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BJS Open Sep 2023Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine....
BACKGROUND
Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine. An objective review is needed to dispel surgical dogma.
METHODS
This systematic review (PROSPERO ID: CRD42022362414) included RCTs and prospective cohort studies. Primary outcomes were (1) onset of analgesia and (2) onset of stable hypoperfusion, assessed directly, or measured indirectly using perfusion imaging. Other data extracted include waiting strategies, means of outcome assessment, anaesthetic concentrations, volume/endpoint of infiltration, and injection sites. Methodological quality was evaluated using the Cochrane risk-of-bias tool for randomized trials. Articles describing waiting strategies were critically appraised by the Joanna Briggs Institute tools.
RESULTS
Twenty-four articles were analysed, comprising 1013 participants. Ten investigated analgesia onset. Their pooled mean was 2.1 min (range 0.4-9.0 min). This varied with anatomic site and targeted nerve diameter. Fourteen articles investigated onset of stable hypoperfusion. Four observed bleeding intraoperatively, finding the minimum time to hypoperfusion at 7.0 min in the eyelid skin and 25.0 min in the upper limb. The ten remaining studies used perfusion imaging, reporting a wide range of results (0.0-30.0 min) due to differences in anatomic sites and depth, resolution and artefacts. Studies using near-infrared reflectance spectroscopy and hyperspectral imaging correlated with clinical observations. Thirteen articles discussed waiting strategies, seven relating to large-volume tumescent local infiltration anaesthesia. Different waiting strategies exist for emergency, arthroscopic and cosmetic surgeries, according to the degree of hypoperfusion required. In tumescent liposuction, waiting 10.0-60.0 min is the norm.
CONCLUSION
Current literature suggests that around 2 min are required for most patients to achieve complete analgesia in all sites and with all anaesthesia concentrations. Waiting around 7 min in eyelids and at least 25 min in other regions results in optimal hypoperfusion. The strategies discussed inform decisions of when and how long to wait.
Topics: Humans; Anesthesia, Local; Prospective Studies; Pain Management; Epinephrine; Lidocaine
PubMed: 37768699
DOI: 10.1093/bjsopen/zrad089 -
Journal of the American Podiatric... 2023There is a long-standing stigma associated with the use of epinephrine in digital nerve blocks (DNBs) over the concern of digital necrosis. We conducted a systematic...
There is a long-standing stigma associated with the use of epinephrine in digital nerve blocks (DNBs) over the concern of digital necrosis. We conducted a systematic review to assess the duration of anesthesia, onset of anesthesia, and complications of lidocaine with epinephrine compared with plain lidocaine for DNBs in adults. We searched Medline via Ovid, Cochrane Library, and ClinicalTrials.gov on January 28, 2020. We included randomized controlled trials that examined lidocaine with epinephrine 1:80,000 to 1:1,000,000 (1-12.5 µg/mL) and plain lidocaine for DNBs of fingers or toes in adults. We completed a blinded review of all unique articles, followed by full-text reviews, data extraction, and quality assessment of all eligible trials. Risk of bias was assessed to inform qualitative data analysis. We identified seven studies with a combined 363 adults and 442 DNBs that met the inclusion criteria. All five studies that reported duration of anesthesia established longer duration in the epinephrine-supplemented lidocaine group, with significant increases in three. Two of the three studies that reported the onset of anesthesia demonstrated significant differences. The two studies that reported complications did not have a single case of digital necrosis. In adults, the use of lidocaine with epinephrine 1:80,000 to 1:1,000,000 (1-12.5 µg/mL) for DNB yields a longer duration of anesthetic effect and seems to be as safe as plain lidocaine in healthy adults. Several studies had some concern for bias, and additional studies are warranted.
