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Anaesthesia, Critical Care & Pain... Aug 2021The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is... (Review)
Review
The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.
Topics: Abdominal Muscles; Humans; Male; Neoplasms; Nerve Block; Pain Management; Pain, Postoperative; Practice Guidelines as Topic; Prostatectomy
PubMed: 34197976
DOI: 10.1016/j.accpm.2021.100922 -
British Journal of Anaesthesia Nov 2022We conducted a systematic review and meta-analysis of contemporary RCTs to determine the clinical effectiveness of spinal vs general anaesthesia (SA vs GA) in patients... (Meta-Analysis)
Meta-Analysis Review
Clinical effectiveness and safety of spinal anaesthesia compared with general anaesthesia in patients undergoing hip fracture surgery using a consensus-based core outcome set and patient-and public-informed outcomes: a systematic review and meta-analysis of randomised controlled trials.
BACKGROUND
We conducted a systematic review and meta-analysis of contemporary RCTs to determine the clinical effectiveness of spinal vs general anaesthesia (SA vs GA) in patients undergoing hip fracture surgery using a consensus-based core outcome set, and outcomes defined as important by patient and public involvement (PPI) initiatives.
METHODS
RCTs comparing any of the core outcomes (mortality, time from injury to surgery, acute coronary syndrome, hypotension, acute kidney injury, delirium, pneumonia, orthogeriatric input, being out of bed at day 1 postoperatively, and pain) or PPI-defined outcomes (return to preoperative residence, quality of life, and mobility status) between SA and GA were identified from MEDLINE, Embase, Cochrane Library, and Web of Science (2000 to February 2022). Pooled relative risks (RRs) and mean differences (95% confidence intervals [CIs]) were estimated.
RESULTS
There was no significant difference in the risk of delirium comparing SA vs GA (RR=1.07; 95% CI, 0.90-1.29). Comparing SA vs GA, the RR for mortality was 0.56 (95% CI, 0.22-1.44) in-hospital, 1.07 (95% CI, 0.52-2.23) at 30 days, and 1.08 (95% CI, 0.55-2.12) at 90 days. Spinal anaesthesia reduced the risk of acute kidney injury compared with GA: RR=0.59 (95% CI, 0.39-0.89). There were no significant differences in the risk of other outcomes. Few studies reported PPI-defined outcomes, with most studies reporting on one to three core outcomes.
CONCLUSIONS
Except for acute kidney injury, there were no differences between SA and GA in hip fracture surgery when using a consensus-based core outcome set and patient and public involvement-defined outcomes. Most studies reported limited outcomes from the core outcome set, and few reported outcomes important to patients, which should be considered when designing future RCTs.
PROSPERO REGISTRATION
CRD42021275206.
Topics: Humans; Anesthesia, Spinal; Consensus; Quality of Life; Postoperative Complications; Anesthesia, General; Hip Fractures; Treatment Outcome; Delirium; Acute Kidney Injury; Randomized Controlled Trials as Topic
PubMed: 36270701
DOI: 10.1016/j.bja.2022.07.031 -
British Journal of Anaesthesia Feb 2023Postoperative delirium (POD) is the most common serious postoperative complication in older adults. It has uncertain aetiology, limited preventative strategies, and poor... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative delirium (POD) is the most common serious postoperative complication in older adults. It has uncertain aetiology, limited preventative strategies, and poor long-term outcomes. This updated systematic review and meta-analysis aimed to estimate the effect of processed electroencephalography (pEEG)-guided general anaesthesia during surgery on POD incidence.
METHODS
We performed a systematic review and meta-analysis by searching OVID MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases. Studies of adult patients having general anaesthesia for any surgery where pEEG was used and POD was an outcome measure were included. Full-text reports of RCTs published from database inception until August 28, 2021, were included. Trials were excluded if sedation rather than general anaesthesia was administered, or the setting was intensive care. The primary outcome was POD assessed by validated tools. The study was prospectively registered with PROSPERO.
RESULTS
Nine studies, which included 4648 eligible subjects, were identified. The incidence of POD in the pEEG-guided general anaesthesia or lighter pEEG target group was 19.0% (440/2310) compared with 23.3% (545/2338) in the usual care or deeper pEEG target group (pooled odds ratio=0.78; 95% confidence interval, 0.60-1.00; P=0.054). Significant heterogeneity was detected (I=53%).
CONCLUSIONS
Our primary analysis demonstrated a highly sensitive result with a pooled analysis of trials in which the intervention group adhered to manufacturer's recommended guidelines, showing reduced incidence of POD with pEEG guidance. High clinical heterogeneity limits inferences from this and any future meta-analyses.
CLINICAL TRIAL REGISTRATION
CRD42020199404 (PROSPERO).
