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Journal of Clinical Anesthesia Aug 2017To compare the use of inhalation versus intravenous anaesthesia for adults undergoing on-pump or off-pump coronary artery bypass grafting. (Comparative Study)
Comparative Study Meta-Analysis Review
Inhalation versus intravenous anaesthesia for adults undergoing on-pump or off-pump coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials.
STUDY OBJECTIVE
To compare the use of inhalation versus intravenous anaesthesia for adults undergoing on-pump or off-pump coronary artery bypass grafting.
DESIGN
A systematic review.
SETTING
A hospital-affiliated university.
MEASUREMENTS
The following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 10), MEDLINE, EMBASE, and LILACS (from inception to October 2016). We used the GRADE approach to rate overall certainty of the evidence.
RESULTS
In total we included 58 studies with a total of 6105 participants. The methodological quality was difficult to assess as it was poorly reported in 35 included studies (three or more domains were rated as unclear risk of bias). Two trials of sevoflurane showed a statistically significant reduction in death within 180 to 365days of surgery (on-pump) (RR 4.10, 95% CI 1.42 to 11.79; p=0.009; I=not applicable; high quality of evidence). There was also a statistically significant difference favouring sevoflurane compared to propofol on both inotropic (RR 2.11, 95% CI 1.53 to 2.90; p<0.00001; I=0%) and vasoconstrictor support needed (RR 1.51, 95% CI 1.04 to 2.22; p=0.03; I=0%) after coronary artery bypass grafting on-pump. Two trials of sevoflurane (MD -0.22, 95% CI -0.41 to -0.03; p=0.02; I=0%) and two further trials of desflurane (MD -0.33, 95% CI -0.45 to -0.20; p<0.00001; I=82%) showed a statistically significant difference on cardiac index during and after coronary artery bypass grafting on-pump, respectively.
CONCLUSIONS
There is high quality evidence that sevoflurane reduces death within 180 to 365days of surgery and, inotropic and vasoconstrictor support compared to propofol for patients undergoing coronary artery bypass grafting. There is also some evidence showing that the cardiac index is minimally influenced by administration of sevoflurane and desflurane compared to propofol.
Topics: Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Coronary Artery Bypass; Coronary Artery Bypass, Off-Pump; Humans; Methyl Ethers; Propofol; Randomized Controlled Trials as Topic; Sevoflurane
PubMed: 28625437
DOI: 10.1016/j.jclinane.2017.05.010 -
Journal of Anaesthesiology, Clinical... 2017Esmolol has been shown to improve postoperative pain and reduce opioid requirements. The aim of this systematic review was to evaluate the effect of perioperative... (Review)
Review
Esmolol has been shown to improve postoperative pain and reduce opioid requirements. The aim of this systematic review was to evaluate the effect of perioperative esmolol as an adjunct on early postoperative pain intensity, recovery profile, and anesthetic requirement. Databases were searched for randomized placebo-controlled trials evaluating the effects of esmolol during general anesthesia. Primary outcomes were related to early postoperative pain whereas secondary outcomes were related to emergence time, postoperative nausea and vomiting, and intraoperative anesthetic requirement. Nineteen trials were identified involving 936 patients (esmolol = 470, placebo = 466). In esmolol group, numeric pain scores at rest in the immediate postoperative period were reduced by 1.16 (95% confidence interval [CI]: 1.97-0.35, = 96.7%) out of 10. Opioid consumption was also decreased in the postanesthesia care unit compared with placebo, mean difference of 5.1 mg (95% CI: 7.0-3.2, = 96.9%) morphine IV equivalents; a 69% reduction in opioid rescue dosing was noted (odds ratio [OR]: 0.31, 95% CI: 0.16-0.80, = 0.0%). A 61% reduction in postoperative nausea and vomiting was also evident (OR: 0.39, 95% CI: 0.20-0.75, = 60.7%). A reduction in propofol induction dose was noted in the esmolol group (mean difference: -0.53 mg/kg, 95% CI: -0.63--0.44, = 0.0%). A decrease in end-tidal desflurane equivalent (mean difference: 1.70%, 95% CI: -2.39--1.02, = 92.0%) and intraoperative opioid usage (fentanyl equivalent, mean difference: 440 μg, 95% CI: -637--244, = 99.6%) was observed in esmolol group. Esmolol had no effect on the emergence time. Perioperative esmolol as an adjunct may reduce postoperative pain intensity, opioid consumption, and postoperative nausea vomiting. Given the heterogeneity, larger clinical trials are warranted to confirm these findings.
