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Journal of Evidence-based Medicine Sep 2021In this abridged version of the recently published Cochrane review on antiemetic drugs, we summarize its most important findings and discuss the challenges and the time... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
In this abridged version of the recently published Cochrane review on antiemetic drugs, we summarize its most important findings and discuss the challenges and the time needed to prepare what is now the largest Cochrane review with network meta-analysis in terms of the number of included studies and pages in its full printed form.
METHODS
We conducted a systematic review with network meta-analyses to compare and rank single antiemetic drugs and their combinations belonging to 5HT₃-, D₂-, NK₁-receptor antagonists, corticosteroids, antihistamines, and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anesthesia.
RESULTS
585 studies (97 516 participants) testing 44 single drugs and 51 drug combinations were included. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 studies, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared to placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single NK receptor antagonists were as effective as other drug combinations. Of the 10 effective single drugs, certainty of evidence was high for aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron, while moderate for fosaprepitant and droperidol. For serious adverse events (SAEs), any adverse event (AE), and drug-class specific side effects evidence for intervention effects was mostly not convincing.
CONCLUSIONS
There is high or moderate evidence for at least seven single drugs preventing postoperative vomiting. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
Topics: Adult; Anesthesia, General; Antiemetics; Humans; Network Meta-Analysis; Pharmaceutical Preparations; Postoperative Nausea and Vomiting
PubMed: 34043870
DOI: 10.1111/jebm.12429 -
Journal of Gastrointestinal and Liver... Jun 2024Mammoplasty, a common cosmetic procedure involving breast augmentation and reduction surgeries, has gained global popularity. Recently, attention has shifted towards...
BACKGROUND AND AIMS
Mammoplasty, a common cosmetic procedure involving breast augmentation and reduction surgeries, has gained global popularity. Recently, attention has shifted towards understanding the prevalence and significance of gastrointestinal (GI) symptoms following mammoplasty. This systematic review aims to consolidate existing literature to provide a comprehensive overview of the type and frequency of GI problems associated with various mammoplasty procedures.
METHODS
A systematic search of PubMed and Scopus databases was conducted until January 22, 2024, identifying observational and interventional studies examining GI symptoms post-mammoplasty. Inclusion criteria covered human studies, while exclusion criteria ensured specificity. Two independent investigators performed screening, and data extraction included study characteristics, surgical procedures, anesthesia methods, and interventions.
RESULTS
Nineteen studies, involving 2,487 subjects, were included in the review. Breast reconstruction emerged as the most studied procedure, followed by breast reduction, augmentation, mastectomy, and breast cancer surgery. Predominant GI symptoms included nausea and vomiting, with varying rates across mammoplasty types. Anesthesia modality influenced symptomatology, with general, local, and combined anesthesia associated with GI disturbances. Antiemetics, notably ondansetron and droperidol, showed variable efficacy. Non-pharmacological approaches, such as preoperative hypnosis, were explored for symptom management.
CONCLUSIONS
Our systematic review reveals insights into GI symptoms post-mammoplasty, emphasizing the common occurrence of symptoms such as nausea and vomiting, alongside less frequent manifestations such as constipation, dry mouth, retching, abdominal pain, and tightness. Variations in symptom prevalence were noted across diverse mammoplasty surgeries, anesthesia methods, and the use of antiemetics, underscoring the complex nature of post-mammoplasty GI disturbances.
Topics: Humans; Mammaplasty; Female; Postoperative Nausea and Vomiting; Gastrointestinal Diseases; Adult; Prevalence
PubMed: 38944853
DOI: 10.15403/jgld-5598 -
The Journal of Pediatrics Nov 2019To synthesize quantitative and qualitative data on pharmacologic interventions of pediatric cyclic vomiting syndrome and their effectiveness in disease management in the...
OBJECTIVES
To synthesize quantitative and qualitative data on pharmacologic interventions of pediatric cyclic vomiting syndrome and their effectiveness in disease management in the acute care setting.
STUDY DESIGN
Using keywords, 799 studies published up from December 1954 to February 2018 were extracted from MEDLINE via Pubmed, Embase via OVID, CINAHL via EBSCO, and Cochrane Controlled Trials Registry. Studies were evaluated for inclusion and exclusion by 2 independent reviewers using predetermined inclusion and exclusion criteria.
