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Journal of Gastrointestinal Surgery :... Nov 2017Colorectal surgeries (CRS) have one of the highest rates of surgical site infections (SSIs) with rates 15 to >30%. Prevention "bundles" or sets of evidence-based... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Colorectal surgeries (CRS) have one of the highest rates of surgical site infections (SSIs) with rates 15 to >30%. Prevention "bundles" or sets of evidence-based interventions are structured ways to improve patient outcomes. The aim sof this study is to evaluate CRS SSI prevention bundles, bundle components, and implementation and compliance strategies.
METHODS
A meta-analysis of studies with pre- and post-implementation data was conducted to assess the impact of bundles on SSI rates (superficial, deep, and organ/space). Subgroup analysis of bundle components identified optimal bundle designs.
RESULTS
Thirty-five studies (51,413 patients) were identified and 23 (17,557 patients) were included in the meta-analysis. A SSI risk reduction of 40% (p < 0.001) was noted with 44% for superficial SSI (p < 0.001) and 34% for organ/space (p = 0.048). Bundles with sterile closure trays (58.6 vs 33.1%), MBP with oral antibiotics (55.4 vs 31.8%), and pre-closure glove changes (56.9 vs 28.5%) had significantly greater SSI risk reduction.
CONCLUSION
Bundles can effectively reduce the risk of SSIs after CRS, by fostering a cohesive environment, standardization, and reduction in operative variance. If implemented successfully and complied with, bundles can become vital to improving patients' surgical quality of care.
Topics: Anti-Bacterial Agents; Colon; Digestive System Surgical Procedures; Gloves, Surgical; Humans; Patient Care Bundles; Quality Improvement; Rectum; Risk Factors; Surgical Wound Infection; Wound Closure Techniques
PubMed: 28620749
DOI: 10.1007/s11605-017-3465-3 -
Anesthesia and Analgesia May 2017Sleep-disordered breathing (SDB) is highly prevalent in the general population and has been associated with cognitive impairment in older individuals. Delirium is an... (Review)
Review
Sleep-disordered breathing (SDB) is highly prevalent in the general population and has been associated with cognitive impairment in older individuals. Delirium is an acute decline in cognitive function and attention that often occurs after surgery, especially in older individuals. Several recent studies suggest an association between SDB and postoperative delirium. The aim of this systematic review is to examine the current literature on SDB, postoperative delirium, and cognitive impairment and to discuss the pathophysiology and perioperative considerations. A literature search was performed of Medline (1946-2016), Medline In-Process (June 2016), Embase (1947-2016), Cochrane Central Register of Controlled Trials (May 2016), and Cochrane Database of Systematic Reviews (2005 to June 2016). Inclusion criteria for studies were (1) polysomnography confirmed SDB; (2) postoperative delirium or cognitive impairment confirmed by a validated diagnostic tool; and (3) publications in the English language. All study designs including randomized controlled trials and observational studies were included. The literature search identified 2 studies on SDB and postoperative delirium, 15 studies on SDB and cognitive impairment, and 5 studies on the effect of continuous positive airway pressure on cognitive impairment and delirium in older individuals. SDB was associated with cognitive impairment, and this systematic review revealed that SDB may be a risk factor for postoperative delirium, especially in older individuals. Although the pathophysiology of SDB and postoperative delirium is unclear and effective treatments for SDB to reduce the incidence of delirium have not been studied extensively, preliminary evidence suggests that continuous positive airway pressure therapy may lower the risk of delirium. Health care professionals need to be aware that undiagnosed SDB may contribute to postoperative delirium. Preoperative screening for SDB and strategies to reduce the risk for postoperative delirium may be helpful in older individuals. Further studies are needed to clarify the relationship between SDB and postoperative delirium and elucidate the pathophysiology of postoperative delirium through SDB.
Topics: Aged; Aged, 80 and over; Anesthesia; Cognition; Cognition Disorders; Continuous Positive Airway Pressure; Female; Humans; Lung; Male; Middle Aged; Neuropsychological Tests; Polysomnography; Postoperative Complications; Risk Assessment; Risk Factors; Sleep Apnea Syndromes; Surgical Procedures, Operative; Treatment Outcome
PubMed: 28431424
DOI: 10.1213/ANE.0000000000001914 -
Otolaryngology--head and Neck Surgery :... Mar 2021Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons use antibiotic prophylaxis (AP). The aim of this study was to assess whether AP is significantly effective in reducing the incidence of SSIs in this kind of surgery.
