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Journal of Clinical Anesthesia Nov 2023To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain. (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain.
DESIGN
Systematic review and meta-analysis of randomized clinical trials.
SETTING
Operating room, postoperative recovery room and ward.
PATIENTS
Patients undergoing general anesthesia.
INTERVENTIONS
After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022).
MEASUREMENTS
Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted.
MAIN RESULTS
We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19-0.59 and 4.02 MME with a CI of 1.73-6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent.
CONCLUSIONS
We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited.
Topics: Humans; Analgesics, Opioid; Chronic Pain; Pain, Postoperative; Anesthesia, General; Postoperative Nausea and Vomiting
PubMed: 37515877
DOI: 10.1016/j.jclinane.2023.111215 -
Critical Care (London, England) Sep 2023Cardiac surgery-associated acute kidney injury (CSA-AKI) is frequent. While two network meta-analyses assessed the impact of pharmacological interventions to prevent... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cardiac surgery-associated acute kidney injury (CSA-AKI) is frequent. While two network meta-analyses assessed the impact of pharmacological interventions to prevent CSA-AKI, none focused on non-pharmacological interventions. We aim to assess the effectiveness of non-pharmacological interventions to reduce the incidence of CSA-AKI.
METHODS
We searched PubMed, Embase, Central and clinical trial registries from January 1, 2004 (first consensus definition of AKI) to July 1, 2023. Additionally, we conducted manual screening of abstracts of major anesthesia and intensive care conferences over the last 5 years and reference lists of relevant studies. We selected all randomized controlled trials (RCTs) assessing a non-pharmacological intervention to reduce the incidence of CSA-AKI, without language restriction. We excluded RCTs of heart transplantation or involving a pediatric population. The primary outcome variable was CSA-AKI. Two reviewers independently identified trials, extracted data and assessed risk of bias. Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence.
RESULTS
We included 86 trials (25,855 patients) evaluating 10 non-pharmacological interventions to reduce the incidence of CSA-AKI. No intervention had high-quality evidence to reduce CSA-AKI. Two interventions were associated with a significant reduction in CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion (RR, 0.55 [95% CI 0.40-0.76], I = 0%; P = 0.44) and remote ischemic preconditioning (RR, 0.86 [0.78-0.95]; I = 23%; P = 0.07). Pulsatile flow during cardiopulmonary bypass was associated with a significant reduction in CSA-AKI incidence but with very low quality of evidence (RR = 0.69 [0.48; 0.99]; I = 53%; P < 0.01). We found high quality of evidence for lack of effect of restrictive transfusion strategy (RR, 1.02 [95% CI 0.92; 1.12; P = 0.67; I = 3%) and tight glycemic control (RR, 0.86 [95% CI 0.55; 1.35]; P = 0.25; I = 26%).
CONCLUSIONS
Two non-pharmacological interventions are likely to reduce CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion and remote ischemic preconditioning.
Topics: Child; Humans; Cardiac Surgical Procedures; Acute Kidney Injury; Anesthesia; Anesthesiology; Cardiopulmonary Bypass
PubMed: 37700297
DOI: 10.1186/s13054-023-04640-1 -
JAMA Network Open Oct 2023Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed.
OBJECTIVE
To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery.
DATA SOURCES
MEDLINE, EMBASE, and CINAHL from inception to May 2020.
STUDY SELECTION
Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020.
DATA EXTRACTION AND SYNTHESIS
Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data.
MAIN OUTCOMES AND MEASURES
The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD.
RESULTS
A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for >85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index <18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for >10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72).
CONCLUSIONS AND RELEVANCE
In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.
Topics: Adult; Humans; Emergence Delirium; Delirium; Postoperative Complications; Risk Factors; Patients
PubMed: 37819663
DOI: 10.1001/jamanetworkopen.2023.37239 -
Journal of Psychiatric Research Sep 2023Insomnia is a common sleep disorder. There are many clinical-intervention methods for treating this condition, but thus far, the most effective method has not been... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Insomnia is a common sleep disorder. There are many clinical-intervention methods for treating this condition, but thus far, the most effective method has not been determined.
