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EClinicalMedicine Jun 2024General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using...
BACKGROUND
General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using only intravenous agents, or through inhalational anaesthesia, using volatile anaesthetic agents. The debate on how this affects postoperative patient outcome is ongoing, despite an abundance of published trials. The relevance of this topic has grown by the increasing concern about the contribution of anaesthetic gases to the environmental impact of surgery. We aimed to summarise all available evidence on relevant patient outcomes with total intravenous anaesthesia versus inhalational anaesthesia.
METHODS
In this systematic review and meta-analysis, we searched PubMed/Medline, Embase and Cochrane Central Register of Controlled trials for works published from January 1, 1985 to August 1, 2023 for randomised controlled trials comparing total intravenous anaesthesia using propofol versus inhalational anaesthesia using the volatile anaesthetics sevoflurane, desflurane or isoflurane. Two reviewers independently screened titles, abstracts and full text articles, and assessed risk of bias using the Cochrane Collaboration tool. Outcomes were derived from a recent series of publications on consensus definitions for Standardised Endpoints for Perioperative trials (StEP). Primary outcomes covered mortality and organ-related morbidity. Secondary outcomes were related to anaesthetic and surgical morbidity. This study is registered with PROSPERO (CRD42023430492).
FINDINGS
We included 317 randomised controlled trials, comprising 51,107 patients. No difference between total intravenous and inhalational anaesthesia was seen in the primary outcomes of in-hospital mortality (RR 1.05, 95% CI 0.67-1.66, 27 trials, 3846 patients), 30-day mortality (RR 0.97, 95% CI 0.70-1.36, 23 trials, 9667 patients) and one-year mortality (RR 1.14, 95% CI 0.88-1.48, 13 trials, 9317 patients). Organ-related morbidity was similar between groups except for the subgroup of elderly patients, in which total intravenous anaesthesia was associated with a lower incidence of postoperative cognitive dysfunction (RR 0.62, 95% CI 0.40-0.97, 11 trials, 3834 patients) and a better score on postoperative cognitive dysfunction tests (standardised mean difference 1.68, 95% CI 0.47-2.88, 9 trials, 4917 patients). In the secondary outcomes, total intravenous anaesthesia resulted in a lower incidence of postoperative nausea and vomiting (RR 0.61, 95% CI 0.56-0.67, 145 trials, 23,172 patients), less emergence delirium (RR 0.40, 95% CI 0.29-0.56, 32 trials, 4203 patients) and a higher quality of recovery score (QoR-40 mean difference 6.45, 95% CI 3.64-9.25, 17 trials, 1835 patients).
INTERPRETATION
The results indicate that postoperative mortality and organ-related morbidity was similar for intravenous and inhalational anaesthesia. Total intravenous anaesthesia offered advantages in postoperative recovery.
FUNDING
Dutch Society for Anaesthesiology (NVA).
PubMed: 38774674
DOI: 10.1016/j.eclinm.2024.102636 -
Pain and Therapy Aug 2023Renal colic is one of the most common urological emergencies, and is usually caused by ureteral colic spasms. Pain management in renal colic remains the central focus of...
INTRODUCTION
Renal colic is one of the most common urological emergencies, and is usually caused by ureteral colic spasms. Pain management in renal colic remains the central focus of emergency treatment. The purpose of this meta-analysis is to identify the efficacy and safety of ketamine versus opioids in the treatment of patients with renal colic.
METHODS
We searched PubMed, EMBASE, Cochrane Library, and Web of Science databases for published randomized controlled trials (RCTs) that referred to the use of ketamine and opioids for patients with renal colic. The methodology was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI) was used to analyze the data. The results were pooled using a fixed-effects model or random-effects model. The primary outcome measure was patient-reported pain scores 5, 15, 30, and 60 min after drug administration. The secondary outcome measure was side effects.
RESULTS
The data analysis revealed that ketamine was similar to opioids in pain intensity at the time of 5 min post-dose (MD = - 0.40, 95% CI - 1.82 to 1.01, P = 0.57), 15 min post-dose (MD = - 0.15, 95% CI - 0.82 to 0.52, P = 0.67), 30 min post-dose (MD = 0.38, 95% CI - 0.25 to 1.01, P = 0.24). Also, the pain score of ketamine was better than that of opioids at 60 min after administration (MD = - 0.12, 95% CI - 0.22 to - 0.02, P = 0.02). As for safety, the ketamine group was linked to a significant decrease in the incidence of hypotensive (OR = 0.08, 95% CI 0.01-0.65, P = 0.02). The two groups did not statistically differ in the incidence of nausea, vomiting, and dizziness.
