-
BMC Gastroenterology Jan 2021Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to...
BACKGROUND
Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures.
METHODS
We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool.
RESULTS
We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations.
CONCLUSIONS
Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.
Topics: Adult; Anesthesia; Conscious Sedation; Endoscopy, Gastrointestinal; Humans; Hypnotics and Sedatives; Propofol
PubMed: 33413147
DOI: 10.1186/s12876-020-01561-z -
PloS One 2020The present meta-analysis was based on the available studies to determine the potential role of the initial and regional cerebral oxygen saturation (rSO2) in monitoring... (Meta-Analysis)
Meta-Analysis
The present meta-analysis was based on the available studies to determine the potential role of the initial and regional cerebral oxygen saturation (rSO2) in monitoring the efficiency of cardiopulmonary resuscitation (CPR) and predicting the return of spontaneous circulation (ROSC). Three electronic databases of PubMed, Embase, and the Cochrane Library were searched to identify the studies that investigated the role of rSO2 on ROSC in CA patients throughout May 2018. The weighted mean difference (WMD) with 95% confidence interval (CI) was calculated to estimate the pooled effect using a random-effects model. Sensitivity, subgroup analyses, and publication bias were conducted. A total of 13 studies involving 678 CA patients (300 in-hospital (IH) patients, and 378 out-hospital (OH) patients) were included. The summary WMD suggested that ROSC patients were associated with higher initial rSO2 (WMD: 10.10%; 95% CI: 5.66-14.55; P<0.001) and mean rSO2 (WMD: 14.16%; 95% CI: 10.51-17.81; P<0.001) levels during CA and ROSC as compared to the non-ROSC. The results of meta-regression suggested that the male percentage and the location of cardiac arrest might bias the initial or mean rSO2 and the incidence of ROSC. These significant differences were observed in nearly all subsets. The findings of this study suggested that high initial or mean rSO2 levels were both associated with an increased incidence of ROSC in CA patients undergoing CPR. These correlations might be affected by the percentage of males or the location of cardiac arrest, thereby necessitating further large-scale studies to substantiate whether these correlations differ according to gender and the location of cardiac arrest.
Topics: Aged; Aged, 80 and over; Blood Circulation; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Female; Heart Arrest; Humans; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Outcome Assessment, Health Care; Oximetry; Oxygen; Prognosis; Spectroscopy, Near-Infrared
PubMed: 32857778
DOI: 10.1371/journal.pone.0234979 -
BMJ Global Health Dec 2021Increasing access to oxygen services may improve outcomes among children with pneumonia living in low-resource settings. We conducted a systematic review to estimate the... (Meta-Analysis)
Meta-Analysis
Oxygen systems strengthening as an intervention to prevent childhood deaths due to pneumonia in low-resource settings: systematic review, meta-analysis and cost-effectiveness.
OBJECTIVES
Increasing access to oxygen services may improve outcomes among children with pneumonia living in low-resource settings. We conducted a systematic review to estimate the impact and cost-effectiveness of strengthening oxygen services in low-income and middle-income countries with the objective of including oxygen as an intervention in the Lives Saved Tool.
DESIGN
We searched EMBASE and PubMed on 31 March 2021 using keywords and MeSH terms related to 'oxygen', 'pneumonia' and 'child' without restrictions on language or date. The risk of bias was assessed for all included studies using the quality assessment tool for quantitative studies, and we assessed the overall certainty of the evidence using Grading of Recommendations, Assessment, Development and Evaluations. Meta-analysis methods using random effects with inverse-variance weights was used to calculate a pooled OR and 95% CIs. Programme cost data were extracted from full study reports and correspondence with study authors, and we estimated cost-effectiveness in US dollar per disability-adjusted life-year (DALY) averted.
RESULTS
Our search identified 665 studies. Four studies were included in the review involving 75 hospitals and 34 485 study participants. We calculated a pooled OR of 0.52 (95% CI 0.39 to 0.70) in favour of oxygen systems reducing childhood pneumonia mortality. The median cost-effectiveness of oxygen systems strengthening was $US62 per DALY averted (range: US$44-US$225). We graded the risk of bias as moderate and the overall certainty of the evidence as low due to the non-randomised design of the studies.
CONCLUSION
Our findings suggest that strengthening oxygen systems is likely to reduce hospital-based pneumonia mortality and may be cost-effective in low-resource settings. Additional implementation trials using more rigorous designs are needed to strengthen the certainty in the effect estimate.
