091.pub2 -
British Journal of Anaesthesia Sep 2023Suggested anaesthetic dose ranges do not differ by sex, likely because of limited studies comparing sexes. Our objective was to systematically synthesise studies with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Suggested anaesthetic dose ranges do not differ by sex, likely because of limited studies comparing sexes. Our objective was to systematically synthesise studies with outcomes of unintended anaesthesia awareness under anaesthesia, intraoperative connected consciousness, time to emergence from anaesthesia, and dosing to achieve adequate depth of anaesthesia, and to compare between females and males.
METHODS
Studies were identified from MEDLINE, Embase, and the Cochrane library databases until August 2, 2022. Controlled clinical trials (randomised/non-randomised) and prospective cohort studies that reported outcomes by sex were included. Results were synthesised by random effects meta-analysis where possible, or narrative form.
RESULTS
Of the 19 749 studies identified, 64 (98 243 participants; 53 143 females and 45 100 males) were eligible for inclusion, and 44 citations contributed to meta-analysis. Females had a higher incidence of awareness with postoperative recall (33 studies, odds ratio 1.38, 95% confidence interval [CI] 1.09-1.75) and connected consciousness during anaesthesia (three studies, OR 2.09, 95% CI 1.04-4.23) than males. Time to emergence was faster in females, including time to eye-opening (10 studies, mean difference -2.28 min, 95% CI -3.58 to -0.98), and time to response to command (six studies, mean difference -2.84 min, 95% CI -4.07 to -1.62). Data on depth of anaesthesia were heterogenous, limiting synthesis to a qualitative review which did not identify sex differences.
CONCLUSIONS
Female sex was associated with a greater incidence of awareness under general anaesthesia, and faster emergence from anaesthesia. These data suggest reappraisal of anaesthetic care, including whether similar drug dosing for females and males represents best care.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42022336087.
Topics: Female; Humans; Male; Prospective Studies; Anesthetics; Anesthesia, General; Anesthesiology
PubMed: 37453840
DOI: 10.1016/j.bja.2023.06.042 -
Surgery Sep 2018Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting...
BACKGROUND
Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting is commonly implemented to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical, obstetric, and anesthetic task shifting is lacking in the literature. We aimed to document the use of task shifting worldwide with a systematic review of the literature.
METHODS
We performed a systematic review of 10 health literature databases. We included journal articles published between January 1, 1995, and February 17, 2017, documenting the provision of surgical or anesthetic care by associate clinicians (any non-physician clinician). We extracted data for health cadres performing task shifting, types of tasks performed, training programs, and levels of supervision, and compared these across regions and income groups.
RESULTS
We identified 55 relevant studies, with data for 52 countries for surgery and 147 countries for anesthesia. Surgical task shifting was documented in 19 of 52 countries and anesthetic task shifting in 119 of 147. Task shifting was documented across all World Bank income groups. No associate clinicians were found to perform surgical procedures unsupervised in high-income countries (0 of 3 countries with data). Independent anesthesia care by associate clinicians was noted in 3 of 19 countries with data. In low-income countries, associate clinicians performed surgical procedures independently in 2 of 3 countries and independent anesthesia care in 17 of 17 countries with data.
CONCLUSION
Task shifting is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce. Further research is required to assess outcomes, especially in low-income and middle-income countries where documented supervision is less robust.
Topics: Anesthesiology; Delivery of Health Care; General Surgery; Health Workforce; Humans; Obstetrics
PubMed: 30145999
DOI: 10.1016/j.surg.2018.04.024 -
The Journal of Arthroplasty Oct 2022Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.
METHODS
We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks.
RESULTS
Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective.
CONCLUSION
Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.
Topics: Analgesics, Opioid; Anesthetics; Anesthetics, Local; Arthroplasty, Replacement, Knee; Femoral Nerve; Humans; Nerve Block; Pain, Postoperative
PubMed: 36162923
DOI: 10.1016/j.arth.2022.03.078 -
Pain Physician Mar 2016The prevalence of chronic low back pain and related disability is rapidly increasing as are the myriad treatments, including epidural injections. Even though epidural... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
The prevalence of chronic low back pain and related disability is rapidly increasing as are the myriad treatments, including epidural injections. Even though epidural injections are one of the most commonly performed procedures in managing low back and lower extremity pain, starting in 1901 with local anesthetic alone, conflicting recommendations have been provided, despite the extensive literature. Recently Chou et al performed a technology assessment review for Agency for Healthcare Research and Quality (AHRQ) part of which was published in Annals of Internal Medicine showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, multiple other publications have supported the efficacy and use of epidural injections.
PURPOSE
To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis: performed with saline with steroids, local anesthetic alone, or steroids with local anesthetic and separate facts from opinions.
DATA SOURCES
PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed through August 2015.
STUDY SELECTION
Randomized trials, either placebo or active control, of epidural injections for lumbar radiculopathy and spinal stenosis.
DATA EXTRACTION
Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing principles of best evidence synthesis.
DATA SYNTHESIS
Thirty-nine randomized controlled trials met inclusion criteria. There were 9 placebo-controlled trials evaluating epidural corticosteroid injections, either with sodium chloride solution or bupivacaine, compared to placebo injections. There were 12 studies comparing local anesthetic alone to local anesthetic with steroid.
RESULTS
A meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showed a lack of efficacy.A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectiveness from baseline to long-term follow-up periods. Meta-analysis showed a similar effectiveness for pain and function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 months and 12 months.
LIMITATIONS
The review was restricted to the data available with at least 3 months of follow-up, which excluded some studies. The inclusion criteria were restricted to English language studies.
CONCLUSION
Epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine in conjunction with steroids were significantly effective.
