Association of scalp block with intraoperative hemodynamic profiles and postoperative pain outcomes at 24-48 hours following craniotomy: An updated systematic review and meta-analysis of randomized controlled studies.

BACKGROUND: Despite the demonstrated analgesic efficacy of scalp block (SB) during the immediate postoperative period, the impact of SB on pain outcomes at postoperative 24 and 48 h in adults receiving craniotomy remains unclear. METHODS: The databases of Medline, Embase, and Cochrane Central Register were searched from inception to January 2022 for available randomized controlled trials (RCTs). The primary outcome was the severity of pain at postoperative 24 and 48 h, while the secondary outcomes included morphine consumption, hemodynamic profiles after surgical incision and in the postanesthesia care unit (PACU), and risk of postoperative nausea/vomiting (PONV). RESULTS: Meta-analysis of 12 studies revealed a lower pain score [MD = -0.83, p = 0.03, 375 patients, certainty of evidence (COE): low] and morphine consumption (MD = -9.21 mg, p = 0.03, 246 patients, COE: low) at postoperative 24 h, while there were no differences in these pain outcomes at postoperative 48 h (COE: low). The use of SB significantly decreased intraoperative heart rate (MD = -10.9 beats/min, p < 0.0001, 189 patients, COE: moderate) and mean blood pressure (MD = -13.02 mmHg, p < 0.00001, 189 patients, COE: moderate) after surgical incision, but these hemodynamic profiles were comparable in both groups in the PACU setting. There was also no difference in the risk of PONV between the two groups (RR = 0.78, p = 0.2, 299 patients, COE: high). CONCLUSION: This meta-analysis demonstrated that scalp block not only provided hemodynamic stability immediately after surgical incision but was also associated with a lower pain score and morphine consumption at postoperative 24 h. Further studies are needed for elucidation of its findings.

Effect of Intraoperative Phrenic Nerve Infiltration on Postoperative Ipsilateral Shoulder Pain After Thoracic Surgeries: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

OBJECTIVES: This meta-analysis was aimed at investigating the effectiveness and safety of phrenic nerve infiltration (PNI) against ipsilateral shoulder pain (ISP) after thoracic surgery. DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING: Operating room. PARTICIPANTS: Patients undergoing thoracic surgery. INTERVENTIONS: PNI. MEASUREMENTS AND MAIN RESULTS: MEDLINE, Cochrane Library, and EMBASE databases were searched from inception through December 2021. The primary outcome was the overall incidence of ISP, with secondary outcomes including incidence and severity of ISP at postoperative 6, 24, and 48 hours. Six RCTs involving 482 patients undergoing thoracic surgery were included. Pooled results found a significantly lower incidence of overall ISP in patients with PNI (ie, 23.6%) compared to those without (ie, 53.2%; risk ratio: 0.46, 95% confidence interval: 0.34-0.61; I2 = 19%; 6 RCTs; n = 474; certainty of evidence = high). At postoperative 6, 24, and 48 hours, there was also a significantly lower incidence of ISP in the PNI group than in the control group (certainty of evidence for all outcomes = high). Besides, the severity of ISP was lower in the PNI group at 6 (certainty of evidence = moderate) and 24 hours (certainty of evidence = high), with insufficient data for analysis at 48 hours because of only 1 trial. CONCLUSION: This meta-analysis showed that PNI not only reduced the incidence but also improved the severity of ipsilateral shoulder pain after thoracic surgery with a prophylactic effect lasting up to 48 hours. The limited number of included studies warrants further research to support these findings.

Efficacy of high-flow nasal oxygenation against peri- and post-procedural hypoxemia in patients with obesity: a meta-analysis of randomized controlled trials.

