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Journal of Neurosurgery. Pediatrics Oct 2023Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in...
OBJECTIVE
Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in adults but remains poorly established in children. Its use has been limited due to concern for children's neuropsychological differences compared with adults and how these differences may interfere with the safety and feasibility of the procedure. Among studies that have reported pediatric ACs, complication rates and anesthetic management vary. This systematic review was performed to comprehensively analyze outcomes and synthesize anesthetic protocols of pediatric ACs.
METHODS
The authors followed PRISMA guidelines to extract studies that reported AC in children with intracranial pathologies. The Medline/PubMed, Ovid, and Embase databases were searched from database inception to 2021, using the terms ("awake") AND ("Pediatric*" OR "child*") AND (("brain" AND "surgery") OR "craniotomy"). Data extracted included patient age, pathology, and anesthetic protocol. Primary outcomes assessed were premature conversion to general anesthesia, intraoperative seizures, completion of monitoring tasks, and postoperative complications.
RESULTS
Thirty eligible studies published from 1997 to 2020 were included that described a total of 130 children ranging in age from 7 to 17 years who had undergone AC. Of all patients reported, 59% were male and 70% had left-sided lesions. Procedure indications included the following etiologies: tumors (77.6%), epilepsy (20%), and vascular disorders (2.4%). Four (4.1%) of 98 patients required conversion to general anesthesia due to complications or discomfort during AC. In addition, 8 (7.8%) of 103 patients experienced intraoperative seizures. Furthermore, 19 (20.6%) of 92 patients had difficulty completing monitoring tasks. Postoperative complications occurred in 19 (19.4%) of 98 patients and included aphasia (n = 4), hemiparesis (n = 2), sensory deficit (n = 3), motor deficit (n = 4), or others (n = 6). The most commonly reported anesthetic techniques were asleep-awake-asleep protocols using propofol, remifentanil or fentanyl, a local scalp nerve block, and with or without dexmedetomidine.
CONCLUSIONS
The findings of this systematic review suggest the tolerability and safety of ACs in the pediatric population. Although pediatric intracranial pathologies pose etiologies that certainly may benefit from AC, there is a need for surgeons and anesthesiologists to perform individualized risk-benefit analyses due to the risks associated with awake procedures in children. Age-specific, standardized guidelines for preoperative planning, intraoperative mapping, monitoring tasks, and anesthesia protocols will help to continue minimizing complications, while improving tolerability, and streamlining workflow in the treatment of this patient population.
Topics: Adult; Humans; Male; Child; Adolescent; Female; Brain Neoplasms; Wakefulness; Retrospective Studies; Craniotomy; Postoperative Complications; Anesthetics; Seizures
PubMed: 37410631
DOI: 10.3171/2023.4.PEDS22296 -
Oral and Maxillofacial Surgery Dec 2023Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs... (Meta-Analysis)
Meta-Analysis Review
Systematic review and meta-analysis comparing the efficacy of dexmedetomidine to midazolam as premedication and a sedative agent in pediatric patients undergoing dental procedures.
INTRODUCTION
Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs like dexmedetomidine (DEX) and midazolam (MID) is a common pharmacological behavior managing technique. We conducted this meta-analysis to evaluate the efficacy of both these drugs in current literature.
METHODOLOGY
A thorough literature search was conducted on PubMed, MEDLINE, Google Scholar, and Cochrane's database for randomized studies that compared sedative efficacy of dexmedetomidine with midazolam in children of 0-15 years of age undergoing dental surgeries. Sedation in children during dental procedure, when used as a premedication, at the time of separation from parents and at the time of mask induction, onset time, duration of anesthesia, and surgery were evaluated. The mean differences (MDs), odds ratio (OR), and their 95% confidence intervals (CIs) were calculated both for continuous and dichotomous outcome data using random-effects model.
