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Clinical Orthopaedics and Related... May 2014The perioperative period of major oncologic surgery is characterized by immunosuppression, angiogenesis, and an increased load of circulating malignant cells. It is a... (Review)
Review
BACKGROUND
The perioperative period of major oncologic surgery is characterized by immunosuppression, angiogenesis, and an increased load of circulating malignant cells. It is a window period in which cancer cells may seed, invade, and proliferate. Thus, it has been hypothesized that the use of regional anesthesia with the goal of reducing surgical stress and opioid and volatile anesthetic consumption would avoid perioperative immune suppression and angiogenesis and ultimately cancer recurrence.
QUESTIONS/PURPOSES
We performed a systematic review of the literature on the use of regional anesthesia and postoperative analgesia to improve cancer-related survival after oncologic surgery. Our primary topic of interest is survival after orthopaedic oncologic surgery, but because that literature is limited, we also have systematically reviewed the question of survival after breast, gastrointestinal, and genitourologic cancers.
METHODS
We searched the PubMed and Embase databases with the search terms: "anesthesia and analgesia", "local neoplasm recurrence", "cancer recurrence", "loco-regional neoplasm recurrence", "disease-free survival", and "cumulative survival rates". Our initial search of the two databases provided 836 studies of which 693 were rejected. Of the remaining 143 studies, only 13 articles qualified for inclusion in this systematic review, based on defined inclusion criteria. All these studies had retrospective design. Due to the high heterogeneity among the identified studies and the complete absence of randomized controlled trials from the literature on this topic, the results of a meta-analysis would be heavily confounded; hence, we instead performed a systematic review of the literature.
RESULTS
No eligible studies addressed the question of whether regional anesthesia and analgesia have an impact on survival after musculoskeletal cancer surgery. Only one relevant clinical study was identified on regional breast cancer survival; it suggested a benefit. The literature on gastrointestinal and genitourinary surgery was larger but mixed, although some preliminary studies do suggest a benefit of regional anesthesia on survival after oncologic surgery in those patient populations.
CONCLUSIONS
Although basic science studies suggest a potential benefit of regional anesthesia and stress response reduction in cancer formation, we found little clinical evidence to support the theory that regional anesthesia and analgesia improve overall patient survival after oncologic surgery.
Topics: Analgesia; Anesthesia, Conduction; Disease Progression; Disease-Free Survival; Humans; Neoplasm Recurrence, Local; Neoplasms; Pain, Postoperative; Risk Factors; Stress, Physiological; Surgical Procedures, Operative; Survival Analysis; Time Factors; Treatment Outcome
PubMed: 24081665
DOI: 10.1007/s11999-013-3306-y -
Journal of Affective Disorders Apr 2024Ketamine and esketamine has been suggested to have potential efficacy in preventing postpartum depression (PPD) recent years. The aim of this meta-analysis was to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Ketamine and esketamine has been suggested to have potential efficacy in preventing postpartum depression (PPD) recent years. The aim of this meta-analysis was to evaluate the effectiveness of ketamine and esketamine on PPD after cesarean delivery.
METHODS
We systematically searched PubMed, Embase, and the Cochrane Library for studies investigating the efficacy of ketamine and esketamine in preventing PPD. The primary outcomes of this study were risk ratios (RRs) and EPDS scores (Edinburgh Postnatal Depression Scale) in relation to PPD after ketamine and esketamine. The second outcomes were the postoperative adverse events.
RESULTS
Thirteen randomized controlled trials (RCTs) and one retrospective study including 2916 patients were analyzed, including six on the use of ketamine and eight on the use of esketamine. The risk ratios and EPDS scores of PPD were significantly decreased in the ketamine/esketamine group compared to those in the control group in one week and four weeks postoperative periods. Subgroup analyses showed that high dosage, administrated in patient controlled intravenous analgesia (PCIA) method and only esketamine exhibited a significant reduction in the incidence and EPDS scores of PPD in one week and four week postoperative. However, the incidences of postoperative adverse events, such as dizziness, diplopia, hallucination, and headache were significantly higher in the ketamine/esketamine group than that in the control group.
CONCLUSION
Ketamine and esketamine appear to be effective in preventing PPD in the one week and four week postoperative periods after cesarean delivery with moderate certainty of evidence. But they can also lead to some short-term complications too. Future high-quality studies are needed to confirm the efficacy of ketamine and esketamine in different countries.