PubMed: 28413270
DOI: 10.4103/0970-9185.202182 -
The Cochrane Database of Systematic... Apr 2017Rapid implementation of robotic transabdominal surgery has resulted in the need for re-evaluation of the most suitable form of anaesthesia. The overall objective of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Rapid implementation of robotic transabdominal surgery has resulted in the need for re-evaluation of the most suitable form of anaesthesia. The overall objective of anaesthesia is to minimize perioperative risk and discomfort for patients both during and after surgery. Anaesthesia for patients undergoing robotic assisted surgery is different from anaesthesia for patients undergoing open or laparoscopic surgery; new anaesthetic concerns accompany robotic assisted surgery.
OBJECTIVES
To assess outcomes related to the choice of total intravenous anaesthesia (TIVA) or inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016 Issue 5), Ovid MEDLINE (1946 to May 2016), Embase via OvidSP (1982 to May 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost (1982 to May 2016) and the Institute for Scientific Information (ISI) Web of Science (1956 to May 2016). We also searched the International Standard Randomized Controlled Trial Number (ISRCTN) Registry and Clinical trials gov for ongoing trials (May 2016).
SELECTION CRITERIA
We searched for randomized controlled trials (RCTs) including adults, aged 18 years and older, of both genders, treated with transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery and focusing on outcomes of TIVA or inhalational anaesthesia.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures of Cochrane. Study findings were not suitable for meta-analysis.
MAIN RESULTS
We included three single-centre, two-arm RCTs involving 170 participants. We found one ongoing trial. All included participants were male and were undergoing radical robotic assisted laparoscopic radical prostatectomy (RALRP). The men were between 50 and 75 years of age and met criteria for American Society of Anesthesiologists physical classification scores (ASA) I, ll and III.We found evidence showing no clinically meaningful differences in postoperative pain between the two types of anaesthetics (mean difference (MD) in visual analogue scale (VAS) scores at one to six hours was -2.20 (95% confidence interval (CI) -10.62 to 6.22; P = 0.61) in a sample of 62 participants from one study. Low-quality evidence suggests that propofol reduces postoperative nausea and vomiting (PONV) over the short term (one to six hours after surgery) after RALRP compared with inhalational anaesthesia (sevoflurane, desflurane) (MD -1.70, 95% CI -2.59 to -0.81; P = 0.0002).We found low-quality evidence suggesting that propofol may prevent an increase in intraocular pressure (IOP) after pneumoperitoneum and steep Trendelenburg positioning compared with sevoflurane (MD -3.90, 95% CI -6.34 to -1.46; P = 0.002) with increased IOP from baseline to 30 minutes in steep Trendelenburg. However, it is unclear whether this surrogate outcome translates directly to clinical avoidance of ocular complications during surgery. No studies addressed the secondary outcomes of adverse effects, all-cause mortality, respiratory or circulatory complications, cognitive dysfunction, length of stay or costs. Overall the quality of evidence was low to very low, as all studies were small, single-centre trials providing unclear descriptions of methods.
AUTHORS' CONCLUSIONS
It is unclear which anaesthetic technique is superior - TIVA or inhalational - for transabdominal robotic assisted surgery in urology, gynaecology and gastroenterology, as existing evidence is scarce, is of low quality and has been generated from exclusively male patients undergoing robotic radical prostatectomy.An ongoing trial, which includes participants of both genders with a focus on quality of recovery, might have an impact on future evidence related to this topic.
