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Medicine Jan 2021To investigate whether closed-loop systems under bispectral index anesthesia depth monitoring can reduce the intraoperative propofol dosage. (Meta-Analysis)
Meta-Analysis
Bispectral index monitoring of the clinical effects of propofol closed-loop target-controlled infusion: Systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
To investigate whether closed-loop systems under bispectral index anesthesia depth monitoring can reduce the intraoperative propofol dosage.
METHODS
All randomized controlled trials (RCTs) on reducing propofol dosage under closed-loop systems were collected, and the literature was screened out, the abstracts and full texts were carefully read, and the references were tracked, data extraction and quality evaluation were conducted on the included research, and the RevMan5.3 software was used for meta-analysis. The main results were propofol and the incidence of adverse reactions such as hypertensive hypotension and postoperative cognitive dysfunction. A total of 879 cases were included in 8 articles, including 450 occurrences in the closed-loop system group and 429 cases in the open-loop system group.
RESULTS
Compared with manual control, closed-loop systems under bispectral index anesthesia depth monitoring reduced the dose of propofol (MD: -0.62, 95% CI: -1.08--0.16, P = .008), with heterogeneity (I2 = 80%). Closed-loop systems significantly reduced the incidence of abnormal blood pressure (MD: -0.02, 95%CI: -0.05-0.01, P = .15, I2 = 74%) and postoperative cognitive dysfunction (MD: -0.08, 95% CI: -0.14 -0.01, P = .02, I2 = 94%).
CONCLUSION
Bispectral index monitoring of propofol closed-loop target-controlled infusion system can reduce the amount of propofol, reduce the incidence of adverse reactions such as hypertensive or hypotension and postoperative cognitive dysfunction.
Topics: Anesthesia, Intravenous; Anesthetics, Intravenous; Consciousness Monitors; Dose-Response Relationship, Drug; Humans; Postoperative Cognitive Complications; Propofol; Randomized Controlled Trials as Topic
PubMed: 33530193
DOI: 10.1097/MD.0000000000023930 -
British Journal of Anaesthesia Jul 2024Propofol and sevoflurane are two of the most commonly used anaesthetics for paediatric surgery. Data from some clinical trials suggest that postoperative pain incidence... (Meta-Analysis)
Meta-Analysis Comparative Study Review
BACKGROUND
Propofol and sevoflurane are two of the most commonly used anaesthetics for paediatric surgery. Data from some clinical trials suggest that postoperative pain incidence is lower when propofol is used for maintenance of anaesthesia compared with sevoflurane, although this is not clear.
METHODS
This meta-analysis compared postoperative pain following maintenance of anaesthesia with propofol or sevoflurane in paediatric surgeries. PubMed Medline, Embase, Scopus, Web of Science and Cochrane Library were searched for randomised controlled trials (RCTs) that compared postoperative pain between sevoflurane and propofol anaesthesia in children. After quality assessment, a meta-analysis was carried out using bias-adjusted inverse heterogeneity methods, heterogeneity using I and publication bias using Doi plots.
RESULTS
In total, 13 RCTs with 1174 children were included. The overall synthesis suggested nearly two-fold higher odds of overall postoperative pain in the sevoflurane group compared with the propofol group (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.12-3.15, I=58.2%). Further, children in the sevoflurane group had higher odds of having higher pain scores (OR 3.18, 95% CI 1.83-5.53, I=20.9%), and a 60% increase in the odds of requiring postoperative rescue analgesia compared with propofol (OR 1.60, 95% CI 0.89-2.88, I=58.2%).
CONCLUSIONS
Children maintained on inhalational sevoflurane had higher odds of postoperative pain compared with those maintained on propofol. The results also suggest that sevoflurane is associated with higher odds of needing postoperative rescue analgesia compared with propofol.
REGISTRATION
The protocol for this systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with registration ID CRD42023445913.