Topics: Female; Pregnancy; Humans; Ketamine; Depression, Postpartum; Cesarean Section; Headache; Randomized Controlled Trials as Topic
PubMed: 38286233
DOI: 10.1016/j.jad.2024.01.202 -
Cureus Nov 2023Dacryocystorhinostomy (DCR) is an effective surgical procedure for addressing lacrimal drainage problems. However, it can be a painful operation that involves incisions... (Review)
Review
Dacryocystorhinostomy (DCR) is an effective surgical procedure for addressing lacrimal drainage problems. However, it can be a painful operation that involves incisions both inside and outside the eye, often leading to a high incidence of postoperative nausea and vomiting. Preemptive analgesics can be employed to alleviate this unrelieved pain. Nonetheless, many of the drugs used can induce a wide range of adverse effects. Therefore, the aim of this systematic review and meta-analysis is to assess the current evidence regarding the efficacy of pregabalin in managing postoperative pain following DCR surgery. We conducted a thorough search of five electronic databases, namely, PubMed, Web of Science, Scopus, Cochrane, and Google Scholar, to identify relevant randomized controlled trials (RCTs) published before September 2023. The quality of the included studies was assessed using the Cochrane Risk of Bias tool for RCTs. The outcomes we evaluated included postoperative pain, surgery duration, time to first analgesia, total pethidine consumption, and postoperative nausea and vomiting (PONV). Continues data reported as mean difference (MD), and dichotomous data reported as risk ratio (RR), with 95% confidence interval (CI). A pooled meta-analysis of three RCTs, including 240 patients in both the pregabalin and placebo groups, was conducted. The results revealed that the pooled MD in pain scores was significantly lower in patients treated with pregabalin compared to those receiving a placebo ((MD = -1.35 (95% CI: -1.83 to -0.87, p < 0.00001)). Additionally, the pooled MD of pethidine consumption was significantly lower in patients treated with pregabalin compared to those receiving a placebo (MD = -54.13 (95% CI: -103.77 to -4.50, p = 0.03)). However, there was no statistical significance between both groups in terms of time to first analgesia and duration of surgery (p > 0.05). On the other hand, the pooled RR of PONV was significantly lower in patients treated with pregabalin compared to those receiving a placebo (RR = 0.37 (95% CI: 0.24-0.57, p < 0.001)). This meta-analysis demonstrates that pregabalin is an effective and well-tolerated intervention for reducing postoperative pain and PONV following DCR surgery, without significantly affecting surgery duration or time to first analgesia. These findings support the use of pregabalin in improving patient comfort and outcomes in this surgical context.
PubMed: 38024096
DOI: 10.7759/cureus.48720 -
Anesthesiology May 2007A systematic review, including a meta-analysis, on the timing effects of neuraxial analgesia (NA) on cesarean and instrumental vaginal deliveries in nulliparous women... (Meta-Analysis)
Meta-Analysis Review
A systematic review, including a meta-analysis, on the timing effects of neuraxial analgesia (NA) on cesarean and instrumental vaginal deliveries in nulliparous women was conducted. Of 20 articles identified, 9 met the inclusion quality criteria (3,320 participants). Cesarean delivery (odds ratio, 1.00; 95% confidence interval, 0.82-1.23) and instrumental vaginal delivery (odds ratio, 1.00; 95% confidence interval, 0.83-1.21) rates were similar in the early NA and control groups. Neonates of women with early NA had a higher umbilical artery pH and received less naloxone. In the early NA group, fewer women were not compliant with assigned treatment and crossed over to the control group. Women receiving early NA for pain relief are not at increased risk of operative delivery, whereas those receiving early parenteral opioid and late epidural analgesia present a higher risk of instrumental vaginal delivery for nonreassuring fetal status, worse indices of neonatal wellness, and a lower quality of maternal analgesia.
Topics: Analgesia, Epidural; Analgesia, Obstetrical; Cesarean Section; Extraction, Obstetrical; Female; Heart Rate, Fetal; Humans; Infant, Newborn; Patient Satisfaction; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 17457137
DOI: 10.1097/01.anes.0000265165.06760.c2 -
Pain Physician Nov 2017It is still a challenge to optimize postoperative pain management. The effects of adding dexmedetomidine (DEX) to opioid-based postoperative intravenous... (Meta-Analysis)
Meta-Analysis Review
Optimization of Postoperative Intravenous Patient-Controlled Analgesia with Opioid-Dexmedetomidine Combinations: An Updated Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials.