Topics: Analgesia, Epidural; Anesthetics, Local; Humans; Injections, Epidural; Pain Management; Radiculopathy; Randomized Controlled Trials as Topic; Spinal Stenosis; Steroids
PubMed: 27008296
DOI: No ID Found -
International Journal of Environmental... Jan 2022Inferior alveolar nerve (IAN) block injections are commonly used in clinical practice, but they are not free from complications. The aim of the present systematic review... (Review)
Review
Inferior alveolar nerve (IAN) block injections are commonly used in clinical practice, but they are not free from complications. The aim of the present systematic review is to assess the nerve-related adverse effects of IAN block anesthesia. A structured and systematic search was performed on the major electronic databases (PubMed, Cochrane Library, Web of Science, Scopus and CINAHL) for studies published in English until 30 September 2021. A total of 131 articles were identified through database searching using combinations of keywords. Fifteen papers were included and assessed for eligibility. Overall, nerve damage following an IAN block anesthesia injection is a rare occurrence, probably due to the direct nerve trauma of the needle, a neurotoxic effect of the used anesthetic solution and/or a combination of them. From a medico-legal point of view, a balanced discussion prior to nerve block anesthesia should be pursued in order to avoid patients' reluctance to undergo necessary dental treatment due to the remote eventuality of nerve injury.
Topics: Anesthetics, Local; Humans; Injections; Mandible; Mandibular Nerve; Nerve Block
PubMed: 35162650
DOI: 10.3390/ijerph19031627 -
Pharmacogenomics Jul 2022This systematic review aimed to outline the outcome of () variants on the effects of anesthetic and analgesic agents used in various procedures. Literature was... (Review)
Review
This systematic review aimed to outline the outcome of () variants on the effects of anesthetic and analgesic agents used in various procedures. Literature was obtained from reliable, established databases and reference tracking. Efficacy and side/adverse effects of anesthetic and analgesic drugs intraoperatively or within 48 h postsurgery were the key outcome measures for all populations. Animal studies were excluded. Twenty-nine studies were chosen for inclusion. In association with the efficacy and safety of anesthetic and analgesic agents, gene polymorphism in displayed a strong correlation in reduced analgesic effect and protection against adverse reactions. This systematic review summarized the correlation between genetic polymorphism in the gene and anesthetic/analgesic effects.
Topics: Analgesics; Analgesics, Opioid; Anesthetics; Animals; Polymorphism, Genetic; Polymorphism, Single Nucleotide; Receptors, Opioid, mu
PubMed: 35735174
DOI: 10.2217/pgs-2022-0042 -
The Canadian Journal of Neurological... Mar 2015Our goal was to perform a systematic review of the literature on the use of modern inhalational anesthetic agents for refractory status epilepticus and their impact on... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Our goal was to perform a systematic review of the literature on the use of modern inhalational anesthetic agents for refractory status epilepticus and their impact on seizure control.
METHODS
All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendation Assessment Development and Education methodology by two independent reviewers.
RESULTS
Overall, 19 studies were identified, with 16 manuscripts and 3 meeting abstracts. A total of 46 patients were treated. Adult (n=28) and pediatric patients (n=18) displayed 92.9% and 94.4% seizure control with treatment, respectively. Isoflurane was used in the majority of cases. Hypotension was the only complication described.
CONCLUSIONS
Oxford level 4, Grading of Recommendation Assessment Development and Education D evidence exists to support the use of isoflurane in refractory status epilepticus to obtain burst suppression. Insufficient data exist to comment on the efficacy of desflurane and xenon at this time.
Topics: Adult; Anesthetics, Inhalation; Child; Drug Resistant Epilepsy; Evidence-Based Medicine; Guidelines as Topic; Humans; Status Epilepticus; Treatment Outcome
PubMed: 25572922
DOI: 10.1017/cjn.2014.121 -
International Journal of Surgery... Mar 2023Controversy remains over the choice of anaesthetic technique for patients undergoing surgery for hip fracture. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Controversy remains over the choice of anaesthetic technique for patients undergoing surgery for hip fracture.
AIM
The aim was to compare the risk of complication of neuraxial anaesthesia with that of general anaesthesia in patients undergoing hip fracture surgery.
METHODS
This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and was registered at PROSPERO (CRD42022337384). The study included eligible randomised controlled trials published before February 2022. Data synthesis was performed to compare the differences between general and neuraxial anaesthesia. Meta-regression analysis was performed to investigate the influence of the publication year. A subgroup analysis was performed based on patient age and the anaesthetic technique used. A grading of recommendations, assessment, development and evaluations assessment was performed to assess the quality of each outcome.
RESULTS
Twenty randomised controlled trials and 4802 patients were included. Data synthesis revealed significant higher risk of acute kidney injury in the general anaesthesia group ( P =0.01). There were no significant differences between the two techniques in postoperative short-term mortality ( P =0.34), delirium ( P =0.40), postoperative nausea and vomiting ( P =0.40), cardiac infarction ( P =0.31), acute heart failure ( P =0.34), pulmonary embolism ( P =0.24) and pneumonia ( P =0.15). Subgroup analysis based on patient age and use of sedative medication did not reveal any significant differences. Meta-regression analysis of the publication year versus each adverse event revealed no statistically significant differences.
CONCLUSION
A significantly higher risk of postoperative acute kidney injury was found in patients receiving general anaesthesia. This study revealed no significant differences in terms of postoperative mortality and other complications between general and neuraxial anaesthesia. The results were consistent across the age groups.
Topics: Humans; Postoperative Complications; Anesthesia, General; Hip Fractures; Postoperative Nausea and Vomiting; Anesthesiology; Randomized Controlled Trials as Topic
PubMed: 36912758
DOI: 10.1097/JS9.0000000000000291