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BMC Geriatrics Dec 2017Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of... (Review)
Review
BACKGROUND
Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.
METHODS
A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.
RESULTS
Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.
CONCLUSIONS
There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.
TRIAL REGISTRATION
This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
Topics: Aged; Benzodiazepines; Delirium; Humans; Postoperative Complications; Premedication; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29284416
DOI: 10.1186/s12877-017-0695-x -
British Journal of Anaesthesia Feb 2017The increased popularity of paravertebral block (PVB) can be attributed to its relative safety and comparable efficacy when compared with epidural analgesia. It has thus... (Meta-Analysis)
Meta-Analysis Review
The increased popularity of paravertebral block (PVB) can be attributed to its relative safety and comparable efficacy when compared with epidural analgesia. It has thus been recommended for open cholecystectomy and other less painful surgeries such as inguinal herniorraphy and appendectomy. We performed a systematic review of PVB in paediatric abdominal conditions to assess its clinical efficacy and side effects compared with other analgesic therapies.A search of Medline, Embase, and Web of Science and hand-searching references from inception date to May 2016 was done. Relevant studies were randomized clinical trials in patients 0-18 years old comparing PVB (single shot or continuous catheter) with any comparator and analgesic medication. Pain scores, rescue analgesia and adverse events were compared.The systematic reviews identified six trials enrolling 358 paediatric patients. PVB medications included bupivacaine, ropivacaine, lidocaine, and fentanyl. Surgical procedures included inguinal herniorraphy, cholecystectomy, and appendectomy. The standardized mean difference in early pain scores favoured PVB: 0.85 [95% confidence interval (CI) 0.12-1.58] at 4-6 h and 0.64 (95% CI 0.28-1.00) at 24 h. One study reported a reduced length of stay. Parental [odds ratio (OR) 5.12 (95% CI 2.59-10.1)] and surgeon [OR 6.05 (95% CI 2.25-16.3)] satisfaction were higher in those receiving a PVB. No major complications occurred with a PVB.PVB resulted in minimally improved pain scores for up to 24 h after surgery, reduced rescue analgesia requirements, and increased surgeon and parental satisfaction. PVB is a good alternative to caudal and ilioinguinal block in paediatric abdominal surgery.
Topics: Abdomen; Adolescent; Child; Child, Preschool; Humans; Nerve Block; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 28100519
DOI: 10.1093/bja/aew387 -
Hepatobiliary & Pancreatic Diseases... Dec 2023Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand... (Review)
Review
BACKGROUND
Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection.
DATA SOURCES
This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis.
RESULTS
This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade.
CONCLUSIONS
Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
Topics: Humans; Hepatectomy; Liver Neoplasms; Liver Failure; Liver Function Tests; Postoperative Complications; Retrospective Studies
PubMed: 36973111
DOI: 10.1016/j.hbpd.2023.03.001 -
Revista Espanola de Cirugia Ortopedica... 2015To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis. (Review)
Review
OBJECTIVE
To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis.
METHODS
A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected.
RESULTS
A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events.
CONCLUSIONS
The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain.
Topics: Analgesics; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Osteoarthritis, Hip; Osteoarthritis, Knee; Pain, Postoperative; Perioperative Care; Treatment Outcome
PubMed: 25450160
DOI: 10.1016/j.recot.2014.09.004 -
Journal of Clinical Anesthesia Feb 2016Goal-directed fluid therapy (GDHT) has been proposed as a method to reduce complications and mortality. (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
Goal-directed fluid therapy (GDHT) has been proposed as a method to reduce complications and mortality.
DESIGN
Meta-analysis of the effects of perioperative GDHT in adult noncardiac surgery on mortality and postoperative complications was performed using the PRISMA methodology. A systematic search was performed in MEDLINE, PubMed, EMBASE, and the Cochrane Library (last update, October 2014). Inclusion criteria were as follows: randomized clinical trials (RCTs) in which perioperative GDHT was compared with conventional fluid management in noncardiac surgery. Exclusion criteria were as follows: trauma and pediatric surgery studies. End points were mortality and number of patients with complications.
SETTING
District general hospital.
PATIENTS
Thirty-nine RCTs were initially identified, with 8 fulfilling the inclusion criteria. Two RCTs were added by manual search, resulting in 10 RCTs in the final analysis, including 1527 patients.
MEASUREMENTS
Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by supraphysiological or physiological hemodynamic goal and by time the intervention was carried out, perioperative or postoperative), and predefined sensitivity analysis.
MAIN RESULTS
A significant reduction was observed in mortality associated with GDHT compared with conventional fluid therapy (risk ratio, 0.63; 95% confidence interval, 0.42-0.94; P = .02). However, no differences were found in the number of patients with complications (risk ratio, 0.75; 95% confidence interval, 0.50-1.17; P = .21), and the sensitivity analysis did not confirm the results.