BACKGROUND
It is still a challenge to optimize postoperative pain management. The effects of adding dexmedetomidine (DEX) to opioid-based postoperative intravenous patient-controlled analgesia (PCA) are not fully understood.
OBJECTIVES
The aim of this study is to assess the efficacy and safety of opioid-DEX combinations for postoperative PCA, and a trial sequential analysis (TSA) is utilized to evaluate the robustness of the current evidence.
STUDY DESIGN
A systematic review and meta-analysis.
SETTING
Randomized controlled trials that compared opioid-DEX combinations with opioid-only for PCA in adult surgical patients.
METHODS
MEDLINE, EMBASE, and CENTRAL databases were searched for relevant articles. The main outcomes analyzed were postoperative pain intensity, opioid requirement, and opioid-related adverse events. The random-effects model was used to estimate mean differences (MDs) or relative risks (RRs) with 95% confidence intervals (CIs). A TSA was performed to test whether the evidence was reliable and significant. The quality of evidence for the main outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.
RESULTS
Eighteen studies involving 1,284 patients were included. The meta-analysis indicated that opioid-DEX combinations were associated with lower postoperative pain intensity (at rest: MD [24 hours] = -0.48, 95% CI [-0.75, -0.21], P = 0.0005), lower morphine-equivalent requirement (MD [0 - 24 hours] = -12.16 mg [-16.12, -8.21], P < 0.00001), and lower adverse events (nausea: RR = 0.66 [0.52, 0.83]; vomiting: RR = 0.65 [0.49, 0.87]; and pruritus: RR = 0.57 [0.40, 0.81]). For the above results, the TSA revealed that the cumulative Z-curve exceeded both the traditional boundary and the trial sequential monitoring boundary for benefit. DEX had no effect on the incidence of hypotension or bradycardia, which was also confirmed by the TSA. The GRADE level of evidence was high for postoperative nausea, moderate for pain intensity at rest at 24 hours postoperatively, morphine-equivalent requirement during 0 - 24 hours postoperatively, and postoperative vomiting, pruritus, and bradycardia, and low for postoperative hypotension.
LIMITATIONS
The risk of introducing potentially significant heterogeneity exists, and this study did not evaluate the effects of DEX combined with opioids on long-term outcomes including chronic pain and patients' satisfaction after hospital discharge.
CONCLUSIONS
Postoperative PCA strategies with opioid-DEX combinations decreased postoperative pain, opioid requirement, and opioid-related adverse events. DEX is a useful adjuvant to opioid-based PCA.
KEY WORDS
Dexmedetomidine, pain, postoperative analgesia, opioid, patient-controlled.
Topics: Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Analgesics, Opioid; Dexmedetomidine; Humans; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 29149140
DOI: No ID Found -
British Journal of Anaesthesia Feb 2016Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic... (Review)
Review
Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use. We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries. The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.
Topics: Analgesia, Epidural; Humans; Pain, Postoperative
PubMed: 26787789
DOI: 10.1093/bja/aev453 -
Perioperative Medicine (London, England) Nov 2023Lumbar spine disorders have become an increasingly common health problem in recent years. Modern clinical studies have shown that perioperative analgesia at certain... (Review)
Review
OBJECTIVE
Lumbar spine disorders have become an increasingly common health problem in recent years. Modern clinical studies have shown that perioperative analgesia at certain doses can reduce postoperative pain by inhibiting the process of peripheral sensitization and central sensitization, which is also known as "preemptive analgesia," Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of drugs that achieve antipyretic and analgesic effects by inhibiting cyclooxygenase (COX) and affecting the production of prostaglandins. Our meta-analysis aimed to assess the efficacy and safety of perioperative preemptive analgesia with non-steroidal anti-inflammatory drugs in patients with lumbar spine surgery.
METHODS
We searched PubMed, ScienceDirect, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that met the inclusion criteria. A total of 12 clinical studies were included to assess the efficacy and safety of perioperative NSAIDs preemptive analgesia for lumbar spine surgery.
RESULT
Twelve studies, including 845 patients, met the inclusion criteria. The results showed that perioperative receipt of NSAIDs for preemptive analgesia was effective and safe. Patient's postoperative morphine consumption (P < 0.05), visual analog scale (P < 0.05), and numerical rating scale (P < 0.05) were not statistically associated with postoperative complications (P > 0.05).
CONCLUSION
Our findings suggest that NSAIDs are effective and safe for preemptive analgesia in the perioperative period of lumbar spine surgery and that more and better quality RCTs and more in-depth studies of pain mechanics are still needed.