Topics: Humans; Sevoflurane; Propofol; Pain, Postoperative; Child; Anesthetics, Inhalation; Anesthetics, Intravenous; Child, Preschool; Randomized Controlled Trials as Topic
PubMed: 38670899
DOI: 10.1016/j.bja.2024.03.022 -
Saudi Journal of Anaesthesia 2023Brugada syndrome (BrS) is a major risk factor for sudden cardiac death and ventricular tachyarrhythmias. Several drugs are contraindicated in patients with BrS,... (Review)
Review
Brugada syndrome (BrS) is a major risk factor for sudden cardiac death and ventricular tachyarrhythmias. Several drugs are contraindicated in patients with BrS, including some commonly administered drugs during anesthesia or in the perioperative period; however, there is still a paucity of evidence regarding BrS and common anesthetic pharmaceuticals. We conducted a systematic literature search (PubMed, updated October 10, 2022), including all studies reporting pharmacological management of BrS patients during anesthesia or intensive care, with a specific focus on proarrhythmic effects and possible pharmacological interactions in the context of BrS. The search revealed 44 relevant items, though only three original studies. Two randomized controlled studies were identified, one comparing propofol and etomidate for the induction of general anesthesia and one investigating lidocaine with or without epinephrine for local anesthesia; there was also one prospective study without a control group. The other studies were case series (n = 5, for a total of 19 patients) or case reports (n = 36). Data are reported on a total population of 199 patients who underwent general or local anesthesia. None of the studies evaluated BrS patients in the intensive care unit (ICU). We found the studies focusing on the pharmacological management of BrS patients undergoing general or local anesthesia to be of generally poor quality. However, it appears that propofol can be used safely, without an increase in arrhythmic events. Regional anesthesia is possible, and lidocaine might be preferred over longer-acting local anesthetics. Considering the quality of the included studies and their anecdotal evidence, it seems increasingly important to conduct large multicenter studies or promote international registries with high-quality data on the anesthesiological management of these patients.
PubMed: 37601502
DOI: 10.4103/sja.sja_205_23 -
The Cochrane Database of Systematic... Jan 2014Awake fibreoptic intubation (AFOI) frequently requires sedation, anxiolysis and relief of discomfort without impairing ventilation and depressing cardiovascular... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Awake fibreoptic intubation (AFOI) frequently requires sedation, anxiolysis and relief of discomfort without impairing ventilation and depressing cardiovascular function. The goal is to allow the patient to be responsive and co-operative. Medications such as fentanyl, remifentanil, midazolam and propofol have been reported to assist AFOI; however,these agents are associated with cardiovascular or respiratory adverse effects. Dexmedetomidine has been proposed as an alternative to facilitate AFOI.
OBJECTIVES
The primary objective of this review is to evaluate and compare the efficacy and safety of dexmedetomidine in the management of patients with a difficult or unstable airway undergoing awake fibreoptic intubation (AFOI).
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2012, Issue 5), MEDLINE (1966 to May 2012) through Ovid, EMBASE (1980 to May 2012) and Web of Science (1945 to May 2012); we screened the reference lists of all eligible trials and reviews to look for further trials and contacted authors of trials to ask for additional information. We searched for ongoing trials at http://www.controlledtrials.com/ and http://clinicaltrials.gov/ . We reran our search of all databases listed above on 21 November 2013.
SELECTION CRITERIA
We included published and unpublished randomized controlled trials, regardless of blinding or language of publication, in participants 18 years of age or older who were scheduled for an elective AFOI because of an anticipated difficult airway. Participants received dexmedetomidine or control medications.
DATA COLLECTION AND ANALYSIS
Three review authors independently extracted data on study design, participants, interventions and outcomes. We assessed risk of bias using The Cochrane Collaboration's tool. We estimated risk ratios (RRs) or mean differences (MDs) with 95% confidence internals (CIs) for outcomes with sufficient data; for other outcomes, we performed a qualitative analysis.