This meta-analysis aimed at investigating the efficacy of high-flow nasal oxygenation (HFNO) against hypoxemia in patients with obesity compared with conventional oxygenation therapy and non-invasive ventilation. Databases were searched from inception to August 2021. Studies involving peri- or post-procedural use of HFNO were included. The primary outcome was risk of hypoxemia, while the secondary outcomes included status of oxygenation and carbon dioxide elimination. Ten randomized controlled trials (RCTs) were included. We found that HFNO prolonged the safe apnea time at induction compared to control group [mean difference (MD) = 73.88 s, p = 0.0004; 2 RCTs] with no difference in risk of peri-procedural hypoxemia [relative risk (RR) = 0.91, p = 0.64; 4 RCTs], minimum SpO2 (MD = 0.09%, p = 0.95; 4 RCTs), PaO2 (MD = - 8.13 mmHg, p = 0.86; 3 RCTs), PaCO2 (MD = - 6.71%, p = 0.2; 2 RCTs), EtCO2 (MD = - 0.28 mmHg, p = 0.8; 4 RCTs) between the two groups. HFNO also did not improve postprocedural PaO2/FiO2 ratio (MD = 41.76, p = 0.58; 2 RCTs) and PaCO2 (MD = - 2.68 mmHg, p = 0.07; 2 RCTs). This meta-analysis demonstrated that the use of HFNO may be associated with a longer safe apnea time without beneficial impact on the risk of hypoxemia, oxygenation, and CO2 elimination in patients with obesity. The limited number of trials warranted further large-scale studies to support our findings.

Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies.

BACKGROUND: To investigate the efficacy of combined epidural anaesthesia/analgesia (EAA) against postoperative delirium/cognitive dysfunction (POD/POCD) in adults after major non-cardiac surgery under general anaesthesia (GA). METHODS: The databases of PubMed, Google Scholar, Embase and Cochrane Central Register were searched from inception to November 2021 for available randomised controlled trials (RCTs) that assessed the impact of EAA on risk of POD/POCD. The primary outcome was risk of POD/POCD, while the secondary outcomes comprised postoperative pain score, length of hospital stay (LOS), risk of complications, and postoperative nausea/vomiting (PONV). RESULTS: Meta-analysis of eight studies with a total of 2376 patients (EAA group: 1189 patients; non-EAA group: 1187 patients) revealed no difference in risk of POD/POCD between the EAA and the non-EAA groups [Risk ratio (RR): 0.68; 95% CI: 0.41 to 1.13, p = 0.14, I2 = 73%], but the certainty of evidence was very low. Nevertheless, the EAA group had lower pain score at postoperative 24 h [mean difference (MD): -1.49, 95% CI: -2.38 to -0.61; I2 = 98%; five RCTs; n = 476] and risk of PONV (RR = 0.73, 95% CI: 0.57 to 0.93, p = 0.01, I2 = 0%; three RCTs, 1876 patients) than those in the non-EAA group. Our results showed no significant impact of EAA on the pain score at postoperative 36-72 h, LOS, and risk of complications. CONCLUSION: This meta-analysis demonstrated that EAA had no significant impact on the incidence of POD/POCD in patients following non-cardiac surgery.

Analgesic efficacy and risk of low-to-medium dose intrathecal morphine in patients undergoing cardiac surgery: An updated meta-analysis.

Background: To evaluate the analgesic efficacy and risk of low-to-medium dose intrathecal morphine (ITM) (i.e., ≤0.5 mg) following cardiac surgery. Methods: Medline, Cochrane Library, Google scholar and EMBASE databases were searched from inception to February 2022. The primary outcome was pain intensity at postoperative 24 h, while the secondary outcomes included intravenous morphine consumption (IMC), extubation time, hospital/intensive care unit (ICU) length of stay (LOS), and ITM-associated side effects (e.g., respiratory depression). Subgroup analysis was performed on ITM dosage (low: <0.3 mg vs. medium: 0.3-0.5 mg). Results: Fifteen RCTs involving 683 patients published from 1988 to 2021 were included. Pooled results showed significantly lower postoperative 24-h pain scores [mean difference (MD) = -1.61, 95% confidence interval: -1.98 to -1.24, p < 0.00001; trial sequential analysis: sufficient evidence; certainty of evidence: moderate] in the ITM group compared to the controls. Similar positive findings were noted at 12 (MD = -2.1) and 48 h (MD = -1.88). Use of ITM was also associated with lower IMC at 24 and 48 h (MD: -13.69 and -14.57 mg, respectively; all p < 0.05) and early tracheal extubation (i.e., 48.08 min). No difference was noted in hospital/ICU LOS, and nausea/vomiting in both groups, but patients receiving ITM had higher risk of pruritus (relative risk = 2.88, p = 0.008). There was no subgroup difference in IMC except a lower pain score with 0.3-0.5 mg than <0.3 mg at postoperative 24 h. Respiratory depression events were not noted in the ITM group. Conclusion: Our results validated the analgesic efficacy of low-to-medium dose ITM for patients receiving cardiac surgery without increasing the risk of respiratory depression.

