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European Urology Feb 2014Priapism is defined as a penile erection that persists beyond or is unrelated to sexual interest or stimulation. It can be classified into ischaemic (low flow), arterial... (Review)
Review
CONTEXT
Priapism is defined as a penile erection that persists beyond or is unrelated to sexual interest or stimulation. It can be classified into ischaemic (low flow), arterial (high flow), or stuttering (recurrent or intermittent).
OBJECTIVE
To provide guidelines on the diagnosis and treatment of priapism.
EVIDENCE ACQUISITION
Systematic literature search on the epidemiology, diagnosis, and treatment of priapism. Articles with highest evidence available were selected to form the basis of these recommendations.
EVIDENCE SYNTHESIS
Ischaemic priapism is usually idiopathic and the most common form. Arterial priapism usually occurs after blunt perineal trauma. History is the mainstay of diagnosis and helps determine the pathogenesis. Laboratory testing is used to support clinical findings. Ischaemic priapism is an emergency condition. Intervention should start within 4-6h, including decompression of the corpora cavernosa by aspiration and intracavernous injection of sympathomimetic drugs (e.g. phenylephrine). Surgical treatment is recommended for failed conservative management, although the best procedure is unclear. Immediate implantation of a prosthesis should be considered for long-lasting priapism. Arterial priapism is not an emergency. Selective embolization is the suggested treatment modality and has high success rates. Stuttering priapism is poorly understood and the main therapeutic goal is the prevention of future episodes. This may be achieved pharmacologically, but data on efficacy are limited.
CONCLUSIONS
These guidelines summarise current information on priapism. The extended version are available on the European Association of Urology Website (www.uroweb.org/guidelines/).
PATIENT SUMMARY
Priapism is a persistent, often painful, penile erection lasting more than 4h unrelated to sexual stimulation. It is more common in patients with sickle cell disease. This article represents the shortened EAU priapism guidelines, based on a systematic literature review. Cases of priapism are classified into ischaemic (low flow), arterial (high flow), or stuttering (recurrent). Treatment for ischaemic priapism must be prompt in order to avoid the risk of permanent erectile dysfunction. This is not the case for arterial priapism.
Topics: Humans; Male; Penile Erection; Priapism; Risk Factors; Sympathomimetics; Treatment Outcome; Urologic Surgical Procedures, Male; Urology
PubMed: 24314827
DOI: 10.1016/j.eururo.2013.11.008 -
Rhinology Dec 2013In the literature various methods are described to reduce bleeding in endoscopic sinus surgery. Scientific evidence and results were gathered and analysed to determine... (Review)
Review
In the literature various methods are described to reduce bleeding in endoscopic sinus surgery. Scientific evidence and results were gathered and analysed to determine the effectiveness of the various methods used. A total of 20 articles fulfilled the inclusion criteria. Two retrospective articles studied the differences between local and general anaesthesia. Three articles analysed the use of local methods to control bleeding. The majority of the articles analysed the use of different systemic drugs to control intraoperative bleeding. Certain procedures, such as the reverse Trendelenburg position, the use of high doses of epinephrine, the infiltration of phenylephrine and lidocaine into the pterygopalatine fossa, the preoperative use of prednisone, and the control of the heart rate (with dexmedetomidine or remifentanil), appear to reduce the intraoperative blood loss and/or improve the visualisation of the surgical field. However, the evidence supporting these conclusions is poor. The benefits of other procedures, such as the preoperative use of β-blockers, antihypertensive agents, and surgical pledgets with oxymetazoline, phenylephrine, or cocaine, for bleeding control are not evidenced in the literature. In addition, the literature does not present any evidence on the benefits of local anaesthesia compared with general anaesthesia or the use of propofol compared to inhaled analgesics in terms of intraoperative bleeding or complication rates.
Topics: Blood Loss, Surgical; Endoscopy; Hemostasis, Surgical; Humans; Paranasal Sinuses
PubMed: 24260761
DOI: 10.4193/Rhino12.048 -
Annals of Plastic Surgery Aug 2014Use of intraoperative vasopressors is of debate in microvascular surgery. Anesthesia is an important factor in maintaining the rate of success of flap transfer by... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Use of intraoperative vasopressors is of debate in microvascular surgery. Anesthesia is an important factor in maintaining the rate of success of flap transfer by affecting regional blood flow and global hemodynamics. We conducted a review of the literature comparing the use of different vasoactive agents on different flaps in various human and animal models.