MAIN RESULTS
We identified four randomized controlled trials (RCTs), which included 211 participants. The four trials compared dexmedetomidine with midazolam, fentanyl, propofol or a sodium chloride placebo, respectively. The trials showed low or unclear risk of bias primarily because information provided on allocation concealment and other potential sources of bias was inadequate. Owing to clinical heterogeneity and potential methodological heterogeneity, it was impossible to conduct a full meta-analysis. We described findings from individual studies or presented them in tabular form. Limited evidence was available for assessment of the outcomes of interest for this review. Results of the limited included trials showed that dexmedetomidine significantly reduced participants' discomfort with no significant differences in airway obstruction, low oxygen levels or treatment-emergent cardiovascular adverse events noted during AFOI compared with control groups. When the search was rerun (from May 2012 to November 2013), it was noted that four studies are awaiting assessment. We will deal with these studies when we update the review.
AUTHORS' CONCLUSIONS
Small, limited trials provide weak evidence to support dexmedetomidine as an option for patients with an anticipated difficult airway who undergo AFOI. The findings of this review should be further corroborated by additional controlled investigations.
Topics: Adrenergic alpha-2 Receptor Agonists; Anti-Anxiety Agents; Dexmedetomidine; Fentanyl; Humans; Hypnotics and Sedatives; Intubation, Intratracheal; Midazolam; Propofol; Randomized Controlled Trials as Topic; Wakefulness
PubMed: 24442817
DOI: 10.1002/14651858.CD009798.pub2 -
World Journal of Gastrointestinal... Aug 2020Patients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in...
BACKGROUND
Patients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in patients with cirrhosis is challenging.
AIM
To conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach.
METHODS
This systematic review and meta-analysis was conducted using the PRISMA guidelines. Electronic searches were performed using MEDLINE, EMBASE, Central Cochrane, LILACS databases. Only randomized control trials (RCTs) were included. The outcomes studied were procedure time, recovery time, discharge time, and adverse events (bradycardia, hypotension, and hypoxemia). The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials (RoB-2). Quality of evidence was evaluated by GRADEpro. The meta-analysis was performed using Review Manager.
RESULTS
The search yielded 3,576 records. Out of these, 8 RCTs with a total of 596 patients (302 in the propofol group and 294 in the midazolam group) were included for the final analysis. Procedure time was similar between midazolam and propofol groups (MD: 0.25, 95%CI: -0.64 to 1.13, = 0.59). Recovery time (MD: -8.19, 95%CI: -10.59 to -5.79, < 0.00001). and discharge time were significantly less in the propofol group (MD: -12.98, 95%CI: -18.46 to -7.50, < 0.00001). Adverse events were similar in both groups (RD: 0.02, 95%CI: 0-0.04, = 0.58). Moreover, no significant difference was found for bradycardia (RD: 0.03, 95%CI: -0.01 to 0.07, = 0.16), hypotension (RD: 0.03, 95%CI: -0.01 to 0.07, = 0.17), and hypoxemia (RD: 0.00, 95%CI: -0.04 to 0.04, = 0.93). Five studies had low risk of bias, two demonstrated some concerns, and one presented high risk. The quality of the evidence was very low for procedure time, recovery time, and adverse events; while low for discharge time.
CONCLUSION
This systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events. These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.
PubMed: 32879659
DOI: 10.4253/wjge.v12.i8.241 -
The Cochrane Database of Systematic... Feb 2017This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 6, 2015).Failure to respond to antiepileptic drugs in... (Review)
Review
BACKGROUND
This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 6, 2015).Failure to respond to antiepileptic drugs in patients with uncontrolled seizure activity such as refractory status epilepticus (RSE) has led to the use of anaesthetic drugs. Coma is induced with anaesthetic drugs to achieve complete control of seizure activity. Thiopental sodium and propofol are popularly used for this purpose. Both agents have been found to be effective. However, there is a substantial lack of evidence as to which of the two drugs is better in terms of clinical outcomes.
OBJECTIVES
To compare the efficacy, adverse effects, and short- and long-term outcomes of refractory status epilepticus (RSE) treated with one of the two anaesthetic agents, thiopental sodium or propofol.
