-
The Cochrane Database of Systematic... Sep 2019The use of clinical signs, or end-tidal anaesthetic gas (ETAG), may not be reliable in measuring the hypnotic component of anaesthesia and may lead to either overdosage...
BACKGROUND
The use of clinical signs, or end-tidal anaesthetic gas (ETAG), may not be reliable in measuring the hypnotic component of anaesthesia and may lead to either overdosage or underdosage resulting in adverse effects because of too deep or too light anaesthesia. Intraoperative awareness, whilst uncommon, may lead to serious psychological disturbance, and alternative methods to monitor the depth of anaesthesia may reduce the incidence of serious events. Bispectral index (BIS) is a numerical scale based on electrical activity in the brain. Using a BIS monitor to guide the dose of anaesthetic may have advantages over clinical signs or ETAG. This is an update of a review last published in 2014.
OBJECTIVES
To assess the effectiveness of BIS to reduce the risk of intraoperative awareness and early recovery times from general anaesthesia in adults undergoing surgery.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, and Web of Science on 26 March 2019. We searched clinical trial registers and grey literature, and handsearched reference lists of included studies and related reviews.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) and quasi-RCTs in which BIS was used to guide anaesthesia compared with standard practice which was either clinical signs or end-tidal anaesthetic gas (ETAG) to guide the anaesthetic dose. We included adult participants undergoing any type of surgery under general anaesthesia regardless of whether included participants had a high risk of intraoperative awareness. We included only studies in which investigators aimed to evaluate the effectiveness of BIS for its role in monitoring intraoperative depth of anaesthesia or potential improvements in early recovery times from anaesthesia.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE.
MAIN RESULTS
We included 52 studies with 41,331 participants; two studies were quasi-randomized and the remaining studies were RCTs. All studies included participants undergoing surgery under general anaesthesia. Three studies recruited only participants who were at high risk of intraoperative awareness, whilst two studies specifically recruited an unselected participant group. We analysed the data according to two comparison groups: BIS versus clinical signs; and BIS versus ETAG. Forty-eight studies used clinical signs as a comparison method, which included titration of anaesthesia according to criteria such as blood pressure or heart rate and, six studies used ETAG to guide anaesthesia. Whilst BIS target values differed between studies, all were within a range of values between 40 to 60.BIS versus clinical signsWe found low-certainty evidence that BIS-guided anaesthesia may reduce the risk of intraoperative awareness in a surgical population that were unselected or at high risk of awareness (Peto odds ratio (OR) 0.36, 95% CI 0.21 to 0.60; I = 61%; 27 studies; 9765 participants). However, events were rare with only five of 27 studies with reported incidences; we found that incidences of intraoperative awareness when BIS was used were three per 1000 (95% CI 2 to 6 per 1000) compared to nine per 1000 when anaesthesia was guided by clinical signs. Of the five studies with event data, one included participants at high risk of awareness and one included unselected participants, four used a structured questionnaire for assessment, and two used an adjudication process to identify confirmed or definite awareness.Early recovery times were also improved when BIS was used. We found low-certainty evidence that BIS may reduce the time to eye opening by mean difference (MD) 1.78 minutes (95% CI -2.53 to -1.03 minutes; 22 studies; 1494 participants), the time to orientation by MD 3.18 minutes (95% CI -4.03 to -2.33 minutes; 6 studies; 273 participants), and the time to discharge from the postanaesthesia care unit (PACU) by MD 6.86 minutes (95% CI -11.72 to -2 minutes; 13 studies; 930 participants).BIS versus ETAGAgain, events of intraoperative awareness were extremely rare, and we found no evidence of a difference in incidences of intraoperative awareness according to whether anaesthesia was guided by BIS or by ETAG in a surgical population at unselected or at high risk of awareness (Peto OR 1.13, 95% CI 0.56 to 2.26; I = 37%; 5 studies; 26,572 participants; low-certainty evidence). Incidences of intraoperative awareness were one per 1000 in both groups. Only three of five studies reported events, two included participants at high risk of awareness and one included unselected participants, all used a structured questionnaire for assessment and an adjudication process to identify confirmed or definite awareness.One large study (9376 participants) reported a reduced time to discharge from the PACU by a median of three minutes less, and we judged the certainty of this evidence to be low. No studies measured or reported the time to eye opening and the time to orientation.Certainty of the evidenceWe used GRADE to downgrade the evidence for all outcomes to low certainty. The incidence of intraoperative awareness is so infrequent such that, despite the inclusion of some large multi-centre studies in analyses, we believed that the effect estimates were imprecise. In addition, analyses included studies that we judged to have limitations owing to some assessments of high or unclear bias and in all studies, it was not possible to blind anaesthetists to the different methods of monitoring depth of anaesthesia.Studies often did not report a clear definition of intraoperative awareness. Time points of measurement differed, and methods used to identify intraoperative awareness also differed and we expected that some assessment tools were more comprehensive than others.
AUTHORS' CONCLUSIONS
Intraoperative awareness is infrequent and, despite identifying a large number of eligible studies, evidence for the effectiveness of using BIS to guide anaesthetic depth is imprecise. We found that BIS-guided anaesthesia compared to clinical signs may reduce the risk of intraoperative awareness and improve early recovery times in people undergoing surgery under general anaesthesia but we found no evidence of a difference between BIS-guided anaesthesia and ETAG-guided anaesthesia. We found six studies awaiting classification and two ongoing studies; inclusion of these studies in future updates may increase the certainty of the evidence.
Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics; Electroencephalography; Humans; Intraoperative Awareness; Monitoring, Intraoperative; Postoperative Period; Randomized Controlled Trials as Topic
PubMed: 31557307
DOI: 10.1002/14651858.CD003843.pub4 -
Anesthesiology Jun 2022
Topics: Atrial Fibrillation; Humans; Postoperative Complications; Postoperative Period; Risk Factors
PubMed: 35482968
DOI: 10.1097/ALN.0000000000004233 -
Annals of Palliative Medicine Aug 2022
Topics: Humans; Postoperative Period
PubMed: 35871274
DOI: 10.21037/apm-22-784 -
Minerva Anestesiologica Mar 2022
Topics: Aged; Delirium; Humans; Postoperative Period
PubMed: 35164497
DOI: 10.23736/S0375-9393.22.16442-4 -
Anesthesiology Aug 2022
Topics: Analgesics, Opioid; Drug Prescriptions; Humans; Pain, Postoperative; Postoperative Period; Practice Patterns, Physicians'
PubMed: 35819864
DOI: 10.1097/ALN.0000000000004297 -
British Journal of Anaesthesia Jul 2022There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also... (Review)
Review
BACKGROUND
There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also unclear whether instruments measure the four dimensions of postoperative recovery, that is physical, psychological, social, and habitual recovery. This scoping review had three objectives: (1) to identify and describe instruments used in clinical trials to assess postoperative recovery; (2) to determine how, when, and the number of times postoperative recovery was measured; and (3) to explore whether the four dimensions of postoperative recovery are represented in the identified instruments.
METHODS
A literature search was conducted in CINAHL, MEDLINE, and Web of Science. The search terms were related to three search strands: postoperative recovery, instrument, and clinical trials. The limits were English language and publication January 2010 to November 2021. In total, 5015 studies were identified.
RESULTS
A total of 198 studies were included in the results. We identified 20 instruments measuring postoperative recovery. Different versions of Quality of Recovery represented 81.8% of the included instruments. Postoperative recovery was often assessed at one time point (47.2%) and most often on postoperative day 1 (81.5%). Thirteen instruments had items covering all four dimensions of postoperative recovery.
CONCLUSIONS
Assessing recovery is important to evaluate and improve perioperative care. We emphasise the importance of choosing the right instrument for the concept studied and, if postoperative recovery is of interest, of assessing more than once. Ideally, instruments should include all four dimensions to cover the whole recovery process.
Topics: Humans; Postoperative Period
PubMed: 35623904
DOI: 10.1016/j.bja.2022.04.015 -
Anesthesiology Oct 2021
Topics: Anesthetics; Anesthetics, Inhalation; Cognition; Humans; Postoperative Period
PubMed: 34464441
DOI: 10.1097/ALN.0000000000003918 -
Acta Orthopaedica Jul 2022
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Knee Joint; Postoperative Period
PubMed: 35848732
DOI: 10.2340/17453674.2022.3977 -
Anaesthesia Jan 2020An ageing population and rising healthcare costs are challenging cost-efficient hospital systems wanting to adapt, employing novel organisational structures designed to... (Review)
Review
An ageing population and rising healthcare costs are challenging cost-efficient hospital systems wanting to adapt, employing novel organisational structures designed to merge diverse skill sets. This needs not only physician and nursing leadership but also new models of care. Anaesthetists have expanded their role into the broader multidisciplinary field of peri-operative medicine, emphasising collaboration and safety in health teams. A greater focus on patient-centred care and shared decision making, along with validated metrics to quantify quality improvement activities, have emphasised the importance of comfort, patient satisfaction and quality of life after surgery. Shared decision-making is more likely to be manifest in a flat hierarchy in which each member of the team brings their own experience and skills to optimise patient care. Successful surgery is best achieved by a coordinated, multidisciplinary team, embedded in a culture of collaboration and safety.
Topics: Humans; Patient Care Team; Patient-Centered Care; Postoperative Complications; Postoperative Period; Recovery of Function
PubMed: 31903575
DOI: 10.1111/anae.14869 -
Indian Journal of Ophthalmology Dec 2022To study the efficacy of dacryocystectomy (DCT) in reducing epiphora in cases of primary acquired nasolacrimal duct obstruction. (Clinical Trial)
Clinical Trial
PURPOSE
To study the efficacy of dacryocystectomy (DCT) in reducing epiphora in cases of primary acquired nasolacrimal duct obstruction.
METHODS
This was a prospective, nonrandomized, interventional study conducted over a period of 12 months. All cases who either opted or satisfied our criteria for DCT in primary acquired nasolacrimal duct obstruction (age above 70 years) were included in the study. Patients with secondary nasolacrimal duct obstruction and those undergoing revision surgeries were excluded. Patients were asked to report the percentage improvement in postoperative watering subjectively. Munk score and fluorescein dye disappearance test (FDDT) were recorded pre- and postoperatively. Wilcoxon signed ranked test was used for analysis.
RESULTS
Eighty-two eyes of 65 patients were included. Most of the patients (46, 70.8%) were females. The mean age was 68.46 ± 5.7 years (range: 60-85 years). The mean subjective improvement in watering was 86.8%. The P value for preoperative and postoperative difference in Munk score and FDDT score was highly significant (P = 0.00001).
CONCLUSION
Apart from providing relief from ocular discharge, DCT also provides significant improvement in watering. Patients can be preoperatively counseled regarding chances of reduction in epiphora following surgery.
Topics: Aged; Female; Humans; Male; Middle Aged; Lacrimal Duct Obstruction; Nasolacrimal Duct; Postoperative Period; Prospective Studies
PubMed: 36453356
DOI: 10.4103/ijo.IJO_972_22