Topics: Child; Cost-Benefit Analysis; Humans; Oxygen; Pneumonia
PubMed: 34930758
DOI: 10.1136/bmjgh-2021-007468 -
Indian Journal of Anaesthesia Aug 2020Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We...
Adverse heart rate responses during beach-chair position for shoulder surgeries - A systematic review and meta-analysis of their incidence, interpretations and associations.
BACKGROUND AND AIMS
Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We analysed the incidence, associations, and interpretations of adverse HR-responses in this clinical setting.
METHODS
We performed a meta-analysis of trials that reported HR-related data in anaesthetised subjects undergoing elective shoulder surgeries in BCP. Studies included prospective, randomised, quasi-randomised and non-randomised, controlled clinical trials as well as observational cohorts. Literature search was conducted in MEDLINE, EMBASE, CINHAL and the Cochrane Central Register of Controlled Trials of the 21 century. In the first analysis, we studied the incidence and associations of bradycardia/hypotension-bradycardia episodes (HBE) with respect to the type of anaesthesia and different pharmacological agents. In the second, we evaluated anaesthetic influences, associations and inter-relationships between monitored parameters with respect to HR-behaviours.
RESULTS
Among the trials designed with bradycardia/HBE as a primary end point, the observed incidence of bradycardia was 9.1% and that of HBE, 14.9% and 22.7% [(for Interscalene block (ISB) ± sedation) subjects and general anaesthesia (GA) + ISB, respectively]. There was evidence of higher observed risk of developing adverse HR-responses for GA subjects over ISB (Risk Difference, < 0.05). Concomitant use of β-agonists did not increase risk of HBEs ( = 0.29, = 11.4%) or with fentanyl ( = 0.45, = 0%) for ISB subjects (subgroup analysis). Fentanyl significantly influenced the HR-drop over time [meta-regression, estimates (standard error), 14.9 (5.4), 9.8 (4.3) and 17 (2.6); = 0.007, 0.024 and <0.001; for early, mid and delayed periods, respectively] in GA subjects. With respect to number of subjects experiencing cerebral desaturation events (CDEs), total intravenous anaesthesia (TIVA)- propofol had higher risk over inhalational anaesthesia ( = 0.006, = 86.7%). Meta-correlation analysis showed relationships between the HR and rSO(regional cerebral oxygen saturation) or SjvO(jugular venous oxygen saturation) values (r = 0.608, 95%CI, 0.439 to 0.735, < 0.001, = 77.4% and r = 0.397, 95%CI, 0.151 to 0.597, < 0.001, = 64.3%, respectively).
CONCLUSIONS
There is not enough evidence to claim the associations of adverse HR-responses with any specific factor. HR-fall is maximal with fentanyl and its variability is associated with changes in rSO. Fall in rSO could be the common link triggering adverse HR-responses in BCP.
PubMed: 32934399
DOI: 10.4103/ija.IJA_228_20 -
BMC Pulmonary Medicine Jun 2021Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and...
BACKGROUND
Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery.
METHODS
This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation.
RESULTS
Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient's tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence.
CONCLUSION
Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.
Topics: Adult; Analgesics, Opioid; Blood Gas Monitoring, Transcutaneous; Bronchoscopy; Carbon Dioxide; Conscious Sedation; Guidelines as Topic; Humans; Hypercapnia; Midazolam; Patient Safety
PubMed: 34112130
DOI: 10.1186/s12890-021-01532-4 -
European Journal of Vascular and... Nov 2021Carotid endarterectomy is recommended for the prevention of ischaemic stroke due to carotid stenosis. However, the risk of stroke after carotid endarterectomy has been... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Carotid endarterectomy is recommended for the prevention of ischaemic stroke due to carotid stenosis. However, the risk of stroke after carotid endarterectomy has been estimated at 2% - 5%. Monitoring intra-operative cerebral oxygenation with near infrared spectroscopy (NIRS) has been assessed as a strategy to reduce intra- and post-operative complications. The aim was to summarise the diagnostic accuracy of NIRS to detect intra-operative ischaemic events, the values associated with ischaemic events, and the relative contribution of external carotid contamination to the NIRS signal in adults undergoing carotid endarterectomy.
DATA SOURCES
EMBASE, MEDLINE, Cochrane Centre Register of Controlled Trials, and reference lists through May 2019 were searched.
REVIEW METHODS
Non-randomised and randomised studies assessing NIRS as an intra-operative monitoring tool in carotid endarterectomy were included. Studies using NIRS as the reference were excluded. Risk of bias was assessed using the Newcastle Ottawa Scale, RoB-2, and QUADAS-2.
