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Medicine Jan 2020Patient-controlled intravenous analgesia (PCIA) has been suggested as an effective method of pain relief. There are several randomized controlled trials (RCTs) of... (Meta-Analysis)
Meta-Analysis
Efficacy and safety of dexmedetomidine combined with tramadol for patient-controlled intravenous analgesia in Chinese surgical patients: A systematic review and meta-analysis.
BACKGROUND
Patient-controlled intravenous analgesia (PCIA) has been suggested as an effective method of pain relief. There are several randomized controlled trials (RCTs) of dexmedetomidine (DEX) combined with tramadol for PCIA in Chinese surgical patients. The purpose of this study was to perform a systematic review and meta-analysis to evaluate the efficacy and safety of DEX combined with tramadol for PCIA in Chinese surgical patients from current data.
METHODS
The RCTs of DEX combined with tramadol for PCIA were gathered from the PubMed, Excerpta Medica Database, Cochrane Library, Cochrane Library, China National Knowledge Infrastructure database, and VIP databases. After data extraction and quality assessment of the included RCTs, RevMan 5.3 software was employed for the meta-analysis of visual analog scale (VAS) scores, Ramsay sedation scores, effective pressure times for PCIA, tramadol consumption, and safety.
RESULTS
Fourteen RCTs were included. Compared with tramadol alone, postoperative intravenous tramadol-DEX combination PCA led to lower VAS scores (weighted mean differences [WMD]12h = 0.14, 95% confidence interval [CI] v1.50 to 1.79; WMD24h = 0.78, 95% CI -0.92 to -0.62; WMD48h = 0.51, 95% CI -0.66 to -0.38; all P < .05), lower Ramsay sedation scores (WMD24h = 0.08, 95% CI -0.14 to -0.02; WMD48h = 0.09, 95% CI -0.11 to -0.07; all P < .05), and less postoperative tramadol consumption (WMD0-24h = -102.59 mg, 95% CI -149.68 to -55.49; WMD0-48h = -152.91 mg, 95% CI -259.93 to -45.89; all P < .05). With regard to safety, there was a significant difference between DEX-tramadol and tramadol for PCIA in terms of the incidence of postoperative nausea and vomiting, dizziness, chills, and restlessness (all P < .05).
CONCLUSION
According to the domestic evidence, this systematic review and meta-analysis suggests that DEX-tramadol PCIA is superior to tramadol in terms of analgesic efficacy and safety for Chinese surgical patients. However, because of some clear limitations (sample size and heterogeneity), these results should be interpreted with caution. Further large-scale and well-designed studies are needed to summarize and analyze the data to draw a more convincing conclusion.
Topics: Administration, Intravenous; Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Analgesics, Opioid; China; Dexmedetomidine; Drug Combinations; Humans; Pain, Postoperative; Tramadol
PubMed: 32011494
DOI: 10.1097/MD.0000000000018825 -
BMC Pregnancy and Childbirth Dec 2019To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates. (Meta-Analysis)
Meta-Analysis
BACKGROUND
To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates.
METHODS
We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT).
RESULTS
Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence.
CONCLUSIONS
This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.
Topics: Cervical Ripening; Cesarean Section; Clinical Trials as Topic; Cohort Studies; Delivery, Obstetric; Female; Humans; Labor, Induced; Pregnancy; Vaginal Birth after Cesarean
PubMed: 31888540
DOI: 10.1186/s12884-019-2689-5 -
British Journal of Clinical Pharmacology Feb 2020To summarise the effectiveness of interventions on appropriate opioid use for noncancer pain among hospital inpatients. (Review)
Review
AIMS
To summarise the effectiveness of interventions on appropriate opioid use for noncancer pain among hospital inpatients.
METHODS
Two reviewers independently searched 6 databases up to March 2018 original research articles reporting on quantitative outcomes of interventions on appropriate opioid use among hospital inpatients. Appropriate opioid use was measured by changes in prescribing, such as the lowest effective opioid dose and duration, or clinical outcomes such as adequate pain control. Quality and intervention complexity assessments were performed by 2 independent reviewers. The full methodological approach was published on PROSPERO (ID: CRD42019145947).