Topics: Adult; Humans; Lidocaine; Anesthetics, Local; Epinephrine; Nerve Block; Necrosis
PubMed: 37713411
DOI: 10.7547/21-066 -
Khirurgiia 2023To optimize endoscopic prevention of bleeding during resection of mucous membrane neoplasms of hollow organs of gastrointestinal tract and minimize the risk of intra-... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To optimize endoscopic prevention of bleeding during resection of mucous membrane neoplasms of hollow organs of gastrointestinal tract and minimize the risk of intra- and postoperative complications.
MATERIAL AND METHODS. A S
Ystematic review and meta-analysis were made in accordance with the PRISMA recommendations. Statistical analysis was performed in Cohrane Review Manager ver. 5.4.
RESULTS. THERE ARE 3
Methods of endoscopic prevention of bleeding during polypectomy, i.e. 0.01% adrenaline injection, endoscopic clip placement and endoscopic polyp band ligation. Endoscopic polyp band ligation is characterized by minimum complication rate.
CONCLUSION
Endoscopic polyp band ligation is preferable due to minimum complication rate. If ligation is impossible, prophylactic clip placement may be performed. Adrenaline injection is the least effective method and may be used only if two above-mentioned methods are ineffective.
Topics: Humans; Endoscopy; Epinephrine; Gastrointestinal Tract; Hemorrhage; Mucous Membrane; Neoplasms; Polyps
PubMed: 37707334
DOI: 10.17116/hirurgia202309166 -
The World Journal of Biological... 2024Adrenergic dysregulation has been proposed as a possible underlying mechanism in feeding and eating disorders (FED). This review aims to synthesise the current evidence... (Review)
Review
BACKGROUND
Adrenergic dysregulation has been proposed as a possible underlying mechanism in feeding and eating disorders (FED). This review aims to synthesise the current evidence on the role of adrenergic dysregulation in the pathogenesis and management of FED.
METHODS
A systematic review was conducted in MEDLINE, Cochrane Library, and Clinicaltrials.gov. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was adopted. Preclinical, clinical, and pharmacological studies assessing the adrenergic system in FED were included.
RESULTS
Thirty-one out of 1415 recognised studies were included. Preclinically, studies on adrenaline's anorectic impact, receptor subtypes, and effects on hepatic function in rats show that catecholamine anorexia is primarily alpha-adrenergic, whereas beta-adrenergic anorexia can be obtained only after puberty, implying an impact of sexual hormones. Clinically, catecholamine levels may be higher in FED patients than in healthy controls (HC). Individuals with anorexia nervosa (AN) may show higher epinephrine-induced platelet aggregability response than HC. Pharmacological trials suggest that the alpha-2-adrenergic medication clonidine may not lower AN symptoms, but agents regulating the adrenaline-noradrenaline neurotransmission (bupropion, reboxetine, duloxetine, sibutramine) have been found to improve binge eating symptoms.
CONCLUSION
Adrenergic dysregulation may be involved in the pathophysiology of FED. More research is needed to comprehend underlying mechanisms and treatment implications.
Topics: Humans; Rats; Animals; Anorexia; Feeding and Eating Disorders; Anorexia Nervosa; Catecholamines; Epinephrine; Adrenergic Agents; Bulimia Nervosa
PubMed: 37691603
DOI: 10.1080/15622975.2023.2245458 -
The Journal of Manual & Manipulative... Feb 2024The aim of this systematic review was to update the current level of evidence for spinal manipulation in influencing various biochemical markers in healthy and/or... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this systematic review was to update the current level of evidence for spinal manipulation in influencing various biochemical markers in healthy and/or symptomatic population.
METHODS
This is a systematic review update. Various databases were searched (inception till May 2023) and fifteen trials (737 participants) that met the inclusion criteria were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. Outcome measure data were synthesized using standard mean differences and meta-analysis for the primary outcome (biochemical markers). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest.
RESULTS
There was low-quality evidence that spinal manipulation influenced various biochemical markers (not pooled). There was low-quality evidence of significant difference that spinal manipulation is better (SMD -0.42, 95% CI - 0.74 to -0.1) than control in eliciting changes in cortisol levels immediately after intervention. Low-quality evidence further indicated (not pooled) that spinal manipulation can influence inflammatory markers such as interleukins levels post-intervention. There was also very low-quality evidence that spinal manipulation does not influence substance-P, neurotensin, oxytocin, orexin-A, testosterone and epinephrine/nor-epinephrine.