CONCLUSIONS
This meta-analysis, with its limitations, shows that the use of perioperative GDHT may reduce postoperative mortality, but it is unable to show a reduction in the number of patients with complications.
Topics: Fluid Therapy; Goals; Hemodynamics; Humans; Perioperative Care; Randomized Controlled Trials as Topic; Surgical Procedures, Operative
PubMed: 26440438
DOI: 10.1016/j.jclinane.2015.08.004 -
World Journal of Surgery Aug 2016This study aimed to assess the efficacy of intraoperative neurophysiologic monitoring (IONM) in preventing recurrent laryngeal nerve palsy (RLNP) during thyroid surgery.... (Review)
Review
This study aimed to assess the efficacy of intraoperative neurophysiologic monitoring (IONM) in preventing recurrent laryngeal nerve palsy (RLNP) during thyroid surgery. When IONM results in false positives, it seeks to evaluate contributing factors. A systematic review was conducted gauging the predictive power of neuromonitoring in determining RLN function intraoperatively, its reductions of temporary and permanent RLNP rates, and surgeons' response to the technology. MEDLINE, EMBASE, and PubMed were searched for RLN monitoring in thyroid surgery following a set of inclusion/exclusion criteria. Seventeen studies comparing thyroid surgery with and without IONM were reviewed, including 30,926 patients. Selected studies were pooled to gage the predictive power. Mean specificity of IONM in identifying functional nerves was 90.24 % among 7366 nerves at risk (NAR). However, mean positive predictive power (PPP) was low, and both specificity and PPP varied substantially when stratified by risk levels. Among the pooled studies focusing on IONM efficacy-there were 44,575 NAR, of which (57.98 %) were operated on with IONM and 18,732 (42.02 %) without (control). The rates of overall RLNP per NAR were 3.18 and 3.83 % for the IONM group and control, respectively. There is no statistically significant difference between IONM and control, a conclusion supported by qualitative analysis from many individual studies. IONM is not recommended as the standard of care for thyroidectomies. Low PPP of IONM and complications associated with IONM-assisted thyroidectomies may be attributed to either the absence of a standardized negative-signal cutoff value or injury from intubation.
Topics: Humans; Intraoperative Complications; Intraoperative Neurophysiological Monitoring; Recurrent Laryngeal Nerve Injuries; Thyroid Gland; Thyroidectomy
PubMed: 27329143
DOI: 10.1007/s00268-016-3594-y -
BMC Surgery Aug 2023Preventive colostomy is required for colorectal surgery, and the incidence of complications associated with ileostomy and colostomy remains controversial. This study... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Preventive colostomy is required for colorectal surgery, and the incidence of complications associated with ileostomy and colostomy remains controversial. This study aimed to compare the incidence of postoperative complications between ileostomy and colostomy procedures.
METHODS
Data analysis was conducted on 30 studies, and meta-analysis and trial sequential analysis (TSA) were performed on five studies. The basic indicators, such as stoma prolapse, leak, wound infection, ileus, and a series of other indicators, were compared.
RESULTS
No statistically significant differences were observed with complications other than stoma prolapse. Meta-analysis and TSA showed that the incidence of ileostomy prolapse was lower than that of colostomy prolapse, and the difference was statistically significant. Apart from the four complications listed above, the general data analysis showed differences in incidence between the two groups. The incidence of skin irritation, parastomal hernia, dehydration, pneumonia, and urinary tract infections was higher with ileostomy than with colostomy. In contrast, the incidence of parastomal fistula, stenosis, hemorrhage, and enterocutaneous fistula was higher with colostomy than with ileostomy.
CONCLUSIONS
There were differences in the incidence of ileostomy and colostomy complications in the selected studies, with a low incidence of ileostomy prolapse.
PROSPERO REGISTRATION NUMBER
CRD42022303133.
Topics: Humans; Colostomy; Ileostomy; Anastomosis, Surgical; Postoperative Complications; Prolapse
PubMed: 37568176
DOI: 10.1186/s12893-023-02129-w -
Journal of Clinical Neuroscience :... Jul 2018Wound drains are routinely used in lumbar decompressive surgery (LDS). However, it remains unclear whether this practice helps to prevent symptomatic epidural hematoma... (Meta-Analysis)
Meta-Analysis Review
Wound drains are routinely used in lumbar decompressive surgery (LDS). However, it remains unclear whether this practice helps to prevent symptomatic epidural hematoma formation and associated complications, particularly following non-instrumented procedures. A systematic review and meta-analysis was therefore completed to critically appraise the literature. The search protocol was conducted using the Ovid MEDLINE, EMBASE, Scopus, Cochrane Library, and Google Scholar databases. Articles meeting the following criteria were included: (i) examined patients undergoing LDS; (ii) included cases receiving post-operative wound drains; (iii) detailed adverse outcomes including symptomatic epidural hematomas or wound infection; and (iv) were published in English in a peer-reviewed journal. Pooled risk differences (RD) for adverse outcomes were calculated using Comprehensive Meta-Analysis software. Three Level 1b prospective randomized studies and five Level 2b retrospective cohort studies were included, from which 5327 cases were identified as having received a surgical drain and 773 were identified as having received no drainage following non-instrumented LDS. There was no difference between groups in the risk of symptomatic epidural hematoma (RD = 0.02; 95% CI -0.02 - 0.06, p = 0.28) or post-operative infection (RD = 0.00; 95% CI -0.01 - 0.01, p = 0.91). In conclusion, symptomatic epidural hematomas and infection are rare following non-instrumented LDS, with incidence rates unaffected by the routine use of wound drainage.