PubMed: 37996936
DOI: 10.1186/s13741-023-00347-7 -
Academic Emergency Medicine : Official... Oct 2022We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral nerve block (PNB) as sedation or analgesia methods for the reduction of anterior shoulder dislocation.
METHODS
We included randomized controlled trials (RCTs) comparing different sedation or analgesia methods for anterior shoulder dislocation reduction. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar databases were searched in October 2021. We conducted a random-effects NMA within a frequentist framework. We evaluated the confidence in each outcome using the CINeMA tool.
RESULTS
Sixteen RCTs (957 patients) were included. Regarding the primary outcomes, the three methods might result in little to no difference in the immediate success rate of reduction and patient satisfaction. The IAA method had a shorter emergency department length of stay than that of the IVS method (mean difference [MD] -107.88 min, 95% confidence interval [CI] -202.58 to -13.18). In the secondary outcomes, the IAA method had a lower pain score than that of the PNB method (standardized MD -1.83, 95% CI -3.64 to -0.02). The IAA and PNB methods might require a longer time for reduction than that of the IVS method (MD 5.3 min, 95% CI 2.4 to 10.36; MD 15.25, 95% CI 5.49 to 25.01). The three methods might result in little to no difference in the number of reduction attempts and total success rate of reduction. However, the confidence ratings for all treatment comparisons were very low. IAA and PNB had no adverse respiratory events.
CONCLUSIONS
The results of our NMA indicated that three sedation or analgesia methods (IVS, IAA, and PNB) might result in little to no difference in the success rate of reduction and patient satisfaction. IAA and PNB had no adverse respiratory events.
Topics: Analgesia; Humans; Nerve Block; Network Meta-Analysis; Shoulder; Shoulder Dislocation
PubMed: 35872652
DOI: 10.1111/acem.14568 -
Clinical Orthopaedics and Related... Sep 2009Total knee arthroplasty (TKA) is amenable to various regional anesthesia techniques that may improve patient outcome. We sought to answer whether regional anesthesia... (Comparative Study)
Comparative Study Review
Total knee arthroplasty (TKA) is amenable to various regional anesthesia techniques that may improve patient outcome. We sought to answer whether regional anesthesia decreased mortality, cardiovascular morbidity, deep venous thrombosis and pulmonary embolism, blood loss, duration of surgery, pain, opioid-related adverse effects, cognitive defects, and length of stay. We also questioned whether regional anesthesia improved rehabilitation. To do so, we performed a systematic review of the contemporary literature comparing general anesthesia and/or systemic analgesia with regional anesthesia and/or regional analgesia for TKA. To reflect contemporary surgical and anesthetic practice, only randomized, controlled trials from 1990 onward were included. We identified 28 studies involving 1538 patients. There was insufficient evidence from randomized, controlled trials alone to conclude if anesthetic technique influenced mortality, cardiovascular morbidity other than postoperative hypotension, or the incidence of deep venous thrombosis and pulmonary embolism when using thromboprophylaxis. Our review suggests there was no difference in perioperative blood loss or duration of surgery in patients who received general anesthesia versus regional anesthesia. Compared with general anesthesia and/or systemic analgesia, regional anesthesia and/or analgesia reduced postoperative pain, morphine consumption, and opioid-related adverse effects. Length of stay may be reduced and rehabilitation facilitated for patients undergoing regional anesthesia and analgesia for TKA.
Topics: Analgesia; Anesthesia, Conduction; Anesthesia, General; Arthroplasty, Replacement, Knee; Cardiovascular Diseases; Databases, Bibliographic; Female; Humans; Male; Postoperative Complications; Randomized Controlled Trials as Topic; Survival Rate
PubMed: 19130163
DOI: 10.1007/s11999-008-0666-9 -
The Cochrane Database of Systematic... Nov 2021Hysteroscopy done in an outpatient setting is the 'gold standard' method for evaluating the uterine cavity. Media used to distend the uterine cavity include gas as... (Review)
Review
BACKGROUND
Hysteroscopy done in an outpatient setting is the 'gold standard' method for evaluating the uterine cavity. Media used to distend the uterine cavity include gas as carbon dioxide and liquid as saline that can be used at room temperature or warmed to body temperature. Both media offer advantages as well as disadvantages.
OBJECTIVES
The objective of this review is to compare the effectiveness, tolerability, and safety of gas (carbon dioxide) and liquid (normal saline) used for uterine distension during outpatient hysteroscopy.