METHODS
A systematic review of the literature was performed. Bibliographies of key articles were also reviewed for additional resources. Analysis was done to determine the overall trend of how flap perfusion is affected by the use of intraoperative vasoactive medication.
RESULTS
The literature search identified 16 relevant articles. Flaps were studied in pigs in 7 studies, rats in 5, and humans in 4. The most common flap was the rectus abdominis musculocutaneous flap. Phenylephrine and norepinephrine were the most common pressor agents used. No significant statistical changes were noted in 8 of the 16 studies; initial ischemia followed by delayed improved perfusion was observed in 4 studies, "true ischemia" and hypoperfusion of the skin flaps was noted in 3. There was no consistency in their effect on flap perfusion: initial ischemia followed by delayed improved perfusion was observed in 4 studies, whereas true ischemia and hypoperfusion of the skin flaps was noted in 3.
CONCLUSIONS
To date, there is no reliable prospective clinical evidence that supports the absolute contraindication of pressor agents during free flap surgery. This topic will continue to be a matter for debate until more definitive data can be obtained.
Topics: Animals; Free Tissue Flaps; Humans; Ischemia; Postoperative Complications; Plastic Surgery Procedures; Vasoconstrictor Agents
PubMed: 23851374
DOI: 10.1097/SAP.0b013e31828d70b3 -
CNS Neuroscience & Therapeutics Jul 2012A systematic literature review comparing the efficacy of ephedrine and phenylephrine for the management of spinal anesthesia-induced hypotension during Cesarean sections... (Comparative Study)
Comparative Study Meta-Analysis
AIMS
A systematic literature review comparing the efficacy of ephedrine and phenylephrine for the management of spinal anesthesia-induced hypotension during Cesarean sections (C-sections) was published in 2002. A number of well-designed trials with controversial results have been published afterward. Therefore, an updated meta-analysis was necessary.
METHODS
The MEDLINE, EMBASE, and the Cochrane Library databases were searched (last search performed on September 26, 2011). Pooled risk ratio (RR) or standard mean difference (SMD) and their 95% confidence intervals (95% CI) were calculated for the incidence of intra-operative hypotension or umbilical blood pH values.
RESULTS
A total number of 15 trials and 742 parturients under elective C-sections were analyzed. When used to prevent hypotension, patients receiving ephedrine and phenylephrine did not differ significantly in the incidence of hypotension (RR = 1.22; 95% CI, 0.83-1.80), umbilical arterial pH values (SMD = -0.38; 95% CI, -1.67 to 0.92) or venous pH values (SMD = -0.18; 95% CI, -0.44 to 0.07). And administration routes did not affect the incidence of hypotension and umbilical blood pH values. When used to treat hypotension, patients given ephedrine and phenylephrine had comparable incidence of intra-operative hypotension (RR = 0.79; 95% CI, 0.40-1.56), while parturients receiving phenylephrine had neonates with higher umbilical arterial pH values (SMD = -1.32; 95% CI, -2.35 to -0.30) and venous pH values (SMD = -0.79; 95% CI, -1.09 to -0.49) than those given ephedrine.
CONCLUSION
Prophylactic use of ephedrine and phenylephrine were both effective in preventing maternal hypotension during C-section under spinal anesthesia; phenylephrine was superior to ephedrine in treating hypotension, evidenced by higher umbilical blood pH values.
Topics: Anesthesia, Spinal; Cesarean Section; Disease Management; Ephedrine; Female; Humans; Hypotension; Phenylephrine; Pregnancy
PubMed: 22759268
DOI: 10.1111/j.1755-5949.2012.00345.x -
Acta Anaesthesiologica Scandinavica Aug 2012Phenylephrine use has been recommended over ephedrine for the management of hypotension after spinal anesthesia for elective caesarean section. The evidence for this is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Phenylephrine use has been recommended over ephedrine for the management of hypotension after spinal anesthesia for elective caesarean section. The evidence for this is rather limited because in previous trials, pH was significantly lower after ephedrine, but absolute values were still within normal range. We pooled the available data to define maternal and neonatal effects of the two vasopressors.