CONCLUSIONS
Compared with opioids, ketamine showed a longer duration of analgesia in renal colic, with satisfactory safety.
TRIAL REGISTRATION
The PROSPERO registration number is CRD42022355246.
PubMed: 37284927
DOI: 10.1007/s40122-023-00530-0 -
BMC Anesthesiology Feb 2023Dexmedetomidine (DEX) has been thought to be an effective adjuvant to local anesthetics (LAs) in erector spinae plane block (ESPB), however, this method of use is not... (Meta-Analysis)
Meta-Analysis
The effect and safety of dexmedetomidine as an adjuvant to local anesthetics in erector spinae plane block: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Dexmedetomidine (DEX) has been thought to be an effective adjuvant to local anesthetics (LAs) in erector spinae plane block (ESPB), however, this method of use is not recorded in the drug instructions. Hence, our meta-analysis will evaluate its efficacy and safety for the first time.
METHODS
A systematic search of published articles was conducted in the PubMed, Embase, Web of science, and Cochrane Library databases up to July 17, 2022, using specific keywords related to our aims. The time first to request rescue analgesia, number of patient controlled intravenous analgesia (PCIA) presses, rate of rescue analgesia use, postoperative nausea and vomiting (PONV), arrhythmia, and hypotension were calculated by using random-effect models. This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42022345488).
RESULTS
Numerous electronic databases were searched and finally 8 studies with a total of 570 patients, 303 in the DEX arm, 267 in the control arm were included. As an adjuvant to LAs, DEX significantly increased the time to first request of rescue analgesia (mean difference [MD] = 8.40, 95% confidence interval [CI] = 4.70-12.10, P < 0.00001), reduced the number of PCIA presses (MD = -4.12, 95% CI = -7.79 to -0.45, P = 0.03) and the rate of rescue analgesia (odds ratio [OR] = 0.33, 95% CI = 0.17-0.65, P = 0.002). Moreover, the combination reduced the risk of PONV (OR = 0.57, 95% CI = 0.36-0.91, P = 0.02). In addition, there was no difference in the incidence of hypotension (OR = 1.01, 95% CI = 0.37-2.74, P = 0.99) and arrhythmia (OR = 0.76, 95% CI = 0.19-3.07, P = 0.70).
CONCLUSION
DEX can reduce analgesic requirements after various surgical procedures when used as an adjuvant to LAs for ESPB. Moreover, there was no significant difference between the two groups in terms of safety indicators (arrhythmia, hypotension).
Topics: Humans; Anesthetics, Local; Dexmedetomidine; Postoperative Nausea and Vomiting; Randomized Controlled Trials as Topic; Analgesia, Patient-Controlled; Hypotension; Nerve Block
PubMed: 36849910
DOI: 10.1186/s12871-023-02019-x -
The Cochrane Database of Systematic... Sep 2010Parenteral opioids are used for pain relief in labour in many countries throughout the world. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Parenteral opioids are used for pain relief in labour in many countries throughout the world.
OBJECTIVES
To assess the acceptability, effectiveness and safety of different types, doses and modes of administration of parenteral opioids given to women in labour.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and reference lists of retrieved studies.
SELECTION CRITERIA
We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient controlled analgesia) for women in labour. We looked at studies comparing an opioid with placebo or another opioid.
DATA COLLECTION AND ANALYSIS
At least two review authors independently assessed study eligibility, collected data and assessed risk of bias.
MAIN RESULTS
We included 54 studies involving more than 7000 women that compared an opioid with placebo or another opioid administered intramuscularly or intravenously. The 54 studies reported on 27 different comparisons, and for many outcomes only one study contributed data. Overall the evidence was of poor quality regarding the analgesic effect of opioids, satisfaction with analgesia, adverse effects and harm to women and babies. There were few statistically significant results. Many of the studies had small sample sizes, and low statistical power. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour, although up to two-thirds of women who received opioids reported moderate or severe pain and/or poor or moderate pain relief one or two hours after administration. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.
AUTHORS' CONCLUSIONS
Parenteral opioids provide some relief from pain in labour but are associated with adverse effects. Maternal satisfaction with opioid analgesia was largely unreported but appeared moderate at best. We did not examine the effectiveness and safety of parenteral opioids compared with other methods of pain relief in labour and this review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse events for mothers and their newborns.