RESULTS
The search yielded 84 studies for full review, of which 54 were included in the systematic review. Studies were subsequently separated into 1 group of 6 case series studies containing quantitative data on sumatriptan, ondansetron, phenothiazines, prokinetic agents, carbohydrate, isometheptene, and aprepitant; 1 one group consisting only of qualitative studies containing expert recommendations.
CONCLUSIONS
Ondansetron has the most quantitative and qualitative evidence to support its inclusion in pediatric emergency department protocols as a rescue therapy. Sumatriptan and aprepitant are potential candidates for inclusion as abortive therapies. Qualitative data from retrospective studies and case reports are not applicable to a larger patient population. This report informs a need for controlled, prospective cohort studies and randomized, controlled trials to optimize current management protocols and to develop new medical interventions.
Topics: Child; Critical Care; Disease Management; Humans; Vomiting
PubMed: 31540764
DOI: 10.1016/j.jpeds.2019.06.057 -
Current Medical Research and Opinion May 2021Postoperative nausea and vomiting (PONV) is a common complication following surgery, and may be one of the most distressing parts of the surgical journey. With... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Postoperative nausea and vomiting (PONV) is a common complication following surgery, and may be one of the most distressing parts of the surgical journey. With combination pharmacological therapy recommended for PONV prophylaxis, this systematic review and meta-analysis evaluates whether perioperative palonosetron and dexamethasone is more efficacious than palonosetron administered alone.
METHODS
We searched CENTRAL; EMBASE; CINAHL; Google Scholar; Web of Science citation index; the US clinical trials register; UK clinical trials register; Australia and New Zealand Clinical trials register; and conference abstracts for major anaesthesia conferences in the last three years.We included randomized controlled trials that compared adult patients undergoing surgery who received palonosetron and dexamethasone, against those who received palonosetron.
RESULTS
A total of 12 studies (1152 patients) were included. Medium-grade evidence showed that the palonosetron and dexamethasone combination significantly reduced 24-hour rescue anti-emetic requirement (RR: 0.59, 95% confidence interval (CI): 0.41-0.86). There was however no significant difference in the 6-hour (RR: 0.82, 95% CI: 0.61-1.09) and 24-hour PONV incidences (RR: 0.60, 95% CI: 0.33-1.10). Similarly, PONV incidences after 24 h did not differ between groups (RR:0.82, 95% CI: 0.59-1.14). Headache and dizziness were the most common side-effects reported.
CONCLUSIONS
Combination prophylaxis with palonosetron and dexamethasone reduces post-operative anti-emetic requirement, although is not associated with a significant difference in PONV. There was considerable heterogeneity in the studies, and trial sequential analysis indicates that further studies are needed to strengthen the clinical evidence.
Topics: Adult; Anesthesia; Antiemetics; Dexamethasone; Humans; Palonosetron; Postoperative Nausea and Vomiting
PubMed: 33617380
DOI: 10.1080/03007995.2021.1893677 -
JAMA Neurology May 2021Mild traumatic brain injury (TBI) is experienced by 55.9 million people globally each year. The symptoms of mild TBI are diverse and sometimes long-lasting, requiring...
IMPORTANCE
Mild traumatic brain injury (TBI) is experienced by 55.9 million people globally each year. The symptoms of mild TBI are diverse and sometimes long-lasting, requiring frequent use of pharmacological interventions to mitigate them. A thorough understanding of the data supporting pharmacological interventions is important for decision-making among clinicians treating this common injury.
OBJECTIVE
To systematically review studies of pharmacological interventions and their associations with symptom burden reduction among patients with mild TBI and to use an evidence-based model to identify potential directions for future research that may aid in clinical decision-making.