RESULTS
Of 398 full-text articles assessed for eligibility, 37 articles were included in the review. Most articles had a moderate or high risk of bias (27 of 37 studies). Thirty-one articles primarily addressed appropriate opioid use and 6 articles targeted opioid safety as a secondary outcome. A multifaceted approach was the most common primary intervention (16 studies) and adequate pain control was the main outcome measured (14 studies). Health provider education, reinforced by hard-copy material and feedback, was associated with a 13.0 to 29.5% increase in the proportion of opioid prescriptions written in concordance with local guidelines and reduced pain scores ranging from 7.0 to 34.5%. Interventions to improve opioid safety in patient-controlled analgesia reduced medication errors by up to 89.1%.
CONCLUSION
Interventions involving academic detailing and education, especially when reinforced by feedback, show positive effects on appropriate opioid use among hospital inpatients. Future studies investigating the impact of administrative interventions on opioid use and related outcomes are warranted.
Topics: Analgesics, Opioid; Hospitals; Humans; Inpatients; Opioid-Related Disorders; Pain
PubMed: 31863503
DOI: 10.1111/bcp.14203 -
Canadian Family Physician Medecin de... Dec 2019To systematically review the literature for studies comparing the efficacy of opioid analgesics for older adults (≥ 65 years) presenting to the emergency department...
OBJECTIVE
To systematically review the literature for studies comparing the efficacy of opioid analgesics for older adults (≥ 65 years) presenting to the emergency department (ED) with acute pain.
DATA SOURCES
The Cochrane Library, MEDLINE, EMBASE, Web of Science, and CINAHL were searched up to August or September 2017. Reference lists were searched for potential articles and ClinicalTrials.gov was searched for unpublished trials.
STUDY SELECTION
Randomized controlled trials (RCTs) were sought that compared the efficacy of 2 or more opioid analgesics for acute pain in older patients (≥ 65 years) in the ED. Two reviewers independently screened abstracts, assessed study quality, and extracted data.
SYNTHESIS
After screening titles and abstracts of 1315 citations, the full texts of 63 studies were reviewed and 1 RCT met the inclusion criteria. This study randomized older adult patients presenting to an urban academic ED with acute, severe pain to receive a single dose of either 0.0075 mg/kg intravenous hydromorphone or 0.05 mg/kg intravenous morphine. This study found no clinical or statistical difference between the 2 treatments.
CONCLUSION
The lack of published research in this area demonstrates a considerable gap in knowledge of the comparative efficacy of opioid analgesics in the growing older adult patient population. Physicians are often uncertain in their choice of analgesia, potentially contributing to the undertreatment of pain. It is clear that well designed RCTs are urgently needed.
Topics: Acute Pain; Administration, Intravenous; Aged; Analgesics, Opioid; Emergency Service, Hospital; Humans; Hydromorphone; Morphine; Pain Management; Pain Measurement; Randomized Controlled Trials as Topic
PubMed: 31831503
DOI: No ID Found -
Pain Apr 2020Opioids are the recommended form of analgesia for patients with persistent cancer pain, and regular dosing "by the clock" is advocated in many international guidelines... (Comparative Study)
Comparative Study Meta-Analysis
Opioids are the recommended form of analgesia for patients with persistent cancer pain, and regular dosing "by the clock" is advocated in many international guidelines on cancer pain management. The development of sustained-release opioid preparations has made regular dosing easier for patients. However, patients report that the intensity and impact of their cancer pain varies considerably day to day, and many try to find a trade-off between acceptable pain control and impact of cognitive (and other) adverse effects on daily activities. In acute care settings, (eg, postoperative) as-needed dosing and other opioid-sparing approaches have resulted in better patient outcomes compared with regular dosing. The aim of this study was to determine whether regular dosing of opioids was superior to as-needed dosing for persistent cancer pain. We systematically searched for randomised controlled trials that directly compared pain outcomes from regular dosing of opioids with as-needed dosing in adult cancer patients. We identified 4347 records, 25 randomised controlled trials meet the inclusion criteria, 9 were included in the review, and 7 of these included in meta-analysis. We found no clear evidence demonstrating superiority of regular dosing of opioids compared with as-needed dosing in persistent cancer pain, and regular dosing was associated with significantly higher total opioid doses. There was, however, a paucity of trials directly answering this question, and low-quality evidence limits the conclusions that can be drawn. It is clear that further high-quality clinical trials are needed to answer this question and to guide clinical practice.