DATA SOURCES
A systematic literature search was performed with PubMed, Scopus, and ISI-Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis.
REVIEW METHODS
The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated.
RESULTS
A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81; = .915). There was no evidence of heterogeneity among the studies ( = 8.36, = .138; = 40.17). The analysis of several continuous moderators, including age, use of drain, and duration of surgery, did not generate any significant result.
CONCLUSION
AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.
Topics: Antibiotic Prophylaxis; Humans; Parathyroidectomy; Surgical Wound Infection; Thyroidectomy
PubMed: 32807010
DOI: 10.1177/0194599820947700 -
Journal of Cardiovascular Pharmacology Apr 2016Atrial fibrillation (AF), which increases morbidity and mortality, is a common occurrence after thoracic surgery and pulmonary resection. Despite several investigations... (Meta-Analysis)
Meta-Analysis Review
Atrial fibrillation (AF), which increases morbidity and mortality, is a common occurrence after thoracic surgery and pulmonary resection. Despite several investigations on various prophylactic measures for AF prevention, the studies were not uniform and do not use similar controls making it difficult to arrive at a meaningful conclusion. In the present systematic analysis review, we evaluated the efficacy of different prophylactic approaches to prevent AF after lung surgery in randomized trials reported during 1991-2014. A total of 12 trials were identified that met the criteria set for this meta-analysis. Among different trials, amiodarone was found to be most effective in preventing postoperative AF (risk ratio, 0.22; P < 0.0001; 95% confidence interval: 0.09-0.54). There were no significant prophylactic effects by MgSO4 (risk ratio, 1.24; P < 0.007; 95% confidence interval, 0.27-5.68), digoxin, or Ca blockers. Single use of amiodarone was able to lower the incidence of AF from 39.2% to 8.3% and seemed to be safe with no major complications. Although several prophylactic measures have been tried to curtail the incidence of AF in patients after lung surgery, prophylaxis with amiodarone seems to be most effective of treatments studied.
Topics: Amiodarone; Atrial Fibrillation; Humans; Incidence; Lung; Pneumonectomy; Postoperative Complications; Randomized Controlled Trials as Topic; Thoracic Surgical Procedures
PubMed: 26779893
DOI: 10.1097/FJC.0000000000000351 -
Physical Therapy Mar 2023Preoperative exercise (prehabilitation) is commonly used as a method to reduce pain and improve function postoperatively. The purpose of this systematic review was to... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Preoperative exercise (prehabilitation) is commonly used as a method to reduce pain and improve function postoperatively. The purpose of this systematic review was to determine therapeutic benefits of preoperative exercise on postoperative pain, function, quality of life (QOL), and risk of complications across various types of surgeries.
METHODS
Three electronic databases were used to perform a literature search. Full articles with randomized designs comparing a preoperative exercise program vs no formal program were included. The primary outcome was postoperative pain. QOL, function, and postoperative complications were analyzed as secondary outcomes. The primary meta-analysis was performed in those with joint replacement surgery because there were only 5 with other surgical types.
RESULTS
A total of 28 articles were included, of which 23 were from individuals with total joint replacement surgery. Preoperative exercise resulted in lower pain ≤2 months and 3 to 5 months after joint replacement surgery with a moderate standardized mean difference (95% CI at <2 months = -0.34 [-0.59 to -0.09]; at 3 to 5 months = -0.41 [-0.70 to -0.11]) compared with nonexercised controls. However, ≥6 months after joint replacement surgery, preoperative exercise groups showed no significant differences in postoperative pain (standardized mean difference = -0.17 [-0.35 to 0.01]) compared with nonexercised controls. QOL and subjective and objective function were improved ≤2 months after joint replacement surgery but were not different ≥6 months post-surgery. Reduction in risk of postoperative complications was favored with preoperative exercise.