METHODS
We conducted a network meta-analysis by including random evidence of insomnia improvement in people over 18 years old, without other physical diseases. From January 1, 1990 to June 15, 2022, we searched multiple electronic databases for randomized controlled trials of different insomnia-related, clinical-intervention methods. R software was used to analyze 10 indices, in order to evaluate the effect of sleep improvement. Primary outcomes comprised Pittsburgh sleep quality-index (PSQI) scores and insomnia severity-index (ISI) scores.
RESULTS
Finally, 122 randomized controlled trials were included in our study. For the PSQI scores, we found the sequence of intervention measures by effect to be as follows: electroacupuncture, acupuncture, repetitive transcranial magnetic stimulation (rTMS), essential oils, herbal medicine, traditional Western medicine, Tai Chi and Baduanjin, music, supplements, cognitive behavioral therapy for insomnia (CBT-I), and exercise. The results for ISI were similar to those for PSQI, but with slight differences.
CONCLUSION
Our research results indicate that various measures have a certain effect on improving sleep, among which the effect of instruments is more prominent. The curative effect of placebo groups was better than that of blank control groups. There is essentially no statistical difference in detailed classification within the same intervention category.
Topics: Humans; Adult; Adolescent; Sleep Initiation and Maintenance Disorders; Network Meta-Analysis; Sleep; Acupuncture Therapy; Electroacupuncture; Randomized Controlled Trials as Topic
PubMed: 37499485
DOI: 10.1016/j.jpsychires.2023.07.004 -
Medicine Sep 2023To provide evidence for medical management of tinnitus based on an assessment of the evidence concerning the effectiveness of acupuncture as a treatment for tinnitus... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To provide evidence for medical management of tinnitus based on an assessment of the evidence concerning the effectiveness of acupuncture as a treatment for tinnitus using network meta-analysis (NMA).
METHODS
We conducted a systematic literature review by searching 8 national and international databases (inception to February 2023) for randomized controlled trials (RCTs) for tinnitus. Only RCTs that recruited participants aged over 18 and diagnosed with tinnitus, and that evaluated acupuncture or acupuncture in combination with conventional western medical therapy were included. We used response rate and tinnitus handicap inventory (THI) to examine efficacy. We conducted NMA with random effects, and the rate ratio or mean difference with its 95% credible interval was calculated. In addition, we ranked all treatments via their SUCRA and assessed the quality of evidence according to the GRADE criteria.
RESULTS
A total of 2575 patients were included in the study. The main findings of the current NMA were that acupoint injection combined with warm acupuncture was the most effective for response rate, followed by warm acupuncture and acupoint injection combined with western medical treatment. Acupuncture combined with western medical treatment was the most effective for THI, followed by electroacupuncture combined with warm acupuncture and acupuncture combined with moxibustion.
CONCLUSION
Acupuncture seems to be a better trend treatment for tinnitus. Further rigorous RCT studies that include direct comparisons for different acupuncture-related treatments are encouraged to provide the most promising evidence for patients with tinnitus.
PROTOCOL REGISTRATION
CRD42023398745.
Topics: Humans; Adolescent; Adult; Tinnitus; Network Meta-Analysis; Acupuncture Therapy; Electroacupuncture; Moxibustion
PubMed: 37773876
DOI: 10.1097/MD.0000000000035019 -
Chest Oct 2023IV fluids are recommended for adults with sepsis. However, the optimal strategy for IV fluid management in sepsis is unknown, and clinical equipoise exists.
BACKGROUND
IV fluids are recommended for adults with sepsis. However, the optimal strategy for IV fluid management in sepsis is unknown, and clinical equipoise exists.
RESEARCH QUESTION
Do lower vs higher fluid volumes improve patient-important outcomes in adult patients with sepsis?
STUDY DESIGN AND METHODS
We updated a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing lower vs higher IV fluid volumes in adult patients with sepsis. The coprimary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. We followed the recommendations from the Cochrane Handbook and used the Grading of Recommendations Assessment, Development and Evaluation approach. Primary conclusions were based on trials with low risk of bias if available.
RESULTS
We included 13 trials (N = 4,006) with four trials (n = 3,385) added to this update. The meta-analysis of all-cause mortality in eight trials with low risk of bias showed a relative risk of 0.99 (97% CI, 0.89-1.10; moderate certainty evidence). Six trials with predefined definitions of serious adverse events showed a relative risk of 0.95 (97% CI, 0.83-1.07; low certainty evidence). Health-related quality of life was not reported.
