Analgesic Effects of Regional Analgesic Techniques in Pediatric Inguinal Surgeries: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Various regional analgesic techniques have been used in pediatric inguinal surgery to facilitate postoperative recovery. However, each technique's relative performance was undetermined owing to the lack of quantitative analysis. METHODS: We systematically searched MEDLINE, Cochrane Library, EMBASE, and Web of Science for randomized controlled trials that compared regional analgesia in pediatric inguinal surgeries. After critical study screening and selection, a random-effects network meta-analysis was performed. The primary outcome was the time to the first rescue analgesic after surgery, and the secondary outcomes were the number of patients requiring rescue analgesics after surgery, postoperative pain scores, incidence of postoperative nausea and vomiting, and other adverse events. RESULTS: This network meta-analysis included 69 randomized controlled trials (4636 patients) that compared 10 regional analgesic techniques. Our study revealed that the quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic after pediatric inguinal surgeries, by 7.7 hours (95% confidence interval [CI], 5.0-10.3) and 6.0 hours (95% CI, 3.9-8.2) when compared with the control group, respectively. In the subgroup involving only inguinal hernia repair, the quadratus lumborum block significantly prolonged the time to the first rescue analgesic than all other regional analgesics. In contrast, in the subgroup involving orchidopexies, only the caudal block significantly prolonged the time to the first rescue analgesic when compared with the control group (4.1 hours; 95% CI, 0.7-7.5). Wound infiltration and landmark-based ilioinguinal-iliohypogastric block had relatively poor analgesic effects than other regional analgesics. No serious adverse effects related to the regional analgesic techniques were reported in any of the included studies. CONCLUSIONS: The quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic and the least rescue analgesic requirement for pediatric inguinal surgeries. Specifically, the quadratus lumborum block had the longest analgesic duration in inguinal hernia repair, and the caudal block was found to be the only regional analgesia that extended the time to the first rescue analgesic in pediatric orchidopexy. Most included randomized controlled trials had some concern or a high risk of bias, and future studies should focus on providing high-quality evidence to further clarify the analgesic effects of regional analgesia for pediatric inguinal surgeries.

Efficacy and safety of intravenous dexmedetomidine as an adjuvant to general anesthesia in gynecological surgeries: A systematic review and meta-analysis of randomized controlled trials.

This study investigated the efficacy and safety of intravenous dexmedetomidine as an adjuvant to general anesthesia in patients undergoing gynecological surgery. We systemically searched for randomized controlled trials (RCTs), and performed a meta-analysis on studies that met the inclusion criteria. The primary outcomes were postoperative nausea and vomiting (PONV), bradycardia, hypotension, and 24 h opioid consumption. The secondary outcomes include postoperative shivering, postoperative pain score, intraoperative anesthetic consumption, extubation time, postoperative sedation, and the time to first flatus. Twenty-five RCTs were included in this study. Meta-analysis showed that intravenous dexmedetomidine significantly reduced the risk of PONV (RR, 0.57 [0.47, 0.68]) and postoperative shivering (RR: 0.31 [0.22, 0.42]), 24 h opioid consumption (Mean Difference: - 4.85 mg [-8.60, -1.11]) and postoperative pain score within 24 h. However, these benefits were at the cost of increased bradycardia (RR, 3.21 [2.41, 4.28]) and hypotension (RR, 2.17 [1.50, 3.14]). Notably, no serious adverse effects were reported in any of the included studies. Thus, our study showed that intravenous dexmedetomidine provided significant antiemetic and anti-shivering effects and moderate analgesic effects in patients that underwent gynecological surgery. However, its benefits should be weighed against the significantly increased risk of bradycardia and hypotension.