METHODS
Literature was identified by a systematic search. Hypotension, hypertension, and bradycardia of the mothers, fetal acidosis defined as a pH < 7.20, and the continuous variables base excess (BE) and arterial pCO(2) of the neonates were recorded. Meta-analysis using the random effects model was performed, and the weighted mean difference (WMD) or risk ratio (RR), and 95% confidence interval (95% CI) were calculated.
RESULTS
The criteria for eligibility were fulfilled by 20 trials including 1069 patients. The RR of true fetal acidosis was 5.29 (95%CI 1.62-17.25, ) for ephedrine vs. phenylephrine (P = 0.006). BE values after ephedrine use were significantly lower than after phenylephrine (WMD -1.17; 95% CI -2.01 - -0.33). Umbilical artery pCO(2) did not differ. Mothers treated with ephedrine had a lower risk for bradycardia (RR 0.17; 95%CI 0.07-0.43; P = 0.004). No differences between vasopressors were observed for hypotension and hypertension.
CONCLUSIONS
Our analysis could clearly demonstrate a decreased risk of fetal acidosis associated with phenylephrine use. In addition with our findings for BE, this suggests a favorable effect of phenylephrine on fetal outcome parameters. The mechanism of pH depression is not related to pCO(2) .
Topics: Acidosis; Anesthesia, Obstetrical; Anesthesia, Spinal; Anesthetics, Local; Bradycardia; Cesarean Section; Clinical Trials as Topic; Double-Blind Method; Elective Surgical Procedures; Ephedrine; Female; Fetal Diseases; Hemodynamics; Humans; Hypertension; Hypotension; Infant, Newborn; Multicenter Studies as Topic; Phenylephrine; Pregnancy; Randomized Controlled Trials as Topic; Risk; Treatment Outcome; Vasoconstrictor Agents
PubMed: 22313496
DOI: 10.1111/j.1399-6576.2011.02646.x -
BMJ Clinical Evidence Dec 2011Acute sinusitis is defined pathologically, by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks. Clinically, it is... (Review)
Review
INTRODUCTION
Acute sinusitis is defined pathologically, by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks. Clinically, it is characterised by nasal congestion, rhinorrhoea, facial pain, hyposmia, sneezing, and, if more severe, additional malaise and fever. It affects 1% to 5% of the adult population each year in Europe.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in people with clinically diagnosed acute sinusitis, and in people with radiologically or bacteriologically confirmed acute sinusitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (amoxicillin, amoxicillin-clavulanic acid [co-amoxiclav], doxycycline, cephalosporins, macrolides; different doses, long-course regimens), antihistamines, decongestants (xylometazoline, phenylephrine, pseudoephedrine), saline nasal washes, steam inhalation, and topical corticosteroids (intranasal).
Topics: Acute Disease; Administration, Oral; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Double-Blind Method; Evidence-Based Medicine; Humans; Macrolides; Sinusitis
PubMed: 22189346
DOI: No ID Found -
The Laryngoscope Feb 2011The objective of this study is to systematically review the literature and examine the safety for the use of topical vasoconstrictors in endoscopic sinus surgery. (Review)
Review
OBJECTIVE
The objective of this study is to systematically review the literature and examine the safety for the use of topical vasoconstrictors in endoscopic sinus surgery.
STUDY DESIGN
Systematic review clinical trials.
METHOD
A systematic literature search was performed in MEDLINE, EMBASE, The Cochrane Library, and National Guideline Clearinghouse, and references in the selected articles.
RESULTS
The search criteria captured 42 manuscripts with relevant titles. A systematic review on the topical use of phenylephrine was found; however, no other systematic review, meta-analyses, or clinical guidelines were identified. Six randomized clinical trials or comparative studies, as well as multiple case reports and review articles were also identified. The literature supports the safety of oxymetazoline and epinephrine when used judiciously in carefully selected patients undergoing endoscopic sinonasal surgery; however, topical phenylephrine is not recommended because of its risk profile.