INTERPRETATION
Among adult patients with sepsis, lower IV fluid volumes probably result in little to no difference in all-cause mortality compared with higher IV fluid volumes, but the interpretation is limited by imprecision in the estimate, which does not exclude potential benefit or harm. Similarly, the evidence suggests lower IV fluid volumes result in little to no difference in serious adverse events. No trials reported on health-related quality of life.
TRIAL REGISTRATION
PROSPERO; No.: CRD42022312572; URL: https://www.crd.york.ac.uk/prospero/.
PubMed: 37142091
DOI: 10.1016/j.chest.2023.04.036 -
International Journal of Colorectal... Jul 2023Secondary constipation refers to constipation that occurs after certain diseases or medications, such as acute stroke or opioids, and the efficacy of electroacupuncture... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Secondary constipation refers to constipation that occurs after certain diseases or medications, such as acute stroke or opioids, and the efficacy of electroacupuncture for secondary constipation is controversial. So, this study aimed to explore the efficacy and safety of electroacupuncture for secondary constipation through a meta-analysis and systematic review.
METHOD
We retrieved articles from PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, and VIP databases up to 28 February 2023. The study was screened strictly according to inclusion and exclusion criteria. Revman5.4 was used for quality evaluation; grade rating was used for index evaluation, and stata15.0 was used for data consolidation analysis.
RESULT
Thirteen randomized controlled studies, involving a total of 1437 people (722 electroacupuncture and 715 control groups), were included in this review. Meta-analysis results indicated that electroacupuncture significantly improved constipation overall response (RR = 1.31, 95%CI: 1.11, 1.55, P < 0.001), reduced defecation straining score (MD = - 0.46, 95%CI: - 0.67, - 0.251, P < 0.001), increased weekly complete spontaneous bowel movements (MD = 0.41, 95%CI: 0.20, 0.63, P = 0.002), and increased in the weekly spontaneous bowel movements (MD = 0.80, 95%CI (0.49, 01.11), P < 0.001), and electroacupuncture had no effect on change stool consistency score compared (MD = - 0.03, 95%CI (- 0.38, 0.33), P = 0.88) and did not increase adverse events (RR = 0.50, 95%CI: 0.18, 1.44, P = 0.20).
CONCLUSION
According to the current studies, the overall relief rate of patients with secondary constipation after electroacupuncture treatment was improved, the defecation pressure score was reduced, the weekly natural defecation was more complete, and adverse reactions were not increased. Electroacupuncture therefore shows potential for treating constipation, but more high-quality studies are needed to confirm these findings.
Topics: Humans; Electroacupuncture; Defecation; Constipation; Research Design; Control Groups
PubMed: 37452920
DOI: 10.1007/s00384-023-04487-6 -
Paediatric Anaesthesia Apr 2024Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with other postoperative complications. Sevoflurane has been associated with emergence agitation, potentially due to low tissue solubility and therefore speed of emergence. Prior meta-analyses comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics did not demonstrate a statistically significant difference. Given the publication of additional relevant studies not included in prior meta-analyses as well as improved diagnosis of emergence agitation, we aim to perform an updated, comprehensive meta-analysis comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics in children.
METHODS
We conducted an updated systematic review and meta-analysis of clinical trials comparing sevoflurane to isoflurane in children <18 years of age, reporting emergence agitation as an outcome, published before July 2023 using databases and registers. Our primary outcome was the incidence of emergence agitation. Secondary outcomes were time to extubation, awakening time, and length of stay in the postanesthetic care unit. We assessed the risk of bias using the Cochrane Risk of Bias tool version 2. We pooled the effect size for the outcomes using the fixed effects model if we had low heterogeneity, otherwise, we used a random-effects model.