CONCLUSION
Preoperative exercise has a modest effect on postoperative pain, function, and quality of life within the first 6 months after surgery and reduces the risk of developing postoperative complications in individuals undergoing joint replacement surgery. The effect of preoperative exercise on other surgery types is inconclusive.
IMPACT
This systematic review supports using preoperative exercise to improve pain and function outcomes for those with joint replacement surgery.
Topics: Humans; Quality of Life; Preoperative Exercise; Preoperative Care; Arthroplasty, Replacement, Knee; Pain, Postoperative; Postoperative Complications
PubMed: 37172124
DOI: 10.1093/ptj/pzac169 -
European Journal of Pain (London,... Jan 2021The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVE
The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery.
DATABASES AND DATA TREATMENT
We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE.
RESULTS
Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available.
CONCLUSIONS
Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed.
SIGNIFICANCE
This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.
Topics: Breast Neoplasms; Humans; Lidocaine; Nerve Block; Pain, Postoperative; Postoperative Nausea and Vomiting
PubMed: 32816362
DOI: 10.1002/ejp.1648 -
Journal of Clinical Anesthesia Nov 2017Perioperative factors are probably essential for different oncological outcomes. This systematic review investigates the literature concerning overall mortality and... (Comparative Study)
Comparative Study Review
Perioperative factors are probably essential for different oncological outcomes. This systematic review investigates the literature concerning overall mortality and postoperative complications after cancer surgery with inhalational (INHA) and intravenous anesthesia (TIVA). A search was conducted according to the PRISMA guidelines, including studies with patients undergoing surgery for cancer and where TIVA was compared with INHA. Two investigators identified relevant papers in the databases: PubMed, Scopus, EMBASE and the Cochrane Library. Risks of bias assessment tools from the Cochrane Collaboration were used for evaluating quality of evidence. Eight studies with a total of 10,696 patients were included. Four studies reported data regarding overall mortality and four studies reported data regarding postoperative complications. Evidence was evaluated to be of moderate to serious risk of bias. Three retrospective studies presented a hazard ratio (HR) adjusting for several confounders. One study reported an increased overall mortality after INHA with a HR of 1.47 (95% CI 1.31-1.64, p≤0.001), while another study reported a tendency of decreased overall mortality after TIVA (HR 0.85, 95% CI 0.72-1.00, p=0.051). A third study showed no difference in the overall mortality, but prolonged recurrence-free survival after TIVA with a HR of 0.48 (95% CI 0.27-0.86, p=0.014). In one study, the rate of pulmonary complications was significantly higher after INHA compared with TIVA, while other postoperative complications were comparable. There are currently four propensity-adjusted retrospective studies indicating that TIVA might be the preferred anesthetic choice in cancer surgery. However, evidence is currently of low quality and randomized clinical trials are required for further investigation.
Topics: Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Disease-Free Survival; Hospital Mortality; Humans; Immunity, Cellular; Incidence; Isoflurane; Killer Cells, Natural; Methyl Ethers; Neoplasm Micrometastasis; Neoplasms; Perioperative Period; Postoperative Complications; Propofol; Sevoflurane; Surgical Procedures, Operative; T-Lymphocytes, Helper-Inducer
PubMed: 28797751
DOI: 10.1016/j.jclinane.2017.08.001 -
Spine Aug 2018Systematic literature review and meta-analysis. (Meta-Analysis)
Meta-Analysis Review
STUDY DESIGN
Systematic literature review and meta-analysis.
OBJECTIVE
The objective of this systematic literature review was to evaluate if intraoperative neurophysiological monitoring (IONM) can prevent neurological injury during spinal operative surgical procedures.
SUMMARY OF BACKGROUND DATA
IONM seems to have presumable positive effects in identifying neurological deficits. However, the role of IONM in the decrease of new neurological deficits remains unclear.
METHODS
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and Meta-analysis, we reviewed clinical comparative studies who evaluate the rate of new neurological events in patients who had a spinal surgery with and without IONM. Studies were then classified according to their level of evidence. Methodological quality was assessed according to methodological index for non-randomized studies instrument.