RESULTS
Seven studies met out inclusion criteria and were analyzed. Results of premedication with DEX was associated with more anxiolysis (OR=0.29, 95% CI: 0.17-0.52, p=0.0001; I=0%) and at the time of separation from parents (OR=0.36, 95% CI: 0.19-0.69, p=0.002; I=52%) in comparison to MID. No significant differences in results were seen at mask induction (OR=0.63, 95% CI: 0.34-1.18, p=0.15; I=47%) and for sedation in children during dental procedures (OR=0.52, 95% CI: 0.07-3.70, p=0.51; I=72%). Also, there were no significant differences in onset time, duration of anesthesia, and surgery between the two agents.
CONCLUSION
DEX proved to be a better premedicant than MID for pediatric patients. No significant difference in efficacy of both sedative agents was observed in children undergoing dental treatment. More clinical trials need to be conducted to see its efficacy in dental surgeries in children of standardized ages and with standard doses.
Topics: Child; Humans; Midazolam; Dexmedetomidine; Hypnotics and Sedatives; Premedication; Anesthesia, Dental
PubMed: 35759132
DOI: 10.1007/s10006-022-01087-6 -
Cureus Jan 2024Post-dural puncture headache (PDPH) is occasionally an inevitable side effect of neuraxial anesthesia, which can happen after spinal anesthesia or if an accidental dural... (Review)
Review
Post-dural puncture headache (PDPH) is occasionally an inevitable side effect of neuraxial anesthesia, which can happen after spinal anesthesia or if an accidental dural puncture (ADP) happens during epidural anesthesia. The treatment and prevention options for PDPH differ widely from one institution to another. The management of PDPH is heterogeneous in many institutions because of the absence of clear guidelines and protocols for the management of PDPH. This study aimed to summarize all articles published during the past decade that discussed the treatment or prevention of PDPH. From 2013 to 2023, 345 publications were filtered for all treatment and prevention approaches used for PDPH patients. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines were followed for conducting this systematic review, and 38 articles were included for analysis and review. Existing data come from small randomized clinical trials and retrospective or prospective cohort studies. This review supports the effect of oral pregabalin and intravenous aminophylline in both treatment and prevention. Intravenous mannitol, intravenous hydrocortisone, triple prophylactic regimen, and neostigmine plus atropine combination showed effective and beneficial outcomes. On the other hand, neither neuraxial morphine nor epidural dexamethasone showed promising results. Consequently, the use of neuraxial morphine or epidural dexamethasone for the prevention of PDPH remains questionable. Regarding the posture of the patient and its consequences on the incidence of the headache, lateral decubitus is better than a sitting position, and a prone position is better than a supine position. Smaller non-cutting needles play a role in avoiding PDPH. Minimally invasive nerve blocks, including sphenopalatine ganglion or greater occipital nerves, are satisfyingly effective. Epidural blood patches remain the more invasive but the gold standard and ultimate solution in patients resisting medical therapy. This study highlights the need for larger research to define the best approach to prevent and treat PDPH.
PubMed: 38361721
DOI: 10.7759/cureus.52330 -
Journal of Clinical Anesthesia Jun 2024To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia. (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia.
DESIGN
A Systematic review and meta-analysis of randomized controlled trials.
SETTING
The major dates were obtained in the operating room and the postoperative recovery ward.
PATIENTS
A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion.
INTERVENTIONS
After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block.
MEASUREMENT
The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system.
MAIN RESULT
Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53;P = 0.16, I = 84%), the onset time of motor and sensory block (motor onset time, -1.17 min, 95% CI, -2.67 to 0.34; P = 0.13, I = 100%; sensory onset time, -0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17;P = 0.08, I = 57%).
CONCLUSION
This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low.
Topics: Female; Humans; Pregnancy; Anesthesia, Conduction; Anesthetics, Local; Brachial Plexus Block; Breast Neoplasms; Cesarean Section; Ketamine; Mastectomy; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 38394922
DOI: 10.1016/j.jclinane.2024.111415 -
The Journal of Evidence-based Dental... Sep 2023The aim of the present paper is to summarize the effectiveness of Phentolamine mesylate on the reversal of local anesthesia (LA). (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of the present paper is to summarize the effectiveness of Phentolamine mesylate on the reversal of local anesthesia (LA).