Topics: Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Humans; Intraocular Pressure; Laparoscopy; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Postoperative Nausea and Vomiting; Propofol; Prostatectomy; Randomized Controlled Trials as Topic; Robotic Surgical Procedures
PubMed: 28374886
DOI: 10.1002/14651858.CD011387.pub2 -
Anesthesia and Analgesia Apr 2017Inhalation agents are being used in place of intravenous agents to provide sedation in some intensive care units. We performed a systematic review and meta-analysis of... (Comparative Study)
Comparative Study Meta-Analysis Review
Safety and Efficacy of Volatile Anesthetic Agents Compared With Standard Intravenous Midazolam/Propofol Sedation in Ventilated Critical Care Patients: A Meta-analysis and Systematic Review of Prospective Trials.
BACKGROUND
Inhalation agents are being used in place of intravenous agents to provide sedation in some intensive care units. We performed a systematic review and meta-analysis of prospective randomized controlled trials, which compared the use of volatile agents versus intravenous midazolam or propofol in critical care units.
METHODS
A search was conducted using MEDLINE (1946-2015), EMBASE (1947-2015), Web of Science index (1900-2015), and Cochrane Central Register of Controlled Trials. Eligible studies included randomized controlled trials comparing inhaled volatile (desflurane, sevoflurane, and isoflurane) sedation to intravenous midazolam or propofol. Primary outcome assessed the effect of volatile-based sedation on extubation times (time between discontinuing sedation and tracheal extubation). Secondary outcomes included time to obey verbal commands, proportion of time spent in target sedation, nausea and vomiting, mortality, length of intensive care unit, and length of hospital stay. Heterogeneity was assessed using the I statistic. Outcomes were assessed using a random or fixed-effects model depending on heterogeneity.
RESULTS
Eight trials with 523 patients comparing all volatile agents with intravenous midazolam or propofol showed a reduction in extubation times using volatile agents (difference in means, -52.7 minutes; 95% confidence interval [CI], -75.1 to -30.3; P < .00001). Reductions in extubation time were greater when comparing volatiles with midazolam (difference in means, -292.2 minutes; 95% CI, -384.4 to -200.1; P < .00001) than propofol (difference in means, -29.1 minutes; 95% CI, -46.7 to -11.4; P = .001). There was no significant difference in time to obey verbal commands, proportion of time spent in target sedation, adverse events, death, or length of hospital stay.
CONCLUSIONS
Volatile-based sedation demonstrates a reduction in time to extubation, with no increase in short-term adverse outcomes. Marked study heterogeneity was present, and the results show marked positive publication bias. However, a reduction in extubation time was still evident after statistical correction of publication bias. Larger clinical trials are needed to further evaluate the role of these agents as sedatives for critically ill patients.
Topics: Anesthetics, Inhalation; Anesthetics, Intravenous; Clinical Trials as Topic; Critical Care; Humans; Hypnotics and Sedatives; Midazolam; Nausea; Propofol; Prospective Studies; Respiration, Artificial; Treatment Outcome; Volatilization
PubMed: 27828800
DOI: 10.1213/ANE.0000000000001634 -
Medicine Sep 2016The differences in the incidence and severity of emergence agitation (EA) and emergence times between desflurane and sevoflurane anesthesia have not been as clearly... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
The differences in the incidence and severity of emergence agitation (EA) and emergence times between desflurane and sevoflurane anesthesia have not been as clearly elucidated in children as in adults.
METHODS
The design of the study is a systematic review with meta-analysis of randomized controlled trials. The study methodology is based on the Cochrane Review Methods. A comprehensive literature search was conducted to identify clinical trials comparing the incidence or severity of EA and emergence times in children anesthetized with desflurane or sevoflurane. Two reviewers independently assessed each study according to predefined inclusion criteria and extracted data from each study using a prespecified data extraction form. The data from each study were combined using a fixed effect or random effect model to calculate the pooled risk ratio (RR) or standardized mean difference (SMD) and 95% confidence interval (CI). Funnel plots were used to assess publication bias. Subgroup and sensitivity analyses were performed.