Topics: Decompression, Surgical; Drainage; Hematoma, Epidural, Spinal; Humans; Incidence; Postoperative Complications; Surgical Wound Infection
PubMed: 29680443
DOI: 10.1016/j.jocn.2018.04.038 -
The Surgeon : Journal of the Royal... Apr 2015Lean and Six Sigma are improvement methodologies developed in the manufacturing industry and have been applied to healthcare settings since the 1990 s. They use a... (Review)
Review
BACKGROUND
Lean and Six Sigma are improvement methodologies developed in the manufacturing industry and have been applied to healthcare settings since the 1990 s. They use a systematic and reproducible approach to provide Quality Improvement (QI), with a flexible process that can be applied to a range of outcomes across different patient groups. This review assesses the literature with regard to the use and utility of Lean and Six Sigma methodologies in surgery.
METHODS
MEDLINE, Embase, PsycINFO, Allied and Complementary Medicine Database, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Health Business Elite and the Health Management Information Consortium were searched in January 2014. Experimental studies were included if they assessed the use of Lean or Six Sigma on the ability to improve specified outcomes in surgical patients.
RESULTS
Of the 124 studies returned, 23 were suitable for inclusion with 11 assessing Lean, 6 Six Sigma and 6 Lean Six Sigma. The broad range of outcomes can be collated into six common aims: to optimise outpatient efficiency, to improve operating theatre efficiency, to decrease operative complications, to reduce ward-based harms, to reduce mortality and to limit unnecessary cost and length of stay. The majority of studies (88%) demonstrate improvement; however high levels of systematic bias and imprecision were evident.
CONCLUSION
Lean and Six Sigma QI methodologies have the potential to produce clinically significant improvement for surgical patients. However there is a need to conduct high-quality studies with low risk of systematic bias in order to further understand their role.
Topics: Efficiency, Organizational; Humans; Length of Stay; Operating Rooms; Patient Safety; Postoperative Complications; Quality Improvement; Surgical Procedures, Operative; Total Quality Management
PubMed: 25189692
DOI: 10.1016/j.surge.2014.08.002 -
Surgery For Obesity and Related... Jun 2016Bariatric surgery is found to prevent type 2 diabetes, improve glycemic control, and decrease long-term incidence of microvascular and macrovascular complications in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Bariatric surgery is found to prevent type 2 diabetes, improve glycemic control, and decrease long-term incidence of microvascular and macrovascular complications in obese persons. However, its effect on urinary albumin excretion (UAE) in patients with diabetic nephropathy (DN) is still unknown. This is a systematic review and meta-analysis of observational studies on bariatric surgery and change in UAE in patients with diabetes.
OBJECTIVE
To explore whether there is improvement in UAE after bariatric surgery.
METHODS
We comprehensively searched the databases of MEDLINE, Embase, and Cochrane. The inclusion criteria were published studies evaluating effects of bariatric surgery in patients with DN at baseline. The primary outcome was the pre- and postbariatric surgery UAE as characterized by urinary albumin-to-creatinine ratio and albuminuria. A meta-analysis comparing pre- and postsurgery UAE was performed.
RESULTS
From 65 full-text articles, 15 observational studies met our inclusion criteria, and 11 studies were included in the meta-analysis based on the random effects model. There was a significant reduction in urinary albumin-to-creatinine ratio after bariatric surgery with a mean difference of -6.60 mg/g of creatinine (95% CI -9.19 to -4.02; P<.001). There was also a reduction in albuminuria with a mean difference of -55.76 mg/24 hours (95% CI -92.11 to -19.41; P<.001) after bariatric surgery.
CONCLUSION
Bariatric surgery significantly decreases urinary albumin excretion in DN. However, studies comparing bariatric surgery and conventional or intensive care of diabetes on UAE outcome should be done.
Topics: Adolescent; Adult; Aged; Albuminuria; Bariatric Surgery; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Nephropathies; Epidemiologic Methods; Humans; Middle Aged; Postoperative Care; Preoperative Care; Treatment Outcome; Young Adult
PubMed: 26948447
DOI: 10.1016/j.soard.2015.11.019