Topics: Analgesia, Obstetrical; Analgesics, Opioid; Female; Humans; Injections, Intramuscular; Injections, Intravenous; Labor Pain; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 20824859
DOI: 10.1002/14651858.CD007396.pub2 -
Scandinavian Journal of Trauma,... May 2021Trauma is a leading cause of morbidity and mortality worldwide with about 5.8 million deaths globally and the leading cause of death in those aged 45 and younger. The...
BACKGROUND
Trauma is a leading cause of morbidity and mortality worldwide with about 5.8 million deaths globally and the leading cause of death in those aged 45 and younger. The pre-hospital phase of traumatic injury is particularly important as care received during this phase has effects on survival. The need for high quality clinical trials in this area has been recognised for several years as a key priority to improve the evidence base and, ultimately, clinical care in prehospital trauma. We aimed to systematically map the existing evidence base for pre-hospital trauma trials, to identify knowledge gaps and inform decisions about the future research agenda.
METHODS
A systematic mapping review was conducted first employing a search of key databases (MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to March 23rd 2020) to identify randomised controlled trials within the pre-hospital trauma and injury setting. The evidence 'map' identified and described the characteristics of included studies and compared these studies against existing priorities for research. Narrative description of studies informed by analysis of relevant data using descriptive statistics was completed.
RESULTS
Twenty-three eligible studies, including 10,405 participants across 14 countries, were identified and included in the systematic map. No clear temporal or geographical trends in publications were identified. Studies were categorised into six broad categories based on intervention type with evaluations of fluid therapy and analgesia making up 60% of the included trials. Overall, studies were heterogenous with regard to individual interventions within categories and outcomes reported. There was poor reporting across several studies. No studies reported patient involvement in the design or conduct of the trials.
CONCLUSION
This mapping review has highlighted that evidence from trials in prehospital trauma is sparse and where trials have been completed, the reporting is generally poor and study designs sub-optimal. There is a continued need, and significant scope, for improvement in a setting where high quality evidence has great potential to make a demonstrable impact on care and outcomes.
Topics: Emergency Medical Services; Hospitals; Humans; Randomized Controlled Trials as Topic; Wounds and Injuries
PubMed: 34001219
DOI: 10.1186/s13049-021-00880-8 -
Burns & Trauma 2022Topical local analgesic and anaesthetic agents have been used both pre- and immediately post-harvest on split-thickness skin graft (STSG) donor site wounds (DSW). There...
BACKGROUND
Topical local analgesic and anaesthetic agents have been used both pre- and immediately post-harvest on split-thickness skin graft (STSG) donor site wounds (DSW). There is no systematic review of their effectiveness in providing post-harvest analgesia, or of the possible toxic effects of systemic absorption. This study is designed to address the question of which agent, if any, is favoured over the others and whether there are any safety data regarding their use.
METHODS
Systematic literature review of randomised controlled trials of topical agents applied to STSG DSWs, with a view to providing analgesia. Studies identified via search of Cochrane and EBSCO databases. No restrictions on language or publication year. Primary outcomes: pain at the time of (awake) STSG, and post-harvest pain (up to first dressing change). Secondary outcome was serum medication levels relative to published data on toxic doses. Cochrane risk of bias assessment tool utilised in assessment of included studies. At least 2 reviewers screened and reviewed included studies. A narrative review is presented.
RESULTS
There were 11 studies meeting inclusion criteria. Overall methodological quality and patient numbers were low. Topical eutectic mixture of lidocaine and prilocaine pre-harvest affords good local anaesthesia in awake STSG harvesting. Topical bupivacaine (5 studies) or lidocaine (1 study) gave significantly better post-harvest anaesthesia/analgesia than placebo. Topical morphine performs no better than placebo. Topical local anaesthetic agents at reported doses were all well below toxic serum levels.
CONCLUSIONS
Topical local anaesthetics (lidocaine or bupivacaine) provide good analgesia, both during and after STSG harvest, at well below toxic serum levels, but there are no good data determining the best local anaesthetic agent to use. There is no evidence morphine performs better than placebo.
PubMed: 36133279
DOI: 10.1093/burnst/tkac020 -
The Cochrane Database of Systematic... Jun 2018Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010.
OBJECTIVES
To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies.
