Neuraxial anaesthesia for lower-limb revascularization.

BACKGROUND: Lower-limb revascularization is a surgical procedure that is performed to restore an adequate blood supply to the limbs. Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. Neuraxial anaesthesia is an anaesthetic technique that uses local anaesthetics next to the spinal cord to block nerve function. Neuraxial anaesthesia may lead to improved survival. This systematic review was originally published in 2010 and was first updated in 2011 and again in 2013. OBJECTIVES: To determine the rates of death and major complications associated with spinal and epidural anaesthesia as compared with other types of anaesthesia for lower-limb revascularization in patients aged 18 years or older who are affected by obstruction of lower-limb vessels. SEARCH METHODS: The original review was published in 2010 and was based on a search until June 2008. In 2011 we reran the search until February 2011 and updated the review. For this second updated version of the review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL and Web of Science from 2011 to April 2013. SELECTION CRITERIA: We included randomized controlled trials comparing neuraxial anaesthesia (spinal or epidural anaesthesia) versus other types of anaesthesia in adults (18 years or older) with arterial vascular obstruction undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and assessed trial quality. We pooled the data on mortality, myocardial infarction, lower-limb amputation and pneumonia. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS: In this updated version of the review, we found no new studies that met our inclusion criteria. We included in this review four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years, and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years, and 66% were men. Four studies had an unclear risk of bias. No difference was observed between participants allocated to neuraxial or general anaesthesia in mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants; four trials), myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants; four trials), and lower-limb amputation (OR 0.84, 95% CI 0.38 to 1.84; 465 participants; three trials). Pneumonia was less common after neuraxial anaesthesia than after general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants; two trials). Evidence was insufficient for cerebral stroke, duration of hospital stay, postoperative cognitive dysfunction, complications in the anaesthetic recovery room and transfusion requirements. No data described nerve dysfunction, postoperative wound infection, patient satisfaction, postoperative pain score, claudication distance and pain at rest. AUTHORS' CONCLUSIONS: Available evidence from included trials that compared neuraxial anaesthesia with general anaesthesia was insufficient to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation, or less common outcomes.

Neuraxial anaesthesia for lower-limb revascularization.

BACKGROUND: Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. The type of anaesthesia used during lower-limb revascularization may affect the risks of both good and bad outcomes. OBJECTIVES: To determine the rates of death and major complications with spinal and epidural anaesthesia compared with other types of anaesthesia for lower-limb revascularization. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2008, Issue 2); MEDLINE (1960 to 10th June 2008); EMBASE (1982 to 10th June 2008); LILACS (1982 to 10th June 2008); CINAHL (1982 to 10th June 2008) and ISI Web of Science (1900 to 10th June 2008). SELECTION CRITERIA: We included randomized controlled trials that evaluated the effect of anaesthetic type in adults aged 18 years or older undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS: Two authors independently performed the data extraction. Primary outcomes were mortality, cerebral stroke, myocardial infarction, nerve dysfunction and postoperative lower-limb amputation rate. The secondary outcome analysed was pneumonia. We judged risk of bias with four criteria: randomization and allocation concealment methods, blinding of treatment and outcome assessment and completeness of follow up. To assess heterogeneity we used the I(2) statistic. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS: We included four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years and 66% were men. There was no difference between participants allocated to neuraxial or general anaesthesia in: mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants, four trials); myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants, four trials); and lower-limb amputation rate (OR 0.84, 95% CI 0.38 to 1.84; 465 participants, three trials). Pneumonia was less common following neuraxial anaesthesia than general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants, two trials). AUTHORS' CONCLUSIONS: There was insufficient evidence available from the included trials that compared neuraxial anaesthesia with general anaesthesia to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation or less common outcomes.

Incidence of lower limbs deep vein thrombosis after open and laparoscopic gastric bypass: a prospective study.