CONCLUSION
Spinal manipulation may influence inflammatory and cortisol post-intervention. However, the wider prediction intervals in most outcome measures point to the need for future research to clarify and establish the clinical relevance of these changes.
Topics: Humans; Manipulation, Spinal; Hydrocortisone; Neurotensin; Biomarkers; Epinephrine
PubMed: 37671460
DOI: 10.1080/10669817.2023.2252187 -
Clinical Ophthalmology (Auckland, N.Z.) 2023Diabetic retinopathy (DR) is a leading cause of blindness. Early DR screening is essential, but the infrastructure can be less affordable in low resource countries. This... (Review)
Review
PURPOSE
Diabetic retinopathy (DR) is a leading cause of blindness. Early DR screening is essential, but the infrastructure can be less affordable in low resource countries. This study aims to review the accuracy of low-cost smartphone-based fundus cameras for DR screening in adult patients with diabetes.
METHODS
We performed a systematic literature search to find studies that reported the sensitivity and specificity of low-cost smartphone-based devices for fundus photography in adult patients with diabetes. We searched three databases (MEDLINE, Google Scholar, Scopus) and one register (Cochrane CENTRAL). We presented the accuracy values by grouping the diagnosis into three: any DR, referrable DR, and diabetic macular oedema (DMO). Risk of bias and applicability of the studies were assessed using QUADAS-2.
RESULTS
Five out of 294 retrieved records were included with a total of six smartphone-based devices reviewed. All of the reference diagnostic methods used in the included studies were either indirect ophthalmoscopy or slit-lamp examinations and all smartphone-based devices' imaging protocols used mydriatic drops. The reported sensitivity and specificity for any DR were 52-92.2% and 73.3-99%; for referral DR were 21-91.4% and 64.9-100%; and for DMO were 29.4-81% and 95-100%, respectively.
CONCLUSION
Sensitivity available low-cost smartphone-based devices for DR screening were acceptable and their specificity particularly for detecting referrable DR and DMO were considerably good. These findings support their potential utilization for DR screening in a low resources setting.
PubMed: 37614846
DOI: 10.2147/OPTH.S416422 -
Shock (Augusta, Ga.) Dec 2023Background: Septic shock is a distributive shock with decreased systemic vascular resistance and MAP. Septic shock contributes to the most common causes of death in the... (Meta-Analysis)
Meta-Analysis
Background: Septic shock is a distributive shock with decreased systemic vascular resistance and MAP. Septic shock contributes to the most common causes of death in the intensive care unit (ICU). Current guidelines recommend the use of norepinephrine as the first-line vasopressor, whereas adrenergic agonists and vasopressin analogs are also commonly used by physicians. To date, very few studies have synthetically compared the effects of multiple types of vasoactive medications. The aim of this study was to systemically evaluate the efficacy of vasoactive agents both individually and in combination to treat septic shock. Methods: The PubMed, MEDLINE, Embase, Web of Science, and Cochrane Central Register for Controlled Trials (CENTRAL) were searched up to May 12, 2022, to identify relevant randomized controlled trials. A network meta-analysis was performed to evaluate the effect of different types of vasopressors. The primary outcome was 28-day all-cause mortality. The secondary outcome was the ICU length of stay. Adverse events are defined as any undesirable outcomes, including myocardial infarction, cardiac arrhythmia, peripheral ischemia, or stroke and cerebrovascular events. Findings: Thirty-three randomized controlled trials comprising 4,966 patients and assessing 8 types of vasoactive treatments were included in the network meta-analysis. The surface under the cumulative ranking curve provided a ranking of vasoactive medications in terms of 28-day all-cause mortality from most effective to least effective: norepinephrine plus dobutamine, epinephrine, vasopressin, terlipressin, norepinephrine, norepinephrine plus vasopressin, dopamine, and dobutamine. Dopamine was associated with a significantly shorter ICU stay than norepinephrine, terlipressin, and vasopressin, whereas other vasoactive medications showed no definite difference in ICU length of stay. Regarding adverse events, norepinephrine was associated with the highest incidences of myocardial infarction and peripheral ischemia. Dopamine was associated with the highest incidence of cardiac arrhythmia. Epinephrine and terlipressin were associated with the highest incidences of myocardial infarction and peripheral ischemia. Interpretation: The results of this network meta-analysis suggest that norepinephrine plus dobutamine is associated with a lower risk of 28-day mortality in septic shock patients than other vasoactive medications, and the use of dopamine is associated with a higher risk of 28-day mortality due to septic shock than norepinephrine, terlipressin, and vasopressin.