EVIDENCE REVIEW
A systematic review was performed in PubMed, Scopus, and Web of Science. Search strings modified for the advanced search interfaces of each search engine were developed in consultation with a librarian and included combinations of search terms, such as brain concussion, post-concussion syndrome, mild traumatic brain injury, and pharmacological treatment. Articles published between January 1, 2000, and July 1, 2020, were analyzed. Studies were included if (1) they were clinical studies with discrete analyses of participants with mild TBI or complicated mild TBI, (2) they were assessments of a pharmacological intervention, (3) they included human participants, and (4) they were published in a peer-reviewed journal in the English language. Studies were excluded if the severity of TBI among participants could not be ascertained (ie, inadequate definition of mild TBI) and the inclusion criteria for the study required intracranial hemorrhage. A total of 23 studies examining 20 pharmacological interventions met the inclusion criteria. Risk of bias was assessed using the Cochrane Risk of Bias for Randomized Trials (for randomized clinical trials) and the Cochrane Risk of Bias in Non-Randomized Studies of Interventions (for all other studies). Data were analyzed from June to September 2020.
FINDINGS
A total of 1495 articles were identified; of those, 131 articles were excluded as duplicates. Titles and abstracts were screened for inclusion and exclusion criteria among the remaining 1364 articles, and 134 of those articles received a full-text review. After exclusions, 23 studies (11 randomized clinical trials, 7 prospective observational studies, 3 retrospective observational studies, and 2 case studies) examining 20 pharmacological interventions were identified for inclusion in the systematic review. Studies included 22 distinct participant populations comprising 8277 participants with mild TBI and 45 participants without TBI. Among 23 total studies, 8 studies specifically addressed the pediatric population, 9 studies had a low risk of bias, and 16 studies reported symptom burden reduction. Of the 20 pharmacological interventions examined in the studies, methylphenidate, sertraline hydrochloride, ondansetron, amitriptyline, and melatonin were the only medications included in multiple studies.
CONCLUSIONS AND RELEVANCE
This systematic review found a limited number of high-quality, clinically meaningful studies, particularly among children and individuals in the acute stage of injury; therefore, performing an evidence-based analysis that would inform clinical decision-making was not possible. Future studies are needed to focus on standardizing measures and increasing sample sizes (including large multicenter clinical trials) to generate a body of research that may provide additional options for the treatment of patients with mild TBI.
Topics: Brain Concussion; Brain Injuries, Traumatic; Child; Clinical Decision-Making; Humans; Post-Concussion Syndrome; Prospective Studies; Retrospective Studies
PubMed: 33464290
DOI: 10.1001/jamaneurol.2020.5079 -
Indian Journal of Anaesthesia Oct 2023Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid...
Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis.
BACKGROUND AND AIMS
Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid receptor agonist properties, has been successfully used to manage post-anaesthesia shivering.
METHODS
After registering the review with the International Prospective Register of Systematic Reviews (PROSPERO), we searched PubMed/Medline, Scopus, Ovid, Cochrane Library and clinicaltrials.gov with keywords for randomised controlled trials. The risk of bias-2 (RoB-2) scale was used to assess the quality of evidence. We also used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines to evaluate the strength of evidence and trial sequential analysis to validate the conclusions.
RESULTS
Of the 240 articles, 10 were considered eligible for review (700 patients, 350- nalbuphine, 350- control or placebo). When compared to placebo, the success rate of nalbuphine controlling shivering was significantly better (risk ratio [RR]: 2.37, 95% confidence interval [CI]:1.91, 2.94; = 0.04, ² = 94%), but comparable to the control group drugs (opioids, dexmedetomidine, ondansetron, pethidine). Compared to placebo, shivering recurrence was significantly less with nalbuphine than with placebo (RR: 0.47, 95% CI: 0.26, 0.83; = 0.01, ² = 61%), but comparable with the control group. The incidence of postoperative nausea/vomiting (PONV) was significantly less with nalbuphine when compared to the control group (RR: 0.67, 95% CI: 0.47, 0.95; = 0.02, ² = 37%), but PONV in the nalbuphine group was comparable to placebo (RR: 1.20, 95% CI: 0.68, 2.12; = 0.54, ² = 0%). Other outcomes, like the grade of shivering and hypotension, were comparable between the nalbuphine and control groups.
CONCLUSION
Nalbuphine successfully controls post-anaesthesia shivering and reduces the recurrence of shivering.
PubMed: 38044924
DOI: 10.4103/ija.ija_482_23 -
Sleep Medicine Reviews Aug 2019Pharmacotherapy represents a desirable potential therapeutic alternative for patients with obstructive sleep apnoea (OSA). We aimed to summarize evidence on the efficacy...