RESULTS
Seventy-six studies were included (n = 8 480), under local (n = 1 864) or general (n = 6 582) anaesthesia. Seven studies were eligible for meta-analysis (n = 524). As a tool for identifying intra-operative ischaemia, specificity increased with more stringent NIRS thresholds, while there was unpredictable variation in sensitivity across studies. A Δ20% threshold under local anaesthesia resulted in pooled estimates for sensitivity and specificity of 70.5% (95% confidence interval, CI, 54.1 - 82.9) and 92.4% (95% CI 85.5 - 96.1) compared with awake neurological monitoring. These studies had low or unclear risk of bias. NIRS signal consistently dropped across clamping and recovered to pre-clamp values upon de-clamp in most studies, and larger decreases were observed in patients with ischaemic events. The contribution of extracranial signal to change in signal across clamp varied from 3% to 50%.
CONCLUSION
NIRS has low sensitivity and high specificity to identify intra-operative ischaemia compared with awake monitoring. Extracranial signal contribution was highly variable. Ultimately, data from high quality studies are desperately needed to determine the utility of NIRS.
Topics: Carotid Stenosis; Endarterectomy, Carotid; Humans; Monitoring, Intraoperative; Sensitivity and Specificity; Spectroscopy, Near-Infrared
PubMed: 34627675
DOI: 10.1016/j.ejvs.2021.08.022 -
Journal of Clinical Sleep Medicine :... Aug 2021Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in...
STUDY OBJECTIVES
Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as a step toward evidence-based clinical decision-making for RS.
METHODS
A literature search was performed in the PubMed and Embase databases (1990-2020) following PRISMA guidelines. Articles reporting on RS and UAO treatment were included if the following objective measures were studied: oximetry, polysomnography, and blood gas. Quality was appraised by the methodological index for nonrandomized studies (range: 0-24).
RESULTS
A total of 91 articles met the inclusion criteria. The mean methodological index for nonrandomized studies score was 7.1 (range: 3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings, in more than half. Of 71 studies that evaluated UAO interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive apnea-hypopnea index (27%), and oxygen desaturation index (16%). Only 42 studies reported indications for UAO intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified.
CONCLUSIONS
This systematic review demonstrates a lack of standardization, interpretation, and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS.
CITATION
Logjes RJH, MacLean JE, de Cort NW, et al. Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review. . 2021;17(8):1717-1729.
Topics: Airway Obstruction; Humans; Infant; Oxygen Saturation; Pierre Robin Syndrome; Polysomnography; Sleep
PubMed: 33960296
DOI: 10.5664/jcsm.9394 -
Restorative Dentistry & Endodontics Nov 2020This systematic review aimed to identify mean oxygen saturation values (SpO) using pulse oximetry in permanent maxillary anterior teeth.
OBJECTIVES
This systematic review aimed to identify mean oxygen saturation values (SpO) using pulse oximetry in permanent maxillary anterior teeth.
MATERIALS AND METHODS
The MEDLINE, Scientific Electronic Library Online, Cochrane Central Register of Controlled Trials, EMBASE, and Literatura Latino Americana em Ciências da Saúde electronic databases were searched. Combinations and variations of "oximetry" AND "dental pulp test" were used as search terms. Studies reporting means and standard deviations of SpO values were included. Two reviewers independently extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Heterogeneity was assessed using the statistic, and all analyses were performed using R software. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Newcastle-Ottawa scale.
RESULTS
Of the 251 studies identified, 19 met the eligibility criteria and were included (total sample, 4,541 teeth). In the meta-analysis, the mean SpO values were 84.94% (95% confidence interval [CI], 84.85%-85.04%) for the central incisors, 89.29% (95% CI, 89.22%-89.35%) for the lateral incisors, and 89.20% (95% CI, 89.05%-89.34%) for the canines. The studies were predominantly low-quality due to the high risk of bias associated with the index test, unclear risk regarding patient selection, and concerns about outcome assessment.
CONCLUSIONS
Although most studies were low-quality, the oxygen saturation levels in normal pulp could be established (minimum saturation, 77.52%). Despite the risk of bias of the included studies, the reference values reported herein are clinically relevant for assessments of changes in pulp status.
TRIAL REGISTRATION
International Prospective Register of Systematic Reviews Identifier: CRD42018085598.