Topics: Humans; Shock, Septic; Dopamine; Terlipressin; Dobutamine; Network Meta-Analysis; Vasoconstrictor Agents; Epinephrine; Norepinephrine; Vasopressins; Arrhythmias, Cardiac; Ischemia; Myocardial Infarction
PubMed: 37548686
DOI: 10.1097/SHK.0000000000002193 -
Journal of Clinical Pharmacology Dec 2023A large number of studies have evaluated the efficacy of low-dose atropine in preventing or slowing myopic progression. However, it is challenging to evaluate the ocular... (Meta-Analysis)
Meta-Analysis
A large number of studies have evaluated the efficacy of low-dose atropine in preventing or slowing myopic progression. However, it is challenging to evaluate the ocular safety from these studies. We aimed to evaluate the incidence of adverse events induced by atropine in children with myopia. We performed a systematic literature search in several databases for studies published until November 2022. The incidence of adverse events induced by atropine was pooled by a common-effect (fixed-effect) or random-effects model. Subgroup analyses were conducted according to drug doses, types of adverse events, and ethnicity. A total of 31 articles were ultimately included in the study. The overall incidence of adverse events for atropine was 5.9%, and the incidence of severe adverse events was 0.0%. The most commonly reported adverse events were photophobia (9.1%) and blurred near vision (2.9%). Other adverse events including eye irritation/discomfort, allergic reactions, headache, stye/chalazion, glare, and dizziness occurred in less than 1% of the patients. The incidence of atropine-induced adverse events varied depending on the drug doses. A lower dose of atropine was associated with a lower incidence of adverse events. There was no significant difference in the incidence of adverse events for low-dose atropine between Asian and White children. Our study suggests photophobia and blurred near vision are the most frequently reported adverse events induced by atropine. Low-dose atropine is safer than moderate- and high-dose atropine. Our study could provide a safe reference for ophthalmologists to prescribe atropine for myopic children.
Topics: Humans; Child; Atropine; Mydriatics; Photophobia; Incidence; Disease Progression; Myopia; Ophthalmic Solutions
PubMed: 37492894
DOI: 10.1002/jcph.2320 -
Arthroscopy : the Journal of... Feb 2024To further clarify the role of tranexamic acid (TXA) in arthroscopic rotator cuff repair (ARCR), especially visual field clarity and operation time. (Meta-Analysis)
Meta-Analysis Review
Intravenous Tranexamic Acid Significantly Improved Visualization and Shortened the Operation Time in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis of Level I and II Studies.
PURPOSE
To further clarify the role of tranexamic acid (TXA) in arthroscopic rotator cuff repair (ARCR), especially visual field clarity and operation time.
METHODS
We searched the PubMed, Cochrane Library, and Embase databases to find prospective randomized controlled clinical trials (RCTs) examining the use of TXA in ARCR. All included RCTs were evaluated for methodological quality using the Cochrane Collaboration's risk of bias tool. We used Review Manager 5.3 for meta-analysis and calculated the weighted mean difference (WMD) and 95% confidence interval (CI) of the related outcome indicators. The GRADE system was used to evaluate the strength of the clinical evidence provided by the included studies.