Topics: Adult; Analgesics, Opioid; Cancer Pain; Chronic Pain; Humans; Neoplasms; Pain Management
PubMed: 31770157
DOI: 10.1097/j.pain.0000000000001755 -
The Cochrane Database of Systematic... Oct 2019Colorectal resection through a midline laparotomy is a commonly performed surgical procedure to treat various bowel conditions. The typical postoperative hospital stay... (Review)
Review
BACKGROUND
Colorectal resection through a midline laparotomy is a commonly performed surgical procedure to treat various bowel conditions. The typical postoperative hospital stay after this operation is 6 to 10 days. The main factors hindering early recovery and discharge are thought to include postoperative pain and delayed return of bowel function.Continuous infusion of a local anaesthetic into tissues surrounding the surgical incision via a multi-lumen indwelling wound catheter placed by the surgeon prior to wound closure may reduce postoperative pain, opioid consumption, the time to return of bowel function, and the length of hospital stay.
OBJECTIVES
To evaluate the efficacy and adverse events of continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults.
SEARCH METHODS
We searched the CENTRAL, MEDLINE and Embase databases to January 2019 to identify trials relevant to this review. We also searched reference lists of relevant trials and reviews for eligible trials. Additionally, we searched two clinical trials registers for ongoing trials.
SELECTION CRITERIA
We considered randomised controlled trials (including non-standard designs) or quasi-randomised controlled trials comparing continuous wound infusion of a local anaesthetic versus a placebo or a sham after midline laparotomy for colorectal resection in adults. We did not compare continuous local anaesthetic wound infusion to other techniques, such as transverse abdominis plane block or thoracic epidural analgesia. We allowed non-randomised analgesic co-interventions carried out equally in the intervention and control groups.
DATA COLLECTION AND ANALYSIS
Two review authors independently identified trials for inclusion and assessed their quality using the Cochrane 'Risk of bias' tool. We extracted data using standardised forms, including pain at rest and on movement (10-point scale), opioid consumption via a patient-controlled analgesia (PCA) system (mg morphine equivalent), postoperative opioid-related adverse events, the time to rescue analgesia, the time to first flatus and to first bowel movement, the time to ambulation, the length of hospital stay, serious postoperative adverse events, and patient satisfaction. We quantitatively synthesised the data by meta-analysis. We summarised and graded the certainty of the evidence for critical outcomes using the GRADEpro tool and created a 'Summary of findings' table.
MAIN RESULTS
This review included six randomised controlled trials that enrolled a total of 564 adults undergoing elective midline laparotomy for colorectal resection comparing continuous wound infusion of a local anaesthetic to a normal saline placebo. Due to 23 post-randomisation exclusions, a total of 541 participants contributed data to the analysis of at least one outcome (local anaesthetic 268; control 273). Most participants were aged 55 to 65 years, with normal body mass index and low to moderate anaesthetic risk (American Society of Anesthesiologists class I-III). Random sequence generation, allocation concealment, and blinding were appropriately carried out in most trials. However, we had to downgrade the certainty of the evidence for most outcomes due to serious study limitations (risk of bias), inconsistency, indirectness, imprecision and reporting bias.Primary outcomesOn postoperative day 1, pain at rest (mean difference (MD) -0.59 (from 3.1), 95% confidence interval (CI) -1.12 to -0.07; 5 studies, 511 participants; high-certainty evidence), pain on movement (MD -1.1 (from 6.1), 95% CI -2.3 to -0.01; 3 studies, 407 participants; low-certainty evidence) and opioid consumption via PCA (MD -12 mg (from 41 mg), 95% CI -20 to -4; 6 studies, 528 participants; moderate-certainty evidence) were reduced in the local anaesthetic group compared to the control group.Secondary outcomesThere was a reduction in the time to first bowel movement (MD -0.67 from 4.4 days, 95% CI -1.17 to -0.17; 4 studies, 197 participants; moderate-certainty evidence) and the length of hospital stay (MD -1.2 from 7.4 days, 95% CI -2.0 to -0.3; 4 studies, 456 participants; high-certainty evidence) in the local anaesthetic group compared to the control group.There was no evidence of a difference in any serious postoperative adverse events until hospital discharge (RR 1.04, 95% CI 0.68 to 1.58; 6 studies, 541 participants; low-certainty evidence) between the two study groups.