CONCLUSION
In sinus or nasal surgery, topical vasoconstrictors should be used in a manner that minimizes the risk of cardiovascular morbidity.
Topics: Administration, Topical; Clinical Trials as Topic; Endoscopy; Humans; Otorhinolaryngologic Surgical Procedures; Paranasal Sinuses; Phenylephrine; Vasoconstrictor Agents
PubMed: 21271600
DOI: 10.1002/lary.21286 -
JBI Library of Systematic Reviews 2010Inadvertent hypothermia is common in patient's undergoing surgical procedures. Hypothermia within the perioperative environment may have many undesired physiological...
BACKGROUND
Inadvertent hypothermia is common in patient's undergoing surgical procedures. Hypothermia within the perioperative environment may have many undesired physiological effects that are associated with significant postoperative morbidity. Patient's temperature drops to below 35°C during the first hour of anaesthesia because of impaired thermoregulatory mechanism and patient getting cold in the operating theatre. For this reason, health care professionals working in the perioperative environment need to know what are the most effective strategies for treating or preventing hypothermia to improving patient outcomes following surgical procedures. However, to date there has been no systematic review of effectiveness with high quality randomised controlled trials to identify effective strategies for the prevention and/or management of hypothermia in the perioperative environment.
OBJECTIVE
The objective of this systematic review was to identify the most effective strategies for the prevention and/or management of hypothermia in the intraoperative and postoperative phases of surgical care.
DATA SOURCES
A comprehensive search was undertaken on electronic databases from their inception to October 2008, including Cochrane library, MEDLINE, PubMed, CENTRAL, CINAHL, Current contents connect, DARE, Dissertations Abstract International, EMBASE, Scopus, and TRIP. The search was restricted to English language.
REVIEW METHODS
Randomised controlled trials or clinical controlled trials were sought, which evaluated the effectiveness of active or passive warming techniques in the prevention and/or treatment of inadvertent hypothermia. Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments. Data extraction was via the Joanna Briggs Institute standard data extraction form for evidence of effectiveness.
RESULTS
Eighteen studies with a combined 1451 patients were included. The results were classified into three categories with a further sub classification within the active warming techniques category.Forced air warming was effective in maintaining intraoperative normothermia when compared to passive warming, routine thermal care and no form of warming. Forced air warming in pregnant women scheduled for caesarean delivery under regional anaesthesia prevented maternal and foetal hypothermia. In contrast, passive warming with tight elastic bandages wrapped around the legs (passive insulation) in the same patient population had no significant benefits in preventing maternal hypothermia.However, in arthroscopic knee surgery patients, forced air warming did not result in a decrease in the incidence of postoperative shivering indicating that it was not effective or feasible to extend active warming into recovery in this patient population. Forced air warming was effective than circulating water mattress in preventing hypothermia in patients who underwent repair of infrarenal aortic aneurysms. Forced air warming was effective against radiant warming in maintaining intraoperative normothermia in lengthier surgical procedures.Prewarming in different patient populations prevents redistribution hypothermia, especially after one hour of anaesthesia induction. Intravenous and irrigating fluids warmed (38-40°C) to a temperature higher than that of room temperature by different fluid warming devices (both dry and water heated) proved significantly beneficial to patients in terms of stable haemodynamic variables, and higher core temperature (core T) at the end of the surgery (transurethral prostatectomy and orthopaedic surgery). However, prewarming irrigation fluids in knee arthroscopy patients did not prove beneficial in maintaining normothermia.Water garment warmer was significantly (P < 0.05) effective than forced air warming in maintaining intraoperative normothermia in orthotopic liver transplantation patients. Extra warming with forced air compared to routine thermal care was effective in reducing the incidence of surgical wound infections and postoperative cardiac complications, as well as shorten the length of hospital stay.Passive warming with reflective heating blankets or elastic bandages wrapped around the legs tightly were found to be ineffective in reducing the incidence or magnitude of hypothermia. Low-flow anaesthesia with active forced air warming was effective in stabilising patient's core T during surgical procedures when compared to low-flow anaesthesia alone or low-flow anaesthesia with passive insulation.Phenylephrine i.v. infusion resulted in a significantly less reduction in core T after first hour of anaesthesia and patients were warmer until the end of the surgery (minor oral surgery).