RESULTS
Eight randomized controlled trials (523 children) were included in the final analysis. The incidence of emergence agitation after isoflurane was significantly lower compared to sevoflurane (risk ratio: 0.62 (95% CI: [0.46-0.83]; I = 40.01%, p < .001)). Time to extubation, awakening times, and postanesthetic care unit duration were not significantly different. The protective effect of isoflurane compared to sevoflurane remained significant in subgroups of patients who received premedication or intraoperative systemic analgesics (risk ratios: (0.48 [0.28-0.82]; I = 60.78%, p = .01), (0.52 [0.37-0.75]; I = 0.00%, p < .001), respectively).
CONCLUSION
The risk of emergence agitation in children after maintenance anesthesia with sevoflurane is significantly greater than with isoflurane; we did not find evidence of prolonged emergence or postanesthetic length of stay. When possible, isoflurane should be considered for maintenance anesthesia over sevoflurane in patients at high risk of emergence agitation.
Topics: Child; Humans; Anesthesia, General; Anesthetics, Inhalation; Emergence Delirium; Incidence; Isoflurane; Sevoflurane
PubMed: 38093624
DOI: 10.1111/pan.14819 -
Obesity Surgery Sep 2023Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients... (Meta-Analysis)
Meta-Analysis
PURPOSE
Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients with obstructive sleep apnea. To promote early recovery, enhanced recovery after surgery guideline advises minimizing opioid use and opting for alternative analgesics. This paper aims to investigate the effect of regional anesthesia techniques through a systematic review and network meta-analysis. Primary outcome is postoperative morphine equivalent consumption at 24 h.
METHODS
Search was conducted in the following databases: PubMed, CENTRAL, Scopus, and EMBASE, from the inception until 10 January 2023. The eligibility criteria were determined by PICOS, including postoperative opioid consumption, pain scores, time to ambulate, use of additional analgesics, and adverse events. The quality assessment was performed using the Risk of Bias 2 Tool, and the certainty of evidence was assessed using the GRADE approach. Funnel plots were used to evaluate publication bias.
RESULTS
We included 22 studies in quantitative synthesis. A review of 12 studies found that all techniques had a lower mean consumption of opioids compared to placebo or no intervention, with TAP block having the greatest reduction. The quality of evidence for postoperative pain, PONV, time to deambulate, and use of rescue analgesics, was rated as moderate, with TAP block being the most effective intervention. There was no publication bias in any outcome.
CONCLUSIONS
TAP block is superior to other regional anesthesia techniques in reducing opioid consumption, pain, PONV, and use of rescue analgesics in bariatric surgery. However, further research is needed.
Topics: Humans; Analgesics, Opioid; Postoperative Nausea and Vomiting; Network Meta-Analysis; Obesity, Morbid; Pain, Postoperative; Bariatric Surgery; Nerve Block
PubMed: 37498489
DOI: 10.1007/s11695-023-06737-6 -
European Journal of Anaesthesiology Oct 2023Pain after craniotomy can be intense and its management is often suboptimal.
BACKGROUND
Pain after craniotomy can be intense and its management is often suboptimal.
OBJECTIVES
We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy.
DESIGN
A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken.
DATA SOURCES
Randomised controlled trials and systematic reviews published in English from 1 January 2010 to 30 June 2021 assessing pain after craniotomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases.
ELIGIBILITY CRITERIA
Each randomised controlled trial (RCT) and systematic review was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and NSAIDs, and current clinical relevance.
RESULTS
Out of 126 eligible studies identified, 53 RCTs and seven systematic review or meta-analyses met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture. Limited evidence was found for flupirtine, intra-operative magnesium sulphate infusion, intra-operative lidocaine infusion, infiltration adjuvants (hyaluronidase, dexamethasone and α-adrenergic agonist added to local anaesthetic solution). No evidence was found for metamizole, postoperative subcutaneous sumatriptan, pre-operative oral vitamin D, bilateral maxillary block or superficial cervical plexus block.
CONCLUSIONS
The analgesic regimen for craniotomy should include paracetamol, NSAIDs, intravenous dexmedetomidine infusion and a regional analgesic technique (either incision-site infiltration or scalp nerve block), with opioids as rescue analgesics. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.
Topics: Humans; Pain Management; Dexmedetomidine; Acetaminophen; Analgesics; Pain, Postoperative; Craniotomy; Anti-Inflammatory Agents, Non-Steroidal
PubMed: 37417808
DOI: 10.1097/EJA.0000000000001877