Pharmacotherapy represents a desirable potential therapeutic alternative for patients with obstructive sleep apnoea (OSA). We aimed to summarize evidence on the efficacy of pharmacotherapy in adults with OSA and delineate the underlying mechanisms. Seven databases were systematically screened for randomised controlled trials (RCTs) from their inception to September 2018. According to a pre-registered study protocol (PROSPERO-ID-CRD42018086446) network meta-analysis was performed to obtain intervention effects on the apnoea-hypopnoea-index (AHI) based on data extracted from published reports. We identified 58 RCTs (n = 1710 patients) investigating 44 different drugs or drug-combinations. Interventions were classified into seven pathomechanism-groups and summarized narratively. A meta-analysis of 17 trials for seven drugs (acetazolamide, donepezil, mirtazapine, ondansetron, paroxetine, protriptyline, theophylline) indicated a small effect for acetazolamide (mean difference in AHI -9.6/h [-17.7; -1.4]; p = 0.02). In the network meta-analysis (I = 50%) nine drugs (tramazoline, liraglutide, spironolactone/furosemide, acetazolamide, dronabinol, zonisamide, phentermine, spironolactone, and ondansetron/fluoxetine) significantly lowered the AHI compared to placebo. Although some trials indicate favorable outcomes, these results are only valid for distinctive OSA-phenotypes or were not clinically significant. The effect sizes were small, the majority of trials were not adequately powered. There is currently insufficient evidence to recommend any pharmacotherapy for OSA and no phase-III trials are available.
Topics: Adult; Drug Therapy; Humans; Network Meta-Analysis; Randomized Controlled Trials as Topic; Sleep Apnea, Obstructive
PubMed: 31075665
DOI: 10.1016/j.smrv.2019.04.009 -
JBI Database of Systematic Reviews and... Oct 2019The objective of this review was to synthesize the best available evidence on the effectiveness and harms of pharmacological interventions for the treatment of delirium...
OBJECTIVE
The objective of this review was to synthesize the best available evidence on the effectiveness and harms of pharmacological interventions for the treatment of delirium in adult patients in the intensive care unit (ICU) after cardiac surgery.
INTRODUCTION
Patients who undergo cardiac surgery are at high risk of delirium (incidence: 50-90%). Delirium has deleterious effects, increasing the risk of death and adversely affecting recovery. Clinical interventional trials have been conducted to prevent and treat postoperative delirium pharmacologically including antipsychotics and sedatives. These trials have provided some evidence about efficacy and influenced clinical decision making. However, much reporting is incomplete and provides biased assessments of efficacy; benefits are emphasized while harms are inadequately reported.
INCLUSION CRITERIA
Participants were ≥ 16 years, any sex or ethnicity, who were treated postoperatively in a cardiothoracic ICU following cardiac surgery and were identified as having delirium. Any pharmacological intervention for the treatment of delirium was included, regardless of drug classification, dosage, intensity or frequency of administration. Outcomes of interest of this review were: mortality, duration and severity of delirium, use of physical restraints, quality of life, family members' satisfaction with delirium management, duration/severity of the aggressive episode, associated falls, severity of accidental self-harm, pharmacological harms, harms related to over-sedation, ICU length of stay, hospital length of stay (post ICU), total hospital length of stay, need for additional intervention medication and need for rescue medication. Randomized controlled trials were considered first and in their absence, non-randomized controlled trials and quasi-experimental would have been considered, followed by analytical observational studies.
METHODS
A search was conducted in PubMed, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, Epistemonikos, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, Clinical Trials in New Zealand, and ProQuest Dissertations and Theses to locate both published and unpublished studies. There was no date limit for the search. A hand search for primary studies published between January 1, 2012 and November 17, 2018 in relevant journals was also conducted. Only studies published in English were considered for inclusion. Two reviewers independently assessed the methodological quality using standardized critical appraisal instruments from JBI and McMaster University. Quantitative data were extracted using the standardized JBI data extraction tool. A meta-analysis was not performed, as there was too much clinical and methodological heterogeneity in the included studies. Results have been presented in a narrative form. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment of outcomes has been reported.
RESULTS
Three RCTs investigating morphine versus haloperidol (n = 53), ondansetron versus haloperidol (n = 72), and dexmedetomidine versus midazolam (n = 80) were included. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Overall, the methodological quality of these studies was found to be low. Additionally, this review found reporting of harms to be inadequate and superficial for all three studies and did not meet the required standards for harms reporting, as defined by the CONSORT statement extension for harms.