SEARCH METHODS
We searched the Cochrane Epilepsy Group Specialized Register (16 August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 16 August 2016), MEDLINE (Ovid, 1946 to 16 August 2016), ClinicalTrials.gov (16 August 2016), and the South Asian Database of Controlled Clinical Trials (16 August 2016). Previously we searched IndMED, but this was not accessible at the time of the latest update.
SELECTION CRITERIA
All randomised controlled trials (RCTs) or quasi-RCTs (regardless of blinding) assessing the control of RSE using either thiopental sodium or propofol in patients of any age and gender.
DATA COLLECTION AND ANALYSIS
Two review authors screened the search results and reviewed the abstracts of relevant and eligible trials before retrieving the full-text publications.
MAIN RESULTS
One study with a total of 24 participants was available for review. This study was a small, single-blind, multicentre trial studying adults with RSE receiving either propofol or thiopental sodium for the control of seizure activity. This study was terminated early due to recruitment problems. For our primary outcome of total control of seizures after the first course of study drug, there were 6/14 patients versus 2/7 patients in the propofol and thiopental sodium groups, respectively (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.40 to 5.61, low quality evidence). Mortality was seen in 3/14 patients versus 1/7 patients in the propofol and thiopental sodium groups, respectively (RR 1.50, 95% CI 0.19 to 11.93, low quality evidence). Our third primary outcome of length of ICU stay was not reported. For our secondary outcomes of adverse events, infection was seen in 7/14 patients versus 5/7 patients in the propofol and thiopental sodium groups, respectively (RR 0.70; 95% CI 0.35 to 1.41). Hypotension during administration of study drugs and requiring use of vasopressors was seen in 7/14 patients versus 4/7 patients in the propofol and thiopental sodium groups, respectively (RR 0.87; 95% CI 0.38 to 2.00). The other severe complication noted was non-fatal propofol infusion syndrome in one patient. Patients receiving thiopental sodium required more days of mechanical ventilation when compared with patients receiving propofol: (median (range) 17 days (5 to 70 days) with thiopental sodium versus four days (2 to 28 days) with propofol). At three months there was no evidence of a difference between the drugs with respect to outcome measures such as control of seizure activity and functional outcome.
AUTHORS' CONCLUSIONS
Since the last version of this review we have found no new studies.There is a lack of robust, randomised, controlled evidence to clarify the efficacy of propofol and thiopental sodium compared to each other in the treatment of RSE. There is a need for large RCTs for this serious condition.
Topics: Adult; Anesthetics, Intravenous; Anticonvulsants; Drug Resistant Epilepsy; Humans; Propofol; Respiration, Artificial; Status Epilepticus; Thiopental
PubMed: 28155226
DOI: 10.1002/14651858.CD009202.pub4 -
Neurotrauma Reports 2020Intravenous propofol, fentanyl, and midazolam are utilized commonly in critical care for metabolic suppression and anesthesia. The impact of propofol, fentanyl, and...
Intravenous propofol, fentanyl, and midazolam are utilized commonly in critical care for metabolic suppression and anesthesia. The impact of propofol, fentanyl, and midazolam on cerebrovasculature and cerebral blood flow (CBF) is unclear in traumatic brain injury (TBI) and may carry important implications, as care is shifting to focus on cerebrovascular reactivity monitoring/directed therapies. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/CBF effects of propofol, fentanyl, and midazolam in human patients with moderate/severe TBI and animal models with TBI. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to May 2020 was performed. All articles were included pertaining to the administration of propofol, fentanyl, and midazolam, in which the impact on CBF/cerebral vasculature was recorded. We identified 14 studies: 8 that evaluated propofol, 5 that evaluated fentanyl, and 2 that evaluated midazolam. All studies suffered from significant limitations, including: small sample size, and heterogeneous design and measurement techniques. In general, there was no significant change seen in CBF/cerebrovascular response to administration of propofol, fentanyl, or midazolam during experiments where PCO and mean arterial pressure (MAP) were controlled. This review highlights the current knowledge gap surrounding the impact of commonly utilized sedative drugs in TBI care. This work supports the need for dedicated studies, both experimental and human-based, evaluating the impact of these drugs on CBF and cerebrovascular reactivity/response in TBI.