METHODOLOGY
Seven electronic databases were searched for randomized clinical trials in patients who received LA (population) and either received a Phentolamine injection (intervention) after LA compared to placebo or sham (control) to cause a return of normal sensation (outcome). Risk of bias assessment was performed using Cochrane risk of bias assessment tool 2.0. The hazard ratio (HR) was calculated as the event (time to return to the normal sensation) was a time-dependent event, as well as the weighted mean difference (WMD), was computed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the certainty of the evidence.
RESULTS
Ten studies met our inclusion criteria and were included in this review. After pooling the results quantitatively, the value of the HR in the tongue was 0.56 (95% CI: 0.41-0.75, P<.001); in lower lip, the value was 0.56 (95% CI: 0.38-0.83, P = .004) and for upper lip, the value was 0.50 (95% CI: 0.31-0.80, P = .004). The WMD for the time to return for normal sensation was -47.71 min for the tongue (95% CI: -73.63 to -21.80 min, P<.001), -73.29 min for lower lip (95% CI: -88.41 to -58.16 min, P<.001) and -86.86 min for upper lip (95% CI: -101.16 to -72.57 min, P<.001). There is a high certainty of evidence that patients who have been administered local anesthesia may achieve faster recovery of normal sensation in tongue, and moderate certainty of evidence for return of normal sensation in lower lip and upper lip, if Phentolamine was administered after the local anesthesia. The adverse effects were reported in a few studies and were minor, not necessitating any medical intervention.
CONCLUSIONS
Phentolamine might be a useful adjunct in patients who desire an earlier return of normal sensation and function after local anesthesia. Future research should be directed to study the cost-effectiveness or dental patient-reported outcomes of Phentolamine after local anesthetic injections.
Topics: Humans; Anesthesia, Local; Phentolamine; Anesthetics, Local; Patient Reported Outcome Measures
PubMed: 37689448
DOI: 10.1016/j.jebdp.2023.101861 -
American Journal of Ophthalmology Aug 2023This network meta-analysis aims to determine the differences between adjuvants that are used in combination with local anesthetics for ophthalmic regional anesthesia. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This network meta-analysis aims to determine the differences between adjuvants that are used in combination with local anesthetics for ophthalmic regional anesthesia.
DESIGN
Systematic review and network meta-analysis.
METHODS
A systematic literature search for randomized controlled trials, comparing the impact of adjuvants in ophthalmic regional anesthesia, in Embase, CENTRAL, MEDLINE and Web of Science was performed. Risk of bias was evaluated using the Cochrane risk of bias tool. Frequentist network meta-analysis was performed using a random effects model with saline as the comparator. Primary endpoints were the onset and the duration of sensory block and globe akinesia, as well as the duration of analgesia. Summary measure was the ratio of means (ROM). Secondary endpoints were the rates of side effects and adverse events.
RESULTS
A total of 39 trials were identified as eligible for network meta-analysis, including 3046 patients. In all, 17 adjuvants were compared in the most extensive network (onset of globe akinesia). The addition of fentanyl (F), clonidine (C), or dexmedetomidine (D) showed the best overall results. Onset of sensory block was as follows: F 0.58 (CI = 0.47-0.72), C 0.75 (0.63-0.88), D 0.71 (0.61-0.84); onset of globe akinesia: F 0.71 (0.61-0.82), C 0.70 (0.61-0.82), D 0.81 (0.71-0.92); duration of sensory block: F 1.20 (1.14-1.26), C 1.22 (1.18-1.27), D 1.44 (1.34-1.55); duration of globe akinesia: F 1.38 (1.22-1.57), C 1.45 (1.26-1.67), D 1.41 (1.24-1.59); and duration of analgesia: F 1.46 (1.33-1.60), C 1.78 (1.63-1.96), D 1.41 (1.28-1.56).