RESULTS
Fourteen studies met the inclusion criteria. Among the 1196 patients in these 14 studies, 588 received desflurane anesthesia and 608 received sevoflurane anesthesia. The incidence of EA was comparable between the 2 groups (pooled RR = 1.21; 95% CI: 0.96-1.53; I = 26%), and so was the severity of EA (EA score) between the 2 groups (SMD = 0.12; 95% CI: -0.02 to 0.27; I = 0%). Extubation and awakening times were shorter in the desflurane group than in the sevoflurane group; the weighted mean differences were -2.21 (95% CI: -3.62 to -0.81; I = 93%) and -2.74 (95% CI: -3.80 to -1.69; I = 85%), respectively. No publication bias was found in the funnel plot. The subgroup analysis based on the type of EA scale showed a higher incidence of EA in the desflurane group than in the sevoflurane group in studies using 3-, 4-, or 5-point EA scales; the pooled RR was 1.38 (95% CI: 1.10-1.73; I = 37%).
CONCLUSION
The incidence and severity of EA were comparable between desflurane and sevoflurane anesthesia in children; however, emergence times, including extubation and awakening times, were shorter in desflurane anesthesia.
Topics: Adolescent; Anesthesia, Inhalation; Anesthetics, Inhalation; Child; Child, Preschool; Desflurane; Emergence Delirium; Humans; Incidence; Isoflurane; Methyl Ethers; Sevoflurane; Time Factors
PubMed: 27661046
DOI: 10.1097/MD.0000000000004927 -
Anesthesia and Analgesia Oct 2016Many studies have compared propofol-based anesthesia with inhalational anesthesia. Results from several studies have shown improved postoperative analgesia after... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Many studies have compared propofol-based anesthesia with inhalational anesthesia. Results from several studies have shown improved postoperative analgesia after propofol anesthesia, but other studies showed contradictory results. There are no large prospective studies that compare postoperative pain after propofol versus inhalational anesthesia. This meta-analysis was designed to focus on this question.
METHODS
A systematic literature search for randomized controlled trials that compared propofol-based anesthesia with volatile agents-based anesthesia in adults undergoing surgery was conducted. Published data were pooled for the meta-analysis with Review Manager (ie, RevMan). The main outcomes included postoperative pain intensity, opioid consumption, need for rescue analgesics, and time to first analgesia.
RESULTS
Thirty-nine clinical trials with a combined subject population of 4520 patients came within the purview of this meta-analysis. The investigated volatile agents included isoflurane, sevoflurane, and desflurane. Compared with inhalational anesthetics, the propofol use was associated with a reduced postoperative pain intensity at rest at 30 minutes, 1 hour, and 12 hours (mean difference in pain scores, 30 minutes, -0.48 [visual analog scale, 0-10]; 99% confidence interval [CI], -1.07 to 0.12, P = 0.04) and reduced morphine-equivalent consumption 0 to 24 hours postoperatively (mean difference in morphine-equivalent consumption, -2.68 mg; 99% CI, -6.17 to 0.82; P = 0.05). Fewer patients required postoperative rescue analgesics during 0 to 24 hours after surgery under propofol anesthesia (risk ratio, 0.87; 99% CI, 0.74-1.03; P = 0.04). In addition, patients anesthetized with propofol required administration of postoperative analgesia later than those anesthetized with volatiles (mean difference in time to first analgesic administration, 6.12 minutes; 99% CI, 0.02-12.21; P = 0.01). Considering that Z statistic in RevMan 5.3 does not perform optimally in highly heterogeneous samples among groups or many combinations of groups with small sample sizes, a P value of <.01 was considered statistically significant. On the basis of this threshold, none of the aforementioned results are statistically significant.
CONCLUSIONS
The current results are affected by substantial heterogeneity, which makes it difficult to predict significant differences in postoperative pain control between propofol anesthesia and inhalational anesthesia. Further large, randomized controlled trials are needed to corroborate these results and to detect differences (if any) between propofol and inhalational anesthesia on postoperative pain.