CONCLUSIONS
It was not possible to draw any valid conclusions regarding the effectiveness of morphine vs haloperidol, ondansetron vs haloperidol or dexmedetomidine vs midazolam in treating delirium after cardiac surgery. This is due to the low number of studies, the poor methodological quality in conducting and reporting and the heterogeneity between the studies.
Topics: Accidental Falls; Antipsychotic Agents; Cardiac Surgical Procedures; Delirium; Family; Hospital Mortality; Humans; Hypnotics and Sedatives; Intensive Care Units; Length of Stay; Quality of Life; Severity of Illness Index
PubMed: 31449136
DOI: 10.11124/JBISRIR-D-18-00010 -
Asian Journal of Anesthesiology Sep 2019Shivering is a common postoperative complication that occurs after both general and regional anesthesia even in the cases when hypothermia during surgery has been...
Shivering is a common postoperative complication that occurs after both general and regional anesthesia even in the cases when hypothermia during surgery has been averted. Patients describe it as a highly unpleasant experience, while clinicians are concerned due to its adverse effects such as increased oxygen consumption. In this article, we present a summary of the pathophysiological mechanisms involved in postoperative shivering (POS), risk factors, and inadvertent effects. The major objective of this article was to review the existing literature on the effi ciency of various drug interventions as a prophylactic measure against POS. Since α2-adrenergic, opioid, anticholinergic, and serotonergic pathways are thought to play a role in the pathogenesis of POS, a wide variety of drugs has been investigated in this regard. Although the methodological diversity of the study designs and regimens does not support drawing defi nite conclusions, there is evidence indicating a benefi cial effect of dexmedetomidine, ketamine, tramadol, meperidine, dexamethasone, nefopam, granisetron, and ondansetron in the prevention of POS. The purpose of this review is to provide a thorough insight on various drug options and to serve as an aid for clinicians for careful analysis of the advantages and disadvantages of each regimen to decide which regimen will be ideally suited for the medical profi le of each patient.
Topics: Adrenergic alpha-2 Receptor Agonists; Humans; Nefopam; Postoperative Complications; Prospective Studies; Randomized Controlled Trials as Topic; Receptors, N-Methyl-D-Aspartate; Shivering; Tramadol
PubMed: 31842530
DOI: 10.6859/aja.201909_57(3).0002 -
The Journal of Emergency Medicine Apr 2020It is common practice for emergency physicians to give parenteral opioids for acute pain, however, some treating physicians have concerns that using parenteral opioids...
Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee.
BACKGROUND
It is common practice for emergency physicians to give parenteral opioids for acute pain, however, some treating physicians have concerns that using parenteral opioids can lead to nausea and vomiting when used alone. Therefore, antiemetics are often given prophylactically with opioids for nausea and vomiting in the emergency department (ED). This systematic review evaluates the use of prophylactic antiemetics with parenteral opioids for the treatment of acute pain in the ED.
METHODS
A 10-year literature search using keywords was performed in PubMed for English-language human studies. Abstracts were screened to identify high-quality studies, which then underwent a more rigorous structured review. The recommendations are made based on the literature review.
RESULTS
Eight articles met criteria for structured review and citation in this article. These include one review article, two randomized controlled trials, three prospective observational trials, one retrospective study, and one pre- and post-intervention trial.
CONCLUSIONS
Based on the literature review, routine use of prophylactic antiemetics are not indicated with administration of parenteral opioids for treatment of acute pain in the ED, as nausea and vomiting are infrequent side effects. The recent literature clearly demonstrates that there are potential undesirable side effects from the use of antiemetics when using opioids. However, one subgroup of patients, those with a known history of nausea and vomiting after opioid use or a history of travel sickness, may benefit from the use of prophylactic antiemetic when being treated with parenteral opioids.
Topics: Acute Pain; Analgesics, Opioid; Antiemetics; Emergency Medicine; Emergency Service, Hospital; Humans; Metoclopramide; Observational Studies as Topic; Ondansetron; Retrospective Studies; United States; Vomiting
PubMed: 32216978
DOI: 10.1016/j.jemermed.2019.12.024