Impact of Opioid-Free Anesthesia on Analgesia and Recovery Following Bariatric Surgery: a Meta-Analysis of Randomized Controlled Studies.

This meta-analysis aimed at exploring the impact of opioid-free anesthesia (OFA) on pain score and opioid consumption in patients undergoing bariatric surgery (BS). Literature search identified eight eligible trials. Forest plot revealed a significantly lower pain score (mean difference (MD) = - 0.96, p = 0.0002; 318 patients), but not morphine consumption (MD = - 5.85 mg, p = 0.1; 318 patients) at postoperative 24 h in patients with OFA than in those without. Pooled analysis also showed a lower pain score (p = 0.002), morphine consumption (p = 0.0003) in the postanesthetic care unit, and risk of postoperative nausea/vomiting (p = 0.0003) in the OFA group compared to the controls. In conclusion, this meta-analysis demonstrated that opioid-free anesthesia improved pain outcomes immediately and at 24 h after surgery without a beneficial impact on opioid consumption at postoperative 24 h. KEY POINTS: • Roles of opioid-free anesthesia (OFA) in bariatric surgery (BS) were investigated. • Outcomes included postoperative pain score, opioid use, and nausea/vomiting risk. • OFA was associated with lower 24-h pain score but not opioid consumption. • Lower pain score and opioid consumption were noted in the postanesthetic care unit. • OFA correlated with a lower risk of postoperative nausea/vomiting.

Conscious sedation/monitored anesthesia care versus general anesthesia in patients undergoing transcatheter aortic valve replacement: A meta-analysis.

Background: To compare the merits and safety between conscious sedation/monitored anesthesia (CS/MAC) and general anesthesia (GA) for patients receiving transcatheter aortic valve replacement (TAVR). Measurements: Databases including EMBASE, MEDLINE, and the Cochrane Library databases were searched from inception to October 2022 to identify studies investigating the impact of CS/MAC on peri-procedural and prognostic outcomes compared to those with GA. The primary outcome was the association of CS/MAC with the risk of 30-day mortality, while secondary outcomes included the risks of adverse peri-procedural (e.g., vasopressor/inotropic support) and post-procedural (e.g., stroke) outcomes. Subgroup analysis was performed based on study design [i.e., cohort vs. matched cohort/randomized controlled trials (RCTs)]. Main results: Twenty-four studies (observational studies, n = 22; RCTs, n = 2) involving 141,965 patients were analyzed. Pooled results revealed lower risks of 30-day mortality [odd ratios (OR) = 0.66, p < 0.00001, 139,731 patients, certainty of evidence (COE): low], one-year mortality (OR = 0.72, p = 0.001, 4,827 patients, COE: very low), major bleeding (OR = 0.61, p = 0.01, 6,888 patients, COE: very low), acute kidney injury (OR = 0.71, p = 0.01, 7,155 patients, COE: very low), vasopressor/inotropic support (OR = 0.25, p < 0.00001, 133,438 patients, COE: very low), shorter procedure time (MD = -12.27 minutes, p = 0.0006, 17,694 patients, COE: very low), intensive care unit stay (mean difference(MD) = -7.53 h p = 0.04, 7,589 patients, COE: very low), and hospital stay [MD = -0.84 days, p < 0.00001, 19,019 patients, COE: very low) in patients receiving CS/MAC compared to those undergoing GA without significant differences in procedure success rate, risks of cardiac-vascular complications (e.g., myocardial infarction) and stroke. The pooled conversion rate was 3.1%. Results from matched cohort/RCTs suggested an association of CS/MAC use with a shorter procedural time and hospital stay, and a lower risk of vasopressor/inotropic support. Conclusion: Compared with GA, our results demonstrated that the use of CS/MAC may be feasible and safe in patients receiving TAVR. However, more evidence is needed to support our findings because of our inclusion of mostly retrospective studies. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022367417.

Sugammadex induced bradycardia and hypotension: A case report and literature review.