Topics: Anesthetics, Inhalation; Anesthetics, Intravenous; Humans; Pain Measurement; Pain, Postoperative; Propofol; Randomized Controlled Trials as Topic
PubMed: 27636574
DOI: 10.1213/ANE.0000000000001504 -
The Cochrane Database of Systematic... Jul 2016Pre-cancerous lesions of cervix (cervical intraepithelial neoplasia (CIN)) are usually treated with excisional or ablative procedures. In the UK, the National Health... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pre-cancerous lesions of cervix (cervical intraepithelial neoplasia (CIN)) are usually treated with excisional or ablative procedures. In the UK, the National Health Service (NHS) cervical screening guidelines suggest that over 80% of treatments should be performed in an outpatient setting (colposcopy clinics). Furthermore, these guidelines suggest that analgesia should always be given prior to laser or excisional treatments. Currently various pain relief strategies are employed that may reduce pain during these procedures.
OBJECTIVES
To assess whether the administration of pain relief (analgesia) reduces pain during colposcopy treatment and in the postoperative period.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE (1950 to March week 3, 2016) and Embase (1980 to week 12, 2016) for studies of any design relating to analgesia for colposcopic management. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.
SELECTION CRITERIA
Randomised controlled trials (RCTs) that compared all types of pain relief before, during or after outpatient treatment to the cervix, in women with CIN undergoing loop excision, laser ablation, laser excision or cryosurgery in an outpatient colposcopy clinic setting.
DATA COLLECTION AND ANALYSIS
We independently assessed study eligibility, extracted data and assessed risk of bias. We entered data into Review Manager 5 and double checked it for accuracy. Where possible, we expressed results as mean pain score and standard error of the mean with 95% confidence intervals (CI) and synthesised data in a meta-analysis.
MAIN RESULTS
We included 19 RCTs (1720 women) of varying methodological quality in the review. These trials compared a variety of interventions aimed at reducing pain in women who underwent treatment for CIN, including cervical injection with lignocaine alone, lignocaine with adrenaline, buffered lignocaine with adrenaline, prilocaine with felypressin, oral analgesics (non-steroidal anti-inflammatory drugs (NSAIDs)), inhalation analgesia (gas mixture of isoflurane and desflurane), lignocaine spray, cocaine spray, local application of benzocaine gel, lignocaine-prilocaine cream (EMLA cream) and transcutaneous electrical nerve stimulation (TENS).Most comparisons were restricted to single trial analyses and were under-powered to detect differences in pain scores between treatments that may or may not have been present. There was no difference in pain relief between women who received local anaesthetic infiltration (lignocaine 2%; administered as a paracervical or direct cervical injection) and a saline placebo (mean difference (MD) -13.74; 95% CI -34.32 to 6.83; 2 trials; 130 women; low quality evidence). However, when local anaesthetic was combined with a vasoconstrictor agent (one trial used lignocaine plus adrenaline while the second trial used prilocaine plus felypressin), there was less pain (on visual analogue scale (VAS)) compared with no treatment (MD -23.73; 95% CI -37.53 to -9.93; 2 trials; 95 women; low quality evidence). Comparing two preparations of local anaesthetic combined with vasoconstrictor, prilocaine plus felypressin did not differ from lignocaine plus adrenaline for its effect on pain control (MD -0.05; 95% CI -0.26 to 0.16; 1 trial; 200 women). Although the mean (± standard deviation (SD)) observed blood loss score was less with lignocaine plus adrenaline (1.33 ± 1.05) compared with prilocaine plus felypressin (1.74 ± 0.98), the difference was not clinically as the overall scores in both groups were low (MD 0.41; 95% CI 0.13 to 0.69; 1 trial; 200 women). Inhalation of gas mixture (isoflurane and desflurane) in addition to standard cervical injection with prilocaine plus felypressin resulted in less pain during the LLETZ (loop excision of the transformation zone) procedure (MD -7.20; 95% CI -12.45 to -1.95; 1 trial; 389 women). Lignocaine plus ornipressin resulted in less measured blood loss (MD -8.75 ml; 95% CI -10.43 to -7.07; 1 trial; 100 women) and a shorter duration of treatment (MD -7.72 minutes; 95% CI -8.49 to -6.95; 1 trial; 100 women) than cervical infiltration with lignocaine alone. Buffered solution (sodium bicarbonate buffer mixed with lignocaine plus adrenaline) was not superior to non-buffered solution of lignocaine plus adrenaline in relieving pain during the procedure (MD -8.00; 95% CI -17.57 to 1.57; 1 trial; 52 women).One meta-analysis found no difference in pain using VAS between women who received oral analgesic and women who received placebo (MD -3.51; 95% CI -10.03 to 3.01; 2 trials; 129 women; low quality evidence).Cocaine spray was associated with less pain (MD -28.00; 95% CI -37.86 to -18.14; 1 trial; 50 women) and blood loss (MD 0.04; 95% CI 0 to 0.70; 1 trial; 50 women) than placebo.None of the trials reported serious adverse events and majority of trials were at moderate or high risk of bias (13 trials).