AUTHORS' CONCLUSIONS
After elective midline laparotomy for colorectal resection, continuous wound infusion of a local anaesthetic compared to a normal saline placebo reduces postoperative pain at rest and the length of hospital stay, on the basis of high-certainty evidence. This means we are very confident that the effect estimates for these outcomes lie close to the true effects. There is moderate-certainty evidence to indicate that the intervention probably reduces opioid consumption via PCA and the time to first bowel movement. This means we are moderately confident that effect estimates for these outcomes are likely to be close to the true effects, but there is a possibility that they are substantially different. The intervention may reduce postoperative pain on movement, however, this conclusion is based on low-certainty evidence. This means our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. There is low-certainty evidence to indicate that the intervention may have little or no effect on the rates of any serious postoperative adverse events until hospital discharge. High-quality randomised controlled trials to evaluate the intervention with a focus on important clinical and patient-centred outcomes are needed.
PubMed: 31627242
DOI: 10.1002/14651858.CD012310.pub2 -
Medicine Oct 2019Controversy still exists regarding the efficiency and safety of ilioinguinal/iliohypogastric nerve (II/IH) block versus transversus abdominis plane (TAP) block for pain... (Meta-Analysis)
Meta-Analysis
Ilioinguinal/iliohypogastric nerve block versus transversus abdominis plane block for pain management following inguinal hernia repair surgery: A systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Controversy still exists regarding the efficiency and safety of ilioinguinal/iliohypogastric nerve (II/IH) block versus transversus abdominis plane (TAP) block for pain management after inguinal hernia repair. The purpose of the current meta-analysis was to perform a relatively credible and comprehensive assessment to compare the efficiency and safety of II/IH versus TAP for pain management after inguinal hernia repair.
METHODS
The PUBMED, CENTRAL, and EMBASE were systematically searched. Studies comparing II/IH versus TAP for pain management in adult patients undergoing inguinal herniorrhaphy were included. The results of this study are synthesized and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
RESULTS
Six studies with 632 patients were included in this study. No statistically significant difference was observed between the II/IH and TAP groups in postoperative opioid use, the time to first request for rescue analgesia, the incidence of postoperative nausea and vomiting (PONV), incidence of complication related with nerve blocks and patient satisfaction. The TAP group had a significantly higher pain score at 6 and 8 hours postoperatively (6 hours: mean difference [MD] = 0.94, 95% confidence interval [CI] 0.67-1.22, I = 0%, P < .01; 8 hours: MD = 1.02, 95% CI 0.3-1.74, I = 59%, P < .01). However, no statistically significant difference was observed at 1, 2, 4, 12, 24, 48 hours, and 6 months postoperatively.
CONCLUSIONS
In general, this meta-analysis revealed that both approaches have similar postoperative opioid consumption and no significant difference in postoperative complication and patient satisfaction. The II/IH block provides excellent analgesic effects at 6 and 8 hours after inguinal herniorrhaphy in compared with the TAP block. However, more high-quality randomized controlled trials with long-term follow-up are still required to make the conclusion.
Topics: Abdominal Muscles; Adult; Aged; Analgesics, Opioid; Female; Hernia, Inguinal; Herniorrhaphy; Humans; Hypogastric Plexus; Male; Middle Aged; Nerve Block; Neuralgia; Pain Management; Pain, Postoperative; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31626118
DOI: 10.1097/MD.0000000000017545 -
Anaesthesia Mar 2020There are numerous possible techniques for delivering local anaesthetic through peripheral nerve catheters. These include continuous infusions, patient-controlled... (Meta-Analysis)
Meta-Analysis
There are numerous possible techniques for delivering local anaesthetic through peripheral nerve catheters. These include continuous infusions, patient-controlled boluses and programmed intermittent boluses. The optimal delivery regimen of local anaesthetic is yet to be conclusively established. In this review, we identified prospective trials of delivery regimens through peripheral nerve catheters. Our primary outcome was visual analogue scale scores for pain at 48 h. Secondary outcomes were: visual analogue scores at 24 h; patient satisfaction scores; rescue opioid use; local anaesthetic consumption; and nausea and vomiting. Network meta-analysis was used to compare these outcomes. Predefined sub-group analyses were performed. Thirty-three studies enrolling 1934 participants were included. In comparison with continuous infusion, programmed intermittent boluses improved visual analogue pain scores at both 48 and 24 h, the weighted mean difference (95%CI) being -0.63 (-1.12 to -0.14), p = 0.012 and -0.48 (-0.92 to -0.03), p = 0.034, respectively. Programmed intermittent boluses also improved satisfaction scores, the weighted mean difference (95%CI) being 0.70 (0.10-1.31), p = 0.023, and reduced rescue opioid use, the weighted mean difference (95%CI) in oral morphine equivalent at 24 h being -23.84 mg (-43.90 mg to -3.77 mg), p = 0.020. Sub-group analysis revealed that these findings were mostly confined to lower limb and truncal catheter studies; there were few studies of programmed intermittent boluses for upper limb catheters. Programmed intermittent boluses may provide optimal delivery of a local anaesthetic through peripheral nerve catheters. Further research is warranted, particularly to delineate the differences between upper and lower limb catheter locations, which will help clarify the clinical relevance of these findings.