Maternal and neonatal outcomes with the addition of intrathecal midazolam as an adjuvant to spinal anesthesia in cesarean delivery: A systematic review and meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: To determine the efficacy and safety, in terms of maternal and neonatal outcomes, of adding intrathecal midazolam to spinal anesthesia for cesarean delivery in healthy pregnant women. DESIGN: A meta-analysis of randomized controlled trials was conducted. PubMed, Cochrane Library, Embase, and Web of Science were searched manually, and citation screening was completed on May 20, 2021. SETTING: Most of the included data were collected in the operating room and postoperative recovery area. PATIENTS: A total of 1382 healthy parturients undergoing cesarean delivery with single-shot spinal anesthesia were recruited in 19 eligible randomized controlled trials. INTERVENTIONS: Single intrathecal midazolam adjuvant was compared to a control, with the local anesthetic dose in spinal anesthesia identical between the intervention and control groups. MEASUREMENTS: The primary outcomes were time to first analgesic use, maternal adverse effects, and neonatal Apgar scores at 1 and 5 min. The secondary outcomes were the onset and duration of the sensory and motor blocks. MAIN RESULTS: Adjuvant intrathecal midazolam prolonged the time to the first analgesic (mean difference [MD]: 59.96 min, 95% confidence interval [CI]: [23.12, 96.79]) and decreased perioperative maternal nausea and/or vomiting (odds ratio [OR], 0.28; 95% CI: [0.17, 0.45]). However, more sedation events were observed with midazolam (OR, 3.93; 95% CI: [1.12, 13.78]). There was no significant difference in the neonatal Apgar scores at 1 or 5 min (MD: -0.29, 95% CI: [-0.61, 0.03]; MD: -0.00, 95% CI: [-0.11, 0.1], respectively). Intrathecal midazolam also shortened sensory and motor block onset by less than 1 min and prolonged sensory block duration but had no significant effect on motor block duration. CONCLUSIONS: Current evidence indicates that intrathecal midazolam, as an adjuvant to spinal anesthesia, provides modest analgesic and significant antiemetic effects at the cost of more sedation events in cesarean delivery patients. The neonatal Apgar score was not affected by intrathecal midazolam administration. However, more objective, sensitive, and long-term measurements of neonatal safety and maternal neurological effects should be performed in the future.

Comparison of the Efficacy of Single-Injection Regional Analgesia Techniques for Total Abdominal Hysterectomy: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Single-injection regional analgesia techniques can provide effective analgesia for abdominal hysterectomy. However, few randomized controlled trials (RCTs) have directly compared these techniques for total abdominal hysterectomy (TAH), and the best strategy remains unknown. OBJECTIVES: In this network meta-analysis, we compared the analgesic efficacy of single-injection regional analgesia techniques in patients who underwent TAH. STUDY DESIGN: A systematic review and network meta-analysis. METHODS: We searched the PubMed, Embase, Cochrane, and CINAHL databases for relevant trials from inception until April 2022. RCTs that examined single-injection regional analgesia techniques for TAH were included. Random-effects network meta-analyses were performed using the frequentist approach. The primary outcome was 24-hour cumulative morphine equivalent consumption. The secondary outcomes were pain scores, time to first request for rescue analgesia, and rates of postoperative nausea and vomiting (PONV). RESULTS: In total, 36 RCTs were included. Network meta-analyses indicated that the erector spinae plane block provided superior analgesia in terms of reduced morphine consumption, low PONV incidence, and longer time to first analgesia request. Moreover, compared with control (i.e., sham or placebo), the quadratus lumborum block provided superior analgesia in terms of time to first analgesia request and resting pain scores. LIMITATIONS: (1) Few studies have examined single-injection regional analgesia techniques other than the transversus abdominis plane block (TAPB) and wound infiltration, leading to a few indirect effect estimates. (2) Heterogeneity existed due to analgesic type/dose, plane block timing, and injection site. (3) Objective outcomes, such as length of hospital stay, were lacking; most studies only included the patient-reported subjective pain score. CONCLUSION: Single-injection blocks are effective analgesic techniques for TAH. Among them, the erector spinae plane block and quadratus lumborum block seem to have superior effects. Further studies should evaluate techniques other than TAPB and wound infiltration to draw definitive conclusions.

Safety of two common laparoscopic inguinal herniorrhaphy approaches: an updated systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Previous evidence indicated that total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) are advantageous in efficacy of inguinal herniorrhaphy. Therefore, our aim in this study was to evaluate the association of the two laparoscopic approaches on safety of inguinal herniorrhaphy. METHODS: In this update study, we searched the Cochrane Library, EMBASE, PubMed, Scopus, and Web of Science and identified randomized clinical trials comparing complications in TEP and TAPP herniorrhaphy. We mainly used Peto odds ratio with 95% confidence interval (CI) for meta-analysis because of zero-cell. RESULTS: Fourteen eligible trials recruited 659 and 682 patients in TEP and TAPP respectively. In overall pooling, although TEP had a higher seroma rate than TAPP (Peto odds ratio =2.01; 95% CI, 1.39 to 2.91), it had a lower scrotal/cord edema rates at immediate postoperative (Peto odds ratio =0.22; 95% CI, 0.09 to 0.57) and 1 week after inguinal hernia repair (Peto odds ratio =0.58; 95% CI, 0.37 to 0.91) than TAPP. CONCLUSIONS: TEP and TAPP have their own advantages in inguinal herniorrhaphy. TAPP was associated with a lower seroma rate, and TEP was associated with a lower edema rate. Therefore, shared decision-making on laparoscopic inguinal herniorrhaphy with TEP and TAPP is still needed.