AUTHORS' CONCLUSIONS
Based on two small trials, there was no difference in pain relief in women receiving oral analgesics compared with placebo or no treatment (MD -3.51; 95% CI -10.03 to 3.01; 129 women). We consider this evidence to be of a low to moderate quality. In routine clinical practice, intracervical injection of local anaesthetic with a vasoconstrictor (lignocaine plus adrenaline or prilocaine plus felypressin) appears to be the optimum analgesia for treatment. However, further high quality, adequately powered trials should be undertaken in order to provide the data necessary to estimate the efficacy of oral analgesics, the optimal route of administration and dose of local anaesthetics.
Topics: Administration, Oral; Adult; Analgesics; Colposcopy; Drug Therapy, Combination; Female; Humans; Intraoperative Complications; Pain Management; Pain Measurement; Pain, Postoperative; Randomized Controlled Trials as Topic; Transcutaneous Electric Nerve Stimulation; Uterine Cervical Neoplasms; Uterine Cervical Dysplasia
PubMed: 27428114
DOI: 10.1002/14651858.CD006120.pub4 -
Anesthesiology Jun 2016It is not known whether modern volatile anesthetics are associated with less mortality and postoperative pulmonary or other complications in patients undergoing general... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is not known whether modern volatile anesthetics are associated with less mortality and postoperative pulmonary or other complications in patients undergoing general anesthesia for surgery.
METHODS
A systematic literature review was conducted for randomized controlled trials fulfilling following criteria: (1) population: adult patients undergoing general anesthesia for surgery; (2) intervention: patients receiving sevoflurane, desflurane, or isoflurane; (3) comparison: volatile anesthetics versus total IV anesthesia or volatile anesthetics; (4) reporting on: (a) mortality (primary outcome) and (b) postoperative pulmonary or other complications; (5) study design: randomized controlled trials. The authors pooled treatment effects following Peto odds ratio (OR) meta-analysis and network meta-analysis methods.
RESULTS
Sixty-eight randomized controlled trials with 7,104 patients were retained for analysis. In cardiac surgery, volatile anesthetics were associated with reduced mortality (OR = 0.55; 95% CI, 0.35 to 0.85; P = 0.007), less pulmonary (OR = 0.71; 95% CI, 0.52 to 0.98; P = 0.038), and other complications (OR = 0.74; 95% CI, 0.58 to 0.95; P = 0.020). In noncardiac surgery, volatile anesthetics were not associated with reduced mortality (OR = 1.31; 95% CI, 0.83 to 2.05, P = 0.242) or lower incidences of pulmonary (OR = 0.67; 95% CI, 0.42 to 1.05; P = 0.081) and other complications (OR = 0.70; 95% CI, 0.46 to 1.05; P = 0.092).
CONCLUSIONS
In cardiac, but not in noncardiac, surgery, when compared to total IV anesthesia, general anesthesia with volatile anesthetics was associated with major benefits in outcome, including reduced mortality, as well as lower incidence of pulmonary and other complications. Further studies are warranted to address the impact of volatile anesthetics on outcome in noncardiac surgery.