RESULTS
Six studies were evaluated comparing neurological events with and without IONM use by the random effects model. There was a great statistical heterogeneity. The pooled odds ratio (OR) was 0.72 {0.71; 1.79}, P = 0.4584. A specific analysis was done for two studies reporting the results of IONM for spinal surgery of intramedullary lesions. The OR was 0.1993 (0.0384; 1.0350), P = 0.0550.
CONCLUSION
IONM did not result into fewer neurological events with the obtained evidence of the included studies. For intramedullary lesions, there was a trend to fewer neurological events in patients who underwent surgery with IONM. Further prospective randomized studies are necessary to clarify the indications of IONM in spinal surgeries.
LEVEL OF EVIDENCE
2.
Topics: Humans; Intraoperative Neurophysiological Monitoring; Neurosurgical Procedures; Postoperative Complications; Spinal Diseases
PubMed: 30063222
DOI: 10.1097/BRS.0000000000002575 -
Facial Plastic Surgery & Aesthetic... Dec 2021To compare the effectiveness of tranexamic acid (TXA) in reducing blood loss and decreasing surgery duration in craniomaxillofacial surgery. The literature was... (Meta-Analysis)
Meta-Analysis
To compare the effectiveness of tranexamic acid (TXA) in reducing blood loss and decreasing surgery duration in craniomaxillofacial surgery. The literature was searched systematically for all comparative studies of the effect of TXA on craniomaxillofacial surgery with placebo to evaluate the efficacy of TXA in craniomaxillofacial surgery. The primary outcome was intraoperative blood loss, and secondary outcomes were postoperative hematocrit, postoperative hemoglobin, and operation duration. This systematic review included 16 studies consisting of 958 patients. Meta-analysis revealed that compared with the placebo group, the TXA group showed a significant reduction in intraoperative blood loss of 139.81 mL (95% confidence interval, CI: -179.66 to -99.96 mL; < 0.01), a shortening of the maxillary surgery duration of 15.48 min (95% CI: -21.03 to -9.92 min; < 0.01), an elevation of the postoperative hemoglobin level of 0.74 mg/dL (95% CI: 0.42 to 1.07 mg/dL; < 0.01), and a limited effect on increasing the postoperative hematocrit level of 1.77% (95% CI: 0.17 to 3.36; = 0.03). The use of TXA in craniomaxillofacial surgery can effectively reduce intraoperative blood loss, maintain elevate postoperative hemoglobin and hematocrit levels, and reduce the operation duration.
Topics: Antifibrinolytic Agents; Blood Loss, Surgical; Hemostasis, Surgical; Humans; Operative Time; Orthopedic Procedures; Skull; Surgery, Oral; Tranexamic Acid; Treatment Outcome
PubMed: 33661026
DOI: 10.1089/fpsam.2020.0590 -
Obesity Reviews : An Official Journal... Sep 2021Iron deficiency (ID) and iron deficiency anemia (IDA) are common following bariatric surgery; however, there are limited standardized treatment recommendations for their... (Review)
Review
Iron deficiency (ID) and iron deficiency anemia (IDA) are common following bariatric surgery; however, there are limited standardized treatment recommendations for their management. The purpose of this study was to review the current strategies for iron supplementation following bariatric surgery and assess their relative efficacy in managing ID and IDA. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched to January 2021. Primary outcomes of interest were prevention or improvement in ID or IDA with iron supplementation. Forty-nine studies with 12,880 patients were included. Most patients underwent Roux-en-Y gastric bypass (61.9%). Iron supplementation was most commonly administered orally for prevention of ID/IDA and was effective in 52% of studies. Both IV and oral iron were given for treatment of ID/IDA. Fifty percent (3/6) of the oral and 100% (3/3) of the IV supplementation strategies were effective at treating ID. Iron supplementation strategies employed following bariatric surgery are highly variable, and many do not provide sufficient iron to prevent the development of ID and IDA, potentially due to poor patient adherence. Further high-quality prospective trials, particularly comparing intravenous and oral iron, are warranted in order to determine the ideal dosage, route, and duration of iron supplementation.
Topics: Anemia, Iron-Deficiency; Bariatric Surgery; Dietary Supplements; Humans; Iron; Prospective Studies
PubMed: 34013662
DOI: 10.1111/obr.13268