PubMed: 33251530
DOI: 10.1089/neur.2020.0040 -
Journal of Pain Research 2024To systematically evaluate the effectiveness and safety of ketamine in preventing propofol injection pain (PIP). (Review)
Review
PURPOSE
To systematically evaluate the effectiveness and safety of ketamine in preventing propofol injection pain (PIP).
PATIENTS AND METHODS
The electronic databases including PubMed, Embase, Web of Science, and Cochrane Library were searched from their inception until 2 August 2023. Randomized controlled trials (RCT) comparing ketamine with placebo or other interventions to alleviate PIP in adults were included. Fixed-effects or random-effects models were used to calculate pooled risk ratios (RR) and corresponding 95% confidence intervals (CI) based on the heterogeneity of the studies included.
RESULTS
Thirteen RCTs involving 2105 patients were included. In terms of reducing the incidence of PIP, ketamine is more effective than placebo (RR = 0.43, 95% CI = [0.34, 0.55], < 0.00001), lidocaine (RR = 0.70, 95% CI = [0.55, 0.90], = 0.005), dexmedetomidine (RR = 0.52, 95% CI = [0.40, 0.66], < 0.00001), and thiopental (RR = 0.25, 95% CI = [0.08, 0.83], = 0.02). In reducing the incidence of severe PIP, ketamine is superior to placebo (RR = 0.12, 95% CI = [0.08, 0.19], < 0.00001), and lidocaine (RR = 0.34, 95% CI = [0.21, 0.56], < 0.0001), except dexmedetomidine (RR = 0.20, 95% CI = [0.04, 1.13], = 0.07), and thiopental (RR = 0.33, 95% CI = [0.04, 3.10], = 0.33). Compared with mixed injection, separate injection of ketamine and propofol showed no significant difference in the incidence of PIP (RR = 0.96, 95% CI = [0.31, 3.00], = 0.95) and severe PIP (RR = 1.19, 95% CI = [0.07, 21.29], = 0.90). Based solely on the reports from the studies included, subanesthetic doses of ketamine are generally safe in preventing PIP.
CONCLUSION
A subanesthetic dose of ketamine can effectively and safely reduce the incidence of PIP and severe PIP in adults, and is more effective than lidocaine, dexmedetomidine, and thiopental.
REGISTRATION
PROSPERO CRD42023455093.
PubMed: 38318331
DOI: 10.2147/JPR.S440250 -
Scientific Reports Mar 2017Sedatives are commonly used for mechanically ventilated patients in intensive care units (ICU). However, a variety of sedatives are available and their efficacy and... (Meta-Analysis)
Meta-Analysis Review
Sedatives are commonly used for mechanically ventilated patients in intensive care units (ICU). However, a variety of sedatives are available and their efficacy and safety have been compared in numerous trials with inconsistent results. To resolve uncertainties regarding usefulness of these sedatives, we performed a systematic review and network meta-analysis. Randomized controlled trials comparing sedatives in mechanically ventilated ICU patients were included. Graph-theoretical methods were employed for network meta-analysis. A total of 51 citations comprising 52 RCTs were included in our analysis. Dexmedetomidine showed shorter MV duration than lorazepam (mean difference (MD): 68.7; 95% CI: 18.2-119.3 hours), midazolam (MD: 10.2; 95% CI: 7.7-12.7 hours) and propofol (MD: 3.4; 95% CI: 0.9-5.9 hours). Compared with dexmedetomidine, midazolam was associated with significantly increased risk of delirium (OR: 2.47; 95% CI: 1.17-5.19). Our study shows that dexmedetomidine has potential benefits in reducing duration of MV and lowering the risk of delirium.
Topics: Critical Care; Humans; Hypnotics and Sedatives; Intensive Care Units; Odds Ratio; Outcome Assessment, Health Care; Publication Bias; Respiration, Artificial
PubMed: 28322337
DOI: 10.1038/srep44979 -
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