Topics: Analgesia, Patient-Controlled; Anesthesia, Local; Anesthetics, Local; Catheterization; Catheters; Humans; Pain; Peripheral Nerves
PubMed: 31612480
DOI: 10.1111/anae.14864 -
Frontiers in Oncology 2019This study aims to explore the effectiveness and safety of the enhanced recovery after surgery (ERAS) protocol vs. traditional perioperative care programs for breast...
This study aims to explore the effectiveness and safety of the enhanced recovery after surgery (ERAS) protocol vs. traditional perioperative care programs for breast reconstruction. Three electronic databases (PubMed, EMBASE, and Cochrane Library) were searched for observational studies comparing an ERAS program with a traditional perioperative care program from database inception to 5 May 2018. Two reviewers independently screened the literature according to the inclusion and exclusion criteria, extracted the data, and evaluated study quality using the Newcastle-Ottawa Scale. Subgroup and sensitivity analyses were performed. The outcomes included the length of hospital stay (LOS), complication rates, pain control, costs, emergency department visits, hospital readmission, and unplanned reoperation. Ten studies were included in the meta-analysis. Compared with a conventional program, ERAS was associated with significantly decreased LOS, morphine administration (including postoperative patient-controlled analgesia usage rate and duration; intravenous morphine administration on postoperative day [POD] 0, 1, 2, and 4; total intravenous morphine administration on POD 0-3; oral morphine consumption on POD 0-4; and total postoperative oral morphine consumption), and pain scores (postoperative pain score on POD 0 and total pain score on POD 0-3). The other variables did not differ significantly. Our results suggest that ERAS protocols can decrease LOS and morphine equivalent dosing; therefore, further larger, and better-quality studies that report on bleeding amount and patient satisfaction are needed to validate our findings.
PubMed: 31417864
DOI: 10.3389/fonc.2019.00675 -
A Meta-Analysis of the Utility of Preoperative Intravenous Paracetamol for Post-Caesarean Analgesia.Medicina (Kaunas, Lithuania) Jul 2019Worldwide, the number of caesarean sections performed has increased exponentially. Some studies have reported better pain control and lower postoperative requirements... (Meta-Analysis)
Meta-Analysis
Worldwide, the number of caesarean sections performed has increased exponentially. Some studies have reported better pain control and lower postoperative requirements for opioids when intravenous (IV) paracetamol was administered preoperatively. This meta-analysis thus aimed to investigate the utility of preoperative IV paracetamol for post-caesarean analgesia. By using the keywords (paracetamol OR acetaminophen) AND [cesarea* OR caesarea* OR cesaria* OR caesaria*], a systematic literature search was conducted using PubMed, Medline, Embase, Google Scholar and ClinicalTrials.gov databases for papers published in English between January 1, 1960 and March 1, 2019. Grey literature was searched as well. Seven clinical trials were reviewed, while five randomized, placebo-controlled, double-blind studies were included in the final meta-analysis. Applying per-protocol analysis and a random-effects model, there was a significant reduction in postoperative opioid consumption and pain score in the group that received preoperative IV paracetamol, compared to placebo, as the standardized mean difference (SMD) were -0.460 (95% CI -0.828 to -0.092, = 0.014) and -0.719 (95% CI: -1.31 to -0.13, = 0.018), respectively. However, there was significant heterogeneity amongst the different studies included in the meta-analysis (I = 70.66%), perhaps owing to their diverse protocols. Some studies administered IV paracetamol 15 min before induction while others gave it before surgical incision. This is the first review on the topic. Overall, preoperative IV paracetamol has convincingly demonstrated useful opioid-sparing effects and it also appears safe for use at the time of delivery. It should be considered as a component of an effective multimodal analgesic regimen. Future studies could be conducted on other patient groups, e.g., those with multiple comorbidities or chronic pain disorders, and further delineate the optimal timing to administer the drug preoperatively.
Topics: Acetaminophen; Adult; Analgesia; Cesarean Section; Female; Humans; Pregnancy; Preoperative Care
PubMed: 31370298
DOI: 10.3390/medicina55080424