CONCLUSIONS
The addition of fentanyl, clonidine, or dexmedetomidine showed beneficial effects regarding onset and duration of sensory block and globe akinesia.
Topics: Humans; Anesthesia, Conduction; Anesthetics, Local; Clonidine; Dexmedetomidine; Fentanyl; Network Meta-Analysis
PubMed: 36906095
DOI: 10.1016/j.ajo.2023.02.023 -
Asian Journal of Surgery Dec 2023
Meta-Analysis
Topics: Child; Humans; Pediatric Anesthesia; Ketamine; Treatment Outcome
PubMed: 37684126
DOI: 10.1016/j.asjsur.2023.08.073 -
Seminars in Cardiothoracic and Vascular... Sep 2023Despite their extensive clinical use, opioids are characterized by several side effects. These complications, coupled with the ongoing opioid epidemic, have favored the... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Despite their extensive clinical use, opioids are characterized by several side effects. These complications, coupled with the ongoing opioid epidemic, have favored the rise of opioid-free-anesthesia (OFA). Herein, we perform the first pairwise meta-analysis of clinical outcomes for OFA vs opioid-based anesthesia (OBA) in patients undergoing cardiovascular and thoracic surgery.
METHODS
We comprehensively searched medical databases to identify studies comparing OFA and OBA in patients undergoing cardiovascular or thoracic surgery. Pairwise meta-analysis was performed using the Mantel-Haenszel method. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% confidence intervals (95% CI).
RESULTS
Our pooled analysis included 919 patients (8 studies), of whom 488 underwent surgery with OBA and 431 with OFA. Among cardiovascular surgery patients, compared to OBA, OFA was associated with significantly reduced post-operative nausea and vomiting (RR, 0.57; = .042), inotrope need (RR .84, = .045), and non-invasive ventilation (RR, .54; = .028). However, no differences were observed for 24hr pain score (SMD, -.35; = .510) or 48hr morphine equivalent consumption (SMD, -1.09; = .139). Among thoracic surgery patients, there was no difference between OFA and OBA for any of the explored outcomes, including post-operative nausea and vomiting (RR, 0.41; = .025).
CONCLUSION
Through the first pooled analysis of OBA vs OFA in a cardiothoracic-exclusive cohort, we found no significant difference in any of the pooled outcomes for thoracic surgery patients. Although limited to 2 cardiovascular surgery studies, OFA was associated with significantly reduced postoperative nausea and vomiting, inotrope need, and non-invasive ventilation in these patients. With growing use of OFA in invasive operations, further studies are needed to assess their efficacy and safety in cardiothoracic patients.
Topics: Humans; Analgesics, Opioid; Anesthesia; Nausea; Pain, Postoperative; Cardiovascular Surgical Procedures; Thoracic Surgical Procedures; Postoperative Nausea and Vomiting
PubMed: 37300532
DOI: 10.1177/10892532231180227 -
Cureus Mar 2024This study delves into the historical trajectory of dermatological anesthesia, tracing its roots from ancient civilizations to modern times. It emphasizes the relentless... (Review)
Review
This study delves into the historical trajectory of dermatological anesthesia, tracing its roots from ancient civilizations to modern times. It emphasizes the relentless pursuit of pain relief in dermatologic procedures and the transformative impact of anesthesia on surgical practices. A comprehensive analysis was conducted through an extensive literature review, employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review model on the PubMed and Embase databases. A total of 1304 articles were initially identified, with six publications from these databases and 10 additional sources from the World Wide Web included in the study. This systematic approach allowed for a thorough examination of the historical journey of dermatological anesthesia. The historical trajectory outlined in this study highlights the progress in dermatological anesthesia, showcasing its impact on contemporary procedures with a continual emphasis on patient comfort and safety. As medical knowledge expands, the ongoing quest for enhanced pain control in dermatology remains a central focus.
PubMed: 38590497
DOI: 10.7759/cureus.55851 -
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