RESULTS
Six RCTs (3 Level I, 3 Level II) from four countries or regions were included in this study: 2 studies used intra-articular (IA) TXA, and 4 studies used intravenous TXA. A total of 451 patients underwent ARCR, including 227 patients in the TXA group and 224 patients in the non-TXA group. In 2 RCTs evaluating good visualization, intravenous TXA achieved a better surgical field of view in ARCR compared to the control group (P =.036; P = .045). Meta-analysis showed that compared with non-TXA, intravenous TXA shortened the operation time (WMD = -12.87 min, 95% CI: -18.81 to -6.93). These two RCTs did not reveal a statistically significant difference in the impact of intravenous TXA and non-TXA on mean arterial pressure (MAP) (P = .306; P = .549). Compared with epinephrine (EPN), IA TXA had no significant effects on improving the visual field clarity under arthroscopy, shortening the operation time or reducing the total amount of irrigation fluid (P > .05). Compared with saline irrigation, IA TXA improved the surgical field of vision and shortened the operation time (P < .001). No adverse events were reported for either intravenous TXA or IA TXA.
CONCLUSIONS
Intravenous TXA can shorten the operation time of ARCR, and the conclusions of existing RCTs suggest that intravenous TXA can improve visual field clarity during ARCR, thus supporting the application of intravenous TXA in ARCR. Compared with EPN, IA TXA was not better at improving the visual field clarity under arthroscopy and shortening the operation time, but it was better than saline irrigation.
LEVEL OF EVIDENCE
Level II, systematic review and meta-analysis of Level I and II studies.
Topics: Humans; Tranexamic Acid; Antifibrinolytic Agents; Arthroscopy; Rotator Cuff; Arthroplasty; Epinephrine; Blood Loss, Surgical
PubMed: 37423470
DOI: 10.1016/j.arthro.2023.06.055 -
Expert Review of Clinical Immunology 2023Studies from more than 10 years ago showed epinephrine treatment of food-induced anaphylaxis in the emergency department (ED) was unacceptably low. We investigated... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Studies from more than 10 years ago showed epinephrine treatment of food-induced anaphylaxis in the emergency department (ED) was unacceptably low. We investigated whether epinephrine treatment of food-induced and other cause anaphylaxis in United States and Canadian EDs has changed over time.
METHODS
Guided by a health sciences librarian, we performed a systematic search in Medline, Embase, and Web of Science on 11 January 2023. We included observational studies that reported epinephrine use to treat anaphylaxis in the ED. We stratified by anaphylaxis etiology (food-, venom-, medication-induced, or any cause). Associations between year and epinephrine use were tested using Spearman correlation and proportional meta-analysis.
RESULTS
Of 2458 records identified in our initial search, 40 met inclusion criteria. Of these, 14 examined food-induced, 4 venom-induced, 0 medication-induced, and 24 any cause anaphylaxis. For epinephrine treatment of food-induced anaphylaxis in the ED, among studies using similar definition of anaphylaxis, meta-analysis showed a pooled value of 20.7% (95% CI 17.8, 23.8) for studies performed >10 years ago and 45.1% (95% CI 38.4, 52.0) from those in the last 10 years. For anaphylaxis of any cause, there was no change over time, with a pooled value of 45.0% (95% CI 39.8, 50.3) over the last 10 years.
DISCUSSION
Epinephrine treatment of food-induced anaphylaxis in the ED has increased over time. There was no clear change for anaphylaxis of any cause. Over the last 10 years, approximately 45% of ED patients with anaphylaxis received epinephrine. A limitation of the evidence is heterogeneity in anaphylaxis definitions.
Topics: Humans; United States; Anaphylaxis; Food Hypersensitivity; Retrospective Studies; Canada; Epinephrine; Emergency Service, Hospital; Allergens
PubMed: 37357788
DOI: 10.1080/1744666X.2023.2229517