SELECTION CRITERIA
We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient-controlled analgesia) for women in labour. Cluster-randomised trials were also eligible for inclusion, although none were identified. We did not include quasi-randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non-pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach.
MAIN RESULTS
We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty-one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre-eclampsia or pre-existing conditions or with a compromised fetus. Overall, the evidence was graded as low- or very low-quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low-quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low-quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low-quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low-quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low-quality evidence).There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.
AUTHORS' CONCLUSIONS
Though most evidence is of low- or very-low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.
Topics: Analgesia, Obstetrical; Analgesics, Opioid; Female; Humans; Injections, Intramuscular; Injections, Intravenous; Labor Pain; Meperidine; Pregnancy; Randomized Controlled Trials as Topic; Transcutaneous Electric Nerve Stimulation
PubMed: 29870574
DOI: 10.1002/14651858.CD007396.pub3 -
British Journal of Anaesthesia Nov 2009Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which... (Meta-Analysis)
Meta-Analysis Review
Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890-990 mg per 24 h compared with 325-472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%-38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.
Topics: Analgesia, Patient-Controlled; Anesthetics, Local; Dose-Response Relationship, Drug; Drug Administration Schedule; Humans; Nerve Block; Pain, Postoperative; Thoracotomy
PubMed: 19837806
DOI: 10.1093/bja/aep272 -
The Cochrane Database of Systematic... Apr 2023Neonates are an extremely vulnerable patient population, with 6% to 9% admitted to the neonatal intensive care unit (NICU) following birth. Neonates admitted to the NICU... (Review)
Review
BACKGROUND
Neonates are an extremely vulnerable patient population, with 6% to 9% admitted to the neonatal intensive care unit (NICU) following birth. Neonates admitted to the NICU will undergo multiple painful procedures per day throughout their stay. There is increasing evidence that frequent and repetitive exposure to painful stimuli is associated with poorer outcomes later in life. To date, a wide variety of pain control mechanisms have been developed and implemented to address procedural pain in neonates. This review focused on non-opioid analgesics, specifically non-steroidal anti-inflammatory drugs (NSAIDs) and N-methyl-D-aspartate (NMDA) receptor antagonists, which alleviate pain through inhibiting cellular pathways to achieve analgesia. The analgesics considered in this review show potential for pain relief in clinical practice; however, an evidence summation compiling the individual drugs they comprise and outlining the benefits and harms of their administration is lacking. We therefore sought to summarize the evidence on the level of pain experienced by neonates both during and following procedures; relevant drug-related adverse events, namely episodes of apnea, desaturation, bradycardia, and hypotension; and the effects of combinations of drugs. As the field of neonatal procedural pain management is constantly evolving, this review aimed to ascertain the scope of non-opioid analgesics for neonatal procedural pain to provide an overview of the options available to better inform evidence-based clinical practice. OBJECTIVES: To determine the effects of non-opioid analgesics in neonates (term or preterm) exposed to procedural pain compared to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration.
SEARCH METHODS
We searched the Cochrane Library (CENTRAL), PubMed, Embase, and two trial registries in June 2022. We screened the reference lists of included studies for studies not identified by the database searches.
SELECTION CRITERIA
We included all randomized controlled trials (RCTs), quasi-RCTs, and cluster-RCTs in neonates (term or preterm) undergoing painful procedures comparing NSAIDs and NMDA receptor antagonists to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our main outcomes were pain assessed during the procedure and up to 10 minutes after the procedure with a validated scale; episodes of bradycardia; episodes of apnea; and hypotension requiring medical therapy.