Topics: Anesthesia, Inhalation; Anesthetics, Inhalation; Humans; Lung Diseases; Postoperative Complications; Randomized Controlled Trials as Topic; Surgical Procedures, Operative
PubMed: 27065094
DOI: 10.1097/ALN.0000000000001120 -
The Laryngoscope Jan 2016Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are... (Review)
Review
OBJECTIVES/HYPOTHESIS
Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are poorly understood. Our aim was to systematically review existing literature on the effects of anesthetic agents on the upper airway.
DATA SOURCES
PubMed, CINAHL, EBM reviews and Scopus (all indexed years).
REVIEW METHODS
Inclusion criteria included English language articles containing original human data. Two investigators independently reviewed all articles for outcomes related to upper airway morphology, dynamics, neuromuscular response, and respiratory control.
RESULTS
The initial search yielded 180 abstracts; 56 articles were ultimately included (total population = 8,540). The anesthetic agents studied were: topical lidocaine, propofol, dexmedetomidine, midazolam, pentobarbital, sevoflurane, desflurane, ketamine, and opioids. Outcome measures were diverse and included imaging studies, genioglossus electromyography, endoscopic airway assessment, polysomnography, upper airway closing pressure, and clinical evidence of obstruction. All agents caused some degrees of airway collapse. Dexmedetomidine did not have dose-dependent effects when evaluated using cine magnetic resonance imaging, unlike sevoflurane, isoflurane, and propofol, and caused less dynamic collapse than propofol.
CONCLUSIONS
Studies assessing the effect of anesthesia on the upper airway in patients with and without OSA are limited, and few compare effects between agents. Medications with minimal effect on respiratory control (e.g., dexmedetomidine) may work best for DISE.
Topics: Airway Resistance; Analgesics, Opioid; Anesthetics; Humans; Larynx; Pharynx; Sleep Apnea, Obstructive
PubMed: 26198715
DOI: 10.1002/lary.25399 -
Canadian Journal of Anaesthesia =... Aug 2015Obese patients present a challenge to safe general anesthesia because of impaired cardiopulmonary physiology and increased risks of aspiration and acute upper airway... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Obese patients present a challenge to safe general anesthesia because of impaired cardiopulmonary physiology and increased risks of aspiration and acute upper airway obstruction. Since studies are lacking regarding the postoperative effects on recovery from general anesthesia in morbidly obese patients, we conducted a systematic review and meta-analysis of recovery outcomes in morbidly obese patients who had undergone general anesthesia.
SOURCE
We systematically searched the PubMed, EMBASE™, Cochrane, and Scopus™ databases for randomized controlled trials that evaluated the outcome of anesthesia with desflurane, sevoflurane, isoflurane, or propofol in morbidly obese patients. Using a random effects model, we conducted meta-analyses to assess recovery times (eye opening, hand squeezing, tracheal extubation, and stating name or birth date), time to discharge from the postanesthesia care unit (PACU), and the incidence and severity of postoperative nausea and vomiting (PONV).
PRINCIPAL FINDINGS
We reviewed results for 11 trials and found that patients given desflurane took less time: to respond to commands to open their eyes (weighted mean difference [WMD] -3.10 min; 95% confidence interval (CI): -5.13 to -1.08), to squeeze the investigator's hand (WMD -7.83 min; 95% CI: -8.81 to -6.84), to be prepared for tracheal extubation (WMD -3.88 min; 95% CI: -7.42 to -0.34), and to state their name (WMD -7.15 min; 95% CI: -11.00 to -3.30). We did not find significant differences in PACU discharge times, PONV, or the PACU analgesic requirement.
CONCLUSION
Postoperative recovery was significantly faster after desflurane than after sevoflurane, isoflurane, or propofol anesthesia in obese patients. No clinically relevant differences were observed regarding PACU discharge time, incidence of PONV, or postoperative pain scores. The systematic review was registered with PROSPERO (CRD42014009480).
Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Humans; Obesity, Morbid; Postoperative Nausea and Vomiting; Randomized Controlled Trials as Topic
PubMed: 26001751
DOI: 10.1007/s12630-015-0405-0