Topics: Humans; Aged; Emergence Delirium; Anesthesia, General; Postoperative Complications; Electroencephalography
PubMed: 35183345
DOI: 10.1016/j.bja.2022.01.006 -
International Journal of Obstetric... Aug 2021Spinal anesthesia is the standard for elective cesarean section but spinal anesthesia-induced hypotension remains an important problem. Accurate prediction of... (Review)
Review
BACKGROUND
Spinal anesthesia is the standard for elective cesarean section but spinal anesthesia-induced hypotension remains an important problem. Accurate prediction of hypotension could enhance clinical decision-making, alter management, and facilitate early intervention. We performed a systematic review of predictors of spinal anesthesia-induced hypotension and their predictive value during cesarean section.
METHODS
PubMed, Embase, Cochrane Library, Google Scholar and Web of Science databases were searched for prospective observational studies assessing the diagnostic accuracy of predictors of spinal anesthesia-induced hypotension in elective cesarean section. The quality of studies was assessed and predictors were grouped in domains based on the type of predictor.
RESULTS
Thirty-eight studies (n=3086 patients) were included. In most studies, patients received 500-1000 mL crystalloid preload or 500-2000 mL crystalloid coload. Vasopressors for post-spinal hypotension were boluses of ephedrine 5-15 mg and/or phenylephrine 25-100 µg in most studies. The hypotension rate varied from 29% to 80% based on the definition. For analysis, >30 predictors were classified into seven domains: demographic characteristics, baseline hemodynamic variables, baseline sympathovagal balance, postural stress testing, peripheral perfusion indices, blood volume and fluid responsiveness indices, and genetic polymorphism.
CONCLUSIONS
Environmental and individual factors increased outcome variability, which restricted the value of the autonomic nervous system and peripheral perfusion indices for prediction of spinal anesthesia-induced hypotension. Supine stress tests may reflect parturients' cardiovascular tolerance during hemodynamic fluctuations and may optimize the predictive value of static state predictors. Future research for predicting spinal anesthesia-induced hypotension should focus on composite and dynamic parameters during the supine stress tests.
Topics: Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Colloids; Female; Humans; Hypotension; Hypotension, Controlled; Observational Studies as Topic; Phenylephrine; Pregnancy; Vasoconstrictor Agents
PubMed: 34034957
DOI: 10.1016/j.ijoa.2021.103175 -
British Journal of Anaesthesia Sep 2019Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. (Meta-Analysis)
Meta-Analysis
Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis.
BACKGROUND
Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.
METHODS
The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.
RESULTS
The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.
CONCLUSIONS
Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.
RECOMMENDATION
neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.
TRIAL REGISTRY NUMBER
PROSPERO CRD42018099935.
Topics: Anesthesia, Epidural; Anesthesia, General; Anesthesia, Spinal; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Evidence-Based Medicine; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31351590
DOI: 10.1016/j.bja.2019.05.042 -
Anesthesia and Analgesia Apr 2021Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic... (Meta-Analysis)
Meta-Analysis
Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.
Topics: Airway Extubation; Anesthesia; Female; Humans; Intubation, Intratracheal; Larynx; Male; Middle Aged; Postoperative Complications; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 33196479
DOI: 10.1213/ANE.0000000000005276 -
Neurology Apr 2023Endovascular thrombectomy (EVT) for large vessel occlusion ischemic stroke is either performed under general anesthesia (GA) or with non-GA techniques such as conscious... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
Endovascular thrombectomy (EVT) for large vessel occlusion ischemic stroke is either performed under general anesthesia (GA) or with non-GA techniques such as conscious sedation or local anesthesia alone. Previous small meta-analyses have demonstrated superior recanalization rates and improved functional recovery with GA when compared with non-GA techniques. The publication of further randomized controlled trials (RCTs) could provide updated guidance when choosing between GA and non-GA techniques.
METHODS
A systematic search for trials in which stroke EVT patients were randomized to GA or non-GA was performed in Medline, Embase, and the Cochrane Central Register of Controlled Trials. A systematic review and meta-analysis using a random-effects model was performed.
RESULTS
Seven RCTs were included in the systematic review and meta-analysis. These trials included a total of 980 participants (GA, N = 487; non-GA, N = 493). GA improves recanalization by 9.0% (GA 84.6% vs non-GA 75.6%; odds ratio [OR] 1.75, 95% CI 1.26-2.42, = 0.0009), and the proportion of patients with functional recovery improves by 8.4% (GA 44.6% vs non-GA 36.2%; OR 1.43, 95% CI 1.04-1.98, = 0.03). There was no difference in hemorrhagic complications or 3-month mortality.