MAIN RESULTS
We included two RCTs involving a total of 269 neonates conducted in Nigeria and India. NMDA receptor antagonists versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention One RCT evaluated using oral ketamine (10 mg/kg body weight) versus sugar syrup (66.7% w/w at 1 mL/kg body weight) for neonatal circumcision. The evidence is very uncertain about the effect of ketamine on pain score during the procedure, assessed with the Neonatal Infant Pain Scale (NIPS), compared with placebo (mean difference (MD) -0.95, 95% confidence interval (CI) -1.32 to -0.58; 1 RCT; 145 participants; very low-certainty evidence). No other outcomes of interest were reported on. Head-to-head comparison of different analgesics One RCT evaluated using intravenous fentanyl versus intravenous ketamine during laser photocoagulation for retinopathy of prematurity. Neonates receiving ketamine followed an initial regimen (0.5 mg/kg bolus 1 minute before procedure) or a revised regimen (additional intermittent bolus doses of 0.5 mg/kg every 10 minutes up to a maximum of 2 mg/kg), while those receiving fentanyl followed either an initial regimen (2 μg/kg over 5 minutes, 15 minutes before the procedure, followed by 1 μg/kg/hour as a continuous infusion) or a revised regimen (titration of 0.5 μg/kg/hour every 15 minutes to a maximum of 3 μg/kg/hour). The evidence is very uncertain about the effect of ketamine compared with fentanyl on pain score assessed with the Premature Infant Pain Profile-Revised (PIPP-R) scores during the procedure (MD 0.98, 95% CI 0.75 to 1.20; 1 RCT; 124 participants; very low-certainty evidence); on episodes of apnea occurring during the procedure (risk ratio (RR) 0.31, 95% CI 0.08 to 1.18; risk difference (RD) -0.09, 95% CI -0.19 to 0.00; 1 study; 124 infants; very low-certainty evidence); and on hypotension requiring medical therapy occurring during the procedure (RR 5.53, 95% CI 0.27 to 112.30; RD 0.03, 95% CI -0.03 to 0.10; 1 study; 124 infants; very low-certainty evidence). The included study did not report pain score assessed up to 10 minutes after the procedure or episodes of bradycardia occurring during the procedure. We did not identify any studies comparing NSAIDs versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention or different routes of administration of the same analgesics. We identified three studies awaiting classification. AUTHORS' CONCLUSIONS: The two small included studies comparing ketamine versus either placebo or fentanyl, with very low-certainty evidence, rendered us unable to draw meaningful conclusions. The evidence is very uncertain about the effect of ketamine on pain score during the procedure compared with placebo or fentanyl. We found no evidence on NSAIDs or studies comparing different routes of administration. Future research should prioritize large studies evaluating non-opioid analgesics in this population. As the studies included in this review suggest potential positive effects of ketamine administration, studies evaluating ketamine are of interest. Furthermore, as we identified no studies on NSAIDs, which are widely used in older infants, or comparing different routes of administration, such studies should be a priority going forward.
Topics: Aged; Humans; Infant, Newborn; Male; Analgesics; Analgesics, Non-Narcotic; Anti-Inflammatory Agents, Non-Steroidal; Apnea; Body Weight; Bradycardia; Fentanyl; Ketamine; Pain; Pain, Procedural; Receptors, N-Methyl-D-Aspartate
PubMed: 37014033
DOI: 10.1002/14651858.CD015179.pub2 -
Paediatric Anaesthesia Jun 2013Perioperative pain in children can be effectively managed with systemic opioids, but addition of paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVES
Perioperative pain in children can be effectively managed with systemic opioids, but addition of paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce opioid requirements and potentially improve analgesia and/or reduce adverse effects.
METHODS
A systematic literature search was conducted to identify trials evaluating postoperative opioid requirements in children and comparing NSAID and/or paracetamol with placebo. Studies were stratified according to design: continuous availability of intravenous opioid (PCA/NCA) vs intermittent 'as needed' bolus; and single vs multiple dose paracetamol/NSAIDs. Primary outcome data were extracted, and the percentage decrease in mean opioid consumption was calculated for statistically significant reductions compared with placebo. Secondary outcomes included differences in pain intensity, adverse effects (sedation, respiratory depression, postoperative nausea and vomiting, pruritus, urinary retention, bleeding), and patient/parent satisfaction.
RESULTS
Thirty-one randomized controlled studies, with 48 active treatment arms compared with placebo, were included. Significant opioid sparing was reported in 38 of 48 active treatment arms, across 21 of the 31 studies. Benefit was most consistently reported when multiple doses of study drug were administered, and 24 h PCA or NCA opioid requirements were assessed. The proportion of positive studies was less with paracetamol, but was influenced by dose and route of administration. Despite availability of opioid for titration, a reduction in pain intensity by NSAIDs and/or paracetamol was reported in 16 of 29 studies. Evidence for clinically significant reductions in opioid-related adverse effects was less robust.
CONCLUSION
This systematic review supports addition of NSAIDs and/or paracetamol to systemic opioid for perioperative pain management in children.
Topics: Acetaminophen; Adolescent; Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Child; Child, Preschool; Dose-Response Relationship, Drug; Female; Fentanyl; Humans; Infant; Infant, Newborn; Male; Morphine; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 23570544
DOI: 10.1111/pan.12163