CONCLUSION
Active warming with forced air warming units keeps all patients warmer in the intraoperative and postoperative periods. Forced air warming compared with alternate forms of warming reduces the incidence of shivering and wound infections, increases thermal comfort and reduces morbid cardiac events.
IMPLICATIONS FOR PRACTICE
Our review indicates that active warming techniques (forced-air warming) are effective in preventing and managing hypothermia in the perioperative environment and based on the results from the review there are several recommendations to guide clinical practice: IMPLICATIONS FOR RESEARCH: Future research should focus on large, high quality randomised controlled trials looking at long-term clinical outcomes, operating temperature forced-air warming devices (not just maximum set temperature), different body sites and percentage of body coverage area of active warming for efficient management of intraoperative hypothermia.
PubMed: 27820534
DOI: 10.11124/01938924-201008190-00001 -
The Cochrane Database of Systematic... Oct 2008It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001.
OBJECTIVES
To assess the effect of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.
SEARCH STRATEGY
We searched the Cochrane Stroke Group Trials Register (last searched July 2007), the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2 2008), MEDLINE, EMBASE and other databases, reference lists of relevant publications and contacted researchers in the field.
SELECTION CRITERIA
Randomised controlled trials of interventions that aimed to alter blood pressure in patients within one week of acute ischaemic or haemorrhagic stroke.
DATA COLLECTION AND ANALYSIS
Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data.
MAIN RESULTS
Twelve trials involving 1153 participants were included (603 participants were assigned active therapy and 550 participants received placebo/control). The trials tested angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), clonidine, glyceryl trinitrate (GTN), thiazide diuretic and mixed antihypertensive therapy. One trial tested phenylephrine. At 24 hours after randomisation ACEIs reduced systolic blood pressure (SBP, mean difference, MD -6 mmHg, 95% confidence interval, CI -22 to 10) and diastolic blood pressure (DBP, MD -5 mmHg, 95% CI -18 to 7), ARA reduced SBP (MD -3, 95% CI -7 to 2) and DBP (MD -3, 95% CI -6 to 0.4), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13 mmHg, 95% CI -31 to 6), oral CCBs reduced SBP (MD -13 mmHg, 95% , CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), GTN reduced SBP (MD -10 mmHg, 95% CI -18 to -3) and DBP (MD -1 mmHg, 95% CI -5 to 3) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16). Functional outcome and death were not altered by any of the drugs.
AUTHORS' CONCLUSIONS
There is insufficient evidence to evaluate the effect of altering blood pressure on outcome during the acute phase of stroke. In patients with acute stroke, CCBs, ACEI, ARA and GTN each lower blood pressure while phenylephrine probably increases blood pressure.
Topics: Acute Disease; Blood Pressure; Calcium Channel Blockers; Humans; Hypertension; Randomized Controlled Trials as Topic; Risk; Stroke; Vasodilator Agents
PubMed: 18843604
DOI: 10.1002/14651858.CD000039.pub2 -
International Journal of Clinical... Aug 2008Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the... (Review)
Review
INTRODUCTION
Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the development of ischaemia ultimately leads to long-term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short-lived painful erections and is commonly encountered in patients with sickle cell disease.
METHODS
A systematic review of the treatment options available for stuttering priapism is presented combined with our own experience in managing this condition over a period of 25 years.
RESULTS
Although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports.
CONCLUSIONS
Stuttering priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. A multicentre randomised trial is required to evaluate the treatment options.
Topics: Anemia, Sickle Cell; Digoxin; Drug Delivery Systems; Etilefrine; Hormones; Humans; Male; Orchiectomy; Penile Prosthesis; Phosphodiesterase Inhibitors; Priapism; Procyclidine; Pseudoephedrine; Terbutaline; Treatment Outcome
PubMed: 18479367
DOI: 10.1111/j.1742-1241.2008.01780.x