RATIONALE: There is evidence that sugammadex can facilitate extubation post-surgery and attenuate postoperative pulmonary complications resulting from postoperative residual neuromuscular blockade. However, it may induce adverse effects, including bronchospasm, laryngospasm, bradycardia, hypotension, and cardiac arrest. Here, we present a case of sugammadex-induced bradycardia and hypotension. PATIENT CONCERNS: An 82-year-old female received video-assisted thoracic surgery decortication and wedge resection of the lung for empyema. Post-surgery, she developed bradycardia, hypotension, hypoxia, and weakness. DIAGNOSES: The patient was suspected to have sugammadex-induced bradycardia, hypotension, hypoxia and weakness. INTERVENTIONS: The patient received immediate treatment with atropine (0.5 mg) for bradycardia. Glycopyrrolate (0.1 mg) and neostigmine (1 mg) were administered to improve the train-of-four (TOF) ratio. OUTCOMES: Following initial management, we observed improvement in the hemodynamics of the patient. She was discharged without any sequelae. LESSONS: Sugammadex-induced bradycardia or cardiac arrest are rare; however, anesthesiologists must consider the possibility of the occurrence of such events and initiate appropriate management measures. Immediate treatment with atropine and inotropic or vasopressors is warranted if the patient presents with bradycardia.

Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache: A meta-analysis.

BACKGROUND: This study aimed at assessing the therapeutic effectiveness of greater occipital nerve block (GONB) against postdural puncture headache (PDPH). METHODS: Studies investigating analgesic effects of GONB against PDPH in adults were retrieved from the MEDLINE, EMBASE, Google scholar, and Cochrane central databases from their inception dates to May, 2021. Pain score at postprocedural 24 hours was the primary endpoint, while secondary endpoints were pain score at postprocedural 1 hour and 12 hours as well as the risk of intervention failure. RESULTS: Of the 7 studies (randomized controlled trials [RCTs], n = 4; non-RCTs, n = 3) that recruited 275 patients, 2 investigated female patients undergoing cesarean section and the other 5 were conducted in both obstetric and nonobstetric settings. Pooled results showed a lower mean pain score at 24 hours (i.e., primary outcome) (mean difference [MD] = -2.66, 95%: CI: -3.98 to -1.33, P < .001; I2 = 97%, 6 studies), 1 hour (MD = -4.23, 95% confidence interval [CI]: -5.08 to -3.37, P < .00001; I2 = 86%, 5 studies), and 6 hours (MD = -2.78, 95% CI: -4.99 to -0.57, P = .01; I2 = 98%, 4 studies) in patients with GONB compared to those without. Trial sequential analysis supported the robustness of evidence at postprocedural 24 hours. The use of GONB also decreased the risk of intervention failure (relative ratio [RR] = 0.4, 95% CI: 0.19 to 0.82, P = .01; I2 = 96%, 6 studies, 277 patients). CONCLUSION: Our results suggested a therapeutic effect of greater occipital nerve block against postdural puncture headache up to postprocedural 24 hours. Further large-scale studies are warranted to evaluate its therapeutic benefit beyond the acute stage.

Serum sclerostin as an independent marker of peripheral artery disease in elderly persons.

Sclerostin is now being recognized as performing a multitude of physiological functions and is associated with coronary artery calcification. Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis in elderly persons. This study aimed to determine whether high serum sclerostin is associated with PAD in elderly persons. Blood samples were obtained from 68 participants in the study older than 65 years. Ankle-brachial index (ABI) values were measured using the automated oscillometric method (VaSera VS-1000). PAD was considered present if the left or right ABI values were less than 0.9 and included in the low ABI group. Serum sclerostin levels were measured using a commercial enzyme-linked immunosorbent assay kit. Among elderly participants, 13 (19.1%) were in the low ABI group. Elderly participants had higher statin use (P = 0.015), serum intact parathyroid hormone (P < 0.001), C-reactive protein (P = 0.027), and sclerostin (P < 0.001) levels in the low ABI group than in the normal ABI group. Serum sclerostin (odds ratio: 1.050, 95% confidence interval: 1.013-1.089, P = 0.008) was the independent predictor of PAD in elderly participants in multivariate logistic regression analysis. A high serum sclerostin level is a risk factor for PAD in the elderly.