DISCUSSION
In patients with ischemic stroke treated with EVT, GA is associated with higher recanalization rates and improved functional recovery at 3 months compared with non-GA techniques. Conversion to GA and subsequent intention-to-treat analysis will underestimate the true therapeutic benefit. GA is established as effective in improving recanalization rates in EVT (7 Class 1 studies) with a high Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) certainty rating. GA is established as effective in improving functional recovery at 3 months in EVT (5 Class 1 studies) with a moderate GRADE certainty rating. Stroke services need to develop pathways to incorporate GA as the first choice for most EVT procedures in acute ischemic stroke with a level A recommendation for recanalization and level B recommendation for functional recovery.
Topics: Humans; Brain Ischemia; Treatment Outcome; Randomized Controlled Trials as Topic; Stroke; Anesthesia, General; Thrombectomy; Ischemic Stroke; Endovascular Procedures
PubMed: 36797071
DOI: 10.1212/WNL.0000000000207066 -
International Journal of Molecular... Feb 2023The use of neuraxial procedures, such as spinal and epidural anaesthesia, has been linked to some possible complications. In addition, spinal cord injuries due to... (Review)
Review
The use of neuraxial procedures, such as spinal and epidural anaesthesia, has been linked to some possible complications. In addition, spinal cord injuries due to anaesthetic practice (Anaes-SCI) are rare events but remain a significant concern for many patients undergoing surgery. This systematic review aimed to identify high-risk patients summarise the causes, consequences, and management/recommendations of SCI due to neuraxial techniques in anaesthesia. A comprehensive search of the literature was conducted in accordance with Cochrane recommendations, and inclusion criteria were applied to identify relevant studies. From the 384 studies initially screened, 31 were critically appraised, and the data were extracted and analysed. The results of this review suggest that the main risk factors reported were extremes of age, obesity, and diabetes. Anaes-SCI was reported as a consequence of hematoma, trauma, abscess, ischemia, and infarction, among others. As a result, mainly motor deficits, sensory loss, and pain were reported. Many authors reported delayed treatments to resolve Anaes-SCI. Despite the potential complications, neuraxial techniques are still one of the best options for opioid-sparing pain prevention and management, reducing patients' morbidity, improving outcomes, reducing the length of hospital stay, and pain chronification, with a consequent economic benefit. The main findings of this review highlight the importance of careful patient management and close monitoring during neuraxial anaesthesia procedures to minimise the risk of spinal cord injury and complications.
Topics: Humans; Anesthesia, Spinal; Anesthesia, Epidural; Spinal Cord Injuries; Pain
PubMed: 36902095
DOI: 10.3390/ijms24054665 -
Anesthesia and Analgesia Apr 2022Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia.
METHODS
We searched the Medline, Scopus, and Web of Science databases from their inception to December 2020. The population of interest included adults who required tracheal intubation for elective surgery under general anesthesia without clear anatomical abnormalities suggesting difficult laryngoscopy. A bivariate model has been used to assess the accuracy of each ultrasound index test to predict difficult direct laryngoscopy.
RESULTS
Fifteen studies have been considered for quantitative analysis of summary receiver operating characteristic (SROC). The sensitivity for distance from skin to epiglottis (DSE), distance from skin to hyoid bone (DSHB), and distance from skin to vocal cords (DSVC) was 0.82 (0.74-0.87), 0.71 (0.58-0.82), and 0.75 (0.62-0.84), respectively. The specificity for DSE, DSHB, and DSVC was 0.79 (0.70-0.87), 0.71 (0.57-0.82), and 0.72 (0.45-0.89), respectively. The area under the curve (AUC) for DSE, DSHB, DSVC, and ratio between the depth of the pre-epiglottic space and the distance from the epiglottis to the vocal cords (Pre-E/E-VC) was 0.87 (0.84-0.90), 0.77 (0.73-0.81), 0.78 (0.74-0.81), and 0.71 (0.67-0.75), respectively. Patients with difficult direct laryngoscopy have higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with a mean difference of 0.38 cm (95% confidence interval [CI], 0.17-0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01-0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08-0.39 cm; P = .004), respectively.
CONCLUSIONS
Our study demonstrates that airway ultrasound index tests are significantly different between patients with easy versus difficult direct laryngoscopy, and the DSE is the most studied index test in literature to predict difficult direct laryngoscopy. However, it is not currently possible to reach a definitive conclusion. Further studies are needed with better standardization of ultrasound assessment to limit all possible sources of heterogeneity.
Topics: Adult; Anesthesia, General; Humans; Intubation, Intratracheal; Laryngoscopy; Respiratory System; Ultrasonography
PubMed: 34914641
DOI: 10.1213/ANE.0000000000005839 -
Anaesthesia Jul 2021Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is... (Meta-Analysis)
Meta-Analysis
Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
Topics: Adult; Anesthesia, General; Antiemetics; Female; Humans; Male; Network Meta-Analysis; Postoperative Nausea and Vomiting; Treatment Outcome
PubMed: 33170514
DOI: 10.1111/anae.15295