SEARCH METHODS
We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register, CENTRAL, MEDLINE, Embase and PsycINFO on 28 April 2021. We checked references of relevant trials and contacted study authors and experts in the field to identify additional studies. CINAHL records and ongoing trials from the trial registries were included in the CENTRAL search.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing saline with carbon dioxide, as well as RCTs comparing saline at different temperatures, for uterine distension in outpatient hysteroscopy done for any indication.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures recommended by Cochrane. Primary review outcomes were patient tolerability and adverse events or complications related to the distending medium. Secondary outcomes were quality of the hysteroscopic view and duration of the procedure.
MAIN RESULTS
We included 12 RCTs (1946 women). The quality of evidence ranged from very low to high: the main limitations were risk of bias due to absence of blinding due to the nature of the procedure, imprecision, and inconsistency. Saline versus carbon dioxide Analysis ruled out a clinically relevant difference in pain scores during the procedure between saline and carbon dioxide, but the quality of evidence was low (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.17 to 0.02; 9 RCTs, N = 1705; I² = 86%). This translates to differences of 0.39 cm (lower) and 0.05 cm (higher) on a 10-cm visual analogue scale (VAS). Evidence was insufficient to show differences between groups in the proportion of procedures abandoned due to intense pain (Peto odds ratio (OR) 0.48, 95% CI 0.09 to 2.42; 1 RCT, N = 189; very low-quality evidence). We are uncertain whether saline decreases the need for analgesia compared to carbon dioxide (Peto OR 0.34, 95% CI 0.12 to 0.99; 1 RCT, N = 189; very low-quality evidence). Saline compared to carbon dioxide is probably associated with fewer vasovagal reaction events (Peto OR 0.53, 95% CI 0.32 to 0.86; 6 RCTs, N = 1076; I² = 0%; moderate-quality evidence) and fewer shoulder-tip pain events (Peto OR 0.28, 95% CI 0.14 to 0.54; 4 RCTs, N = 623; I² = 0%, moderate-quality evidence). Evidence suggests that if 10% of women undergoing outpatient hysteroscopy experience a vasovagal reaction event with the use of carbon dioxide, this rate would be between 3% and 9% with the use of saline. Similarly, if the rate of shoulder-tip pain with carbon dioxide is 9%, it would be between 1% and 5% with saline. We are uncertain whether saline is similar to carbon dioxide in terms of endometrial bleeding (Peto OR 0.83, 95% CI 0.25 to 2.75; 2 RCTs, N = 349; I² = 0%; very low-quality evidence). Infection was not reported by any study in this comparison. Saline may result in fewer procedures with an unsatisfactory hysteroscopic view than carbon dioxide (Peto OR 0.51, 95% CI 0.32 to 0.82; 5 RCTs, N = 1082; I² = 67%; low-quality evidence). The duration of the procedure was shorter with saline in three of the four studies that reported this outcome, and duration was similar in both arms in the fourth study. Warm saline versus room temperature saline Use of warm saline for uterine distension during office hysteroscopy may reduce pain scores when compared with room temperature saline (mean difference (MD) -1.14, 95% CI -1.55 to -0.73; 3 RCTs, N = 241; I² = 77%; low-quality evidence). Evidence is insufficient to show differences between groups in either the proportion of procedures abandoned due to intense pain (Peto OR 0.97, 95% CI 0.06 to 15.87; 1 RCT, N = 77; very low-quality evidence) or the need for analgesia (Peto OR 1.00, 95% CI 0.14 to 7.32; 1 RCT, N = 100; very low-quality evidence). Analysis ruled out a clinically relevant difference in duration of the procedure between warm and room temperature saline, but the quality of evidence is low (MD 13.17 seconds, 95% CI -12.96 to 39.29; 2 RCTs, N = 141; I² = 21%). No cases of infection were reported in either group (1 RCT, N = 100). No other adverse events and no information on quality of the hysteroscopic view were reported by any study in this comparison.
AUTHORS' CONCLUSIONS
Evidence was insufficient to show differences between different distension media used for uterine distension in outpatient hysteroscopy in terms of patient tolerability, operator satisfaction, or duration of the procedure. However, saline was superior to carbon dioxide in producing fewer adverse events (shoulder-tip pain and vasovagal reaction).
Topics: Endometrium; Female; Humans; Hysteroscopy; Outpatients; Pain; Pregnancy; Uterus
PubMed: 34826139
DOI: 10.1002/14651858.CD006604.pub2