PubMed: 33294413
DOI: 10.5395/rde.2020.45.e48 -
BMJ Open Sep 2017Goal-directed optimisation of cerebral oxygenation using near-infrared spectroscopy (NIRS) during cardiopulmonary bypass is widely used. We tested the hypotheses that... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Goal-directed optimisation of cerebral oxygenation using near-infrared spectroscopy (NIRS) during cardiopulmonary bypass is widely used. We tested the hypotheses that the use of NIRS cerebral oximetry results in reductions in cerebral injury (neurocognitive function, serum biomarkers), injury to other organs including the heart and brain, transfusion rates, mortality and resource use.
DESIGN
Systematic review and meta-analysis.
SETTING
Tertiary cardiac surgery centres in North America, Europe and Asia.
PARTICIPANTS
A search of Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature Plus from inception to November 2016 identified 10 randomised trials, enrolling a total of 1466 patients, all in adult cardiac surgery.
INTERVENTIONS
NIRS-based algorithms designed to optimise cerebral oxygenation versus standard care (non-NIRS-based) protocols in cardiac surgery patients during cardiopulmonary bypass.
OUTCOME MEASURES
Mortality, organ injury affecting the brain, heart and kidneys, red cell transfusion and resource use.
RESULTS
Two of the 10 trials identified in the literature search were considered at low risk of bias. Random-effects meta-analysis demonstrated similar mortality (risk ratio (RR) 0.76, 95% CI 0.30 to 1.96), major morbidity including stroke (RR 1. 08, 95% CI 0.40 to 2.91), red cell transfusion and resource use in NIRS-treated patients and controls, with little or no heterogeneity. Grades of Recommendation, Assessment, Development and Evaluation of the quality of the evidence was low or very low for all of the outcomes assessed.
CONCLUSIONS
The results of this systematic review did not support the hypotheses that cerebral NIRS-based algorithms have clinical benefits in cardiac surgery.
TRIAL REGISTRATION NUMBER
PROSPERO CRD42015027696.
Topics: Adult; Brain Injuries; Cardiopulmonary Bypass; Cerebrovascular Circulation; Erythrocyte Transfusion; Humans; Oximetry; Randomized Controlled Trials as Topic; Spectroscopy, Near-Infrared; Stroke
PubMed: 28882917
DOI: 10.1136/bmjopen-2017-016613 -
Brain and Behavior Dec 2018Sleep-Disordered Breathing (SDB) is frequent in stroke patients. Polysomnography (PSG) and cardiorespiratory polygraphy are used to confirm SDB, but the need for PSG...
OBJECTIVES
Sleep-Disordered Breathing (SDB) is frequent in stroke patients. Polysomnography (PSG) and cardiorespiratory polygraphy are used to confirm SDB, but the need for PSG exceeds the available resources for systematic testing. Therefore, a simple and robust pre-screening instrument is necessary to identify the patients with an urgent need for a targeted PSG. The aim of this systematic review was to identify and evaluate the available methods to pre-screen stroke patients possibly suffering from SDB.
MATERIALS AND METHODS
Eleven studies out of 3,561 studies met the inclusion criteria. The selected studies assessed the efficiency of seven instruments based on the data acquired clinically or by inquiries (Berlin Questionnaire, Epworth Sleepiness Scale, SOS, Modified Sleep Apnea Scale of the Sleep Disorders Questionnaire, STOP-BANG, Four-variable Screening Tool and Multivariate Apnea Index) and three physiological measures (capnography, nocturia, nocturnal oximetry). The instruments were used to predict SDB in patients after acute or subacute stroke. Either PSG or cardiorespiratory polygraphy was used as a standard to measure SDB.
RESULTS
No independent studies using the same questionnaires, methods or criteria were published reducing generalizability. Overall, the questionnaires were quite sensitive in finding SDB but not highly specific in identifying the non-affected. The physiological measures (capnography) indicated promising results in predicting SDB, but capnography is not an ideal pre-screening instrument as it requires a specialist to interpret the results.
CONCLUSIONS
The results of pre-screening of SDB in acute and subacute stroke patients are promising but inconsistent. The current pre-screening methods cannot readily be referred to clinicians in neurologic departments. Thus, it is necessary to conduct more research on developing novel pre-screening methods for detecting SDB after stroke.
Topics: Aged; Early Diagnosis; Female; Humans; Male; Middle Aged; Nocturia; Oximetry; Polysomnography; Sleep Apnea Syndromes; Stroke; Surveys and Questionnaires
PubMed: 30371010
DOI: 10.1002/brb3.1146