BACKGROUND: Lower limbs deep vein thrombosis (DVT) and pulmonary embolism (PE) are major causes of morbidity and mortality and are even higher in bariatric patients. The longer operative time and higher immobility in these patients increase the DVT risk. Although deaths after bariatric surgery have been reported, there is no consensus regarding the prophylaxis of DVT. This study's objective is to determine the incidence of lower limbs DVT in patients submitted to Roux-en-Y-gastric bypass (RYGBP) under prophylaxis by enoxaparin. METHODS: Patients with body mass index (BMI) equal to or higher than 35 kg/m(2) who submitted to RYGBP by laparotomy or laparoscopy using 40 mg/day of enoxaparin for 15 days were recruited between October 2004 and August 2005. Individuals with previous DVT and heparin allergy were excluded. Patients were tested for DVT using color Doppler ultrasound performed before surgery and on the second and fifth weeks after surgery. RESULTS: The study population included 136 patients, with 126 concluding the protocol. There were 79% (100/126) of female patients aged 19 to 65 years old, with mean of 40 years SD = 10 and BMI between 35 and 61 kg/m(2), mean of 43 kg/m(2) (SD = 5). All patients who submitted to RYGBP were divided as 55% (69/126) by laparoscopy and 45% (57/126) by laparotomy. The incidence rate of lower limbs DVT was 0.79% (1/126). CONCLUSION: The low incidence rate of DVT found in our study suggests that obesity might not be a major risk factor for venous thromboembolism in patients submitted to RYGBP.

Colony-stimulating factors for chemotherapy-induced febrile neutropenia: a meta-analysis of randomized controlled trials.

PURPOSE: Current treatment for febrile neutropenia (FN) includes hospitalization for evaluation, empiric broad-spectrum antibiotics, and other supportive care. Clinical trials have reported conflicting results when studying whether the colony-stimulating factors (CSFs) improve outcomes in patients with FN. This Cochrane Collaboration review was undertaken to further evaluate the safety and efficacy of the CSFs in patients with FN. METHODS: An exhaustive literature search was undertaken including major electronic databases (CANCERLIT, EMBASE, LILACS, MEDLINE, SCI, and the Cochrane Controlled Trials Register). All randomized controlled trials that compare CSFs plus antibiotics versus antibiotics alone for the treatment of established FN in adults and children were sought. A meta-analysis of the selected studies was performed. RESULTS: More than 8,000 references were screened, with 13 studies meeting eligibility criteria for inclusion. The overall mortality was not influenced significantly by the use of CSF (odds ratio [OR] = 0.68; 95% CI, 0.43 to 1.08; P = .1). A marginally significant result was obtained for the use of CSF in reducing infection-related mortality (OR = 0.51; 95% CI, 0.26 to 1.00; P = .05). Patients treated with CSFs had a shorter length of hospitalization (hazard ratio [HR] = 0.63; 95% CI, 0.49 to 0.82; P = .0006) and a shorter time to neutrophil recovery (HR = 0.32; 95% CI, 0.23 to 0.46; P < .00001). CONCLUSION: The use of the CSFs in patients with established FN caused by cancer chemotherapy reduces the amount of time spent in hospital and the neutrophil recovery period. The possible influence of the CSFs on infection-related mortality requires further investigation.

Clinical value of preoperative mechanical bowel cleansing in elective colorectal surgery: a systematic review.

PURPOSE: This study was designed to establish scientific evidence for and clinical results of preoperative mechanical bowel cleansing before elective colorectal surgery. METHODS: Systematic literature searches in electronic databases, conference proceedings, and hand searches of reference lists of previously retrieved literature without any language restrictions were used. Only randomized trials were included. A quality assessment of each retrieved trial was performed. Outcome measures were surgical infections, mortality, and anastomotic dehiscence. Meta-analyses of the selected trials were performed using the Peto odds ratio. RESULTS: The results of each outcome were as follows. 1). Overall anastomotic leakage-six studies: 5.5 percent with cleansing compared with 2.9 percent without cleansing; odds ratio 1.94, 95 percent confidence interval: 1.09 to 3.43 (P = 0.02). 2). Peritonitis-three studies: 5.1 percent with cleansing compared with 2.8 percent without cleansing; odds ratio 1.90, 95 percent confidence interval: 0.78 to 4.64 (not significant). 3). Wound infection-six studies: 7.4 percent with cleansing compared with 5.7 percent without cleansing; odds ratio 1.34, 95 percent confidence interval: 0.85 to 2.13 (not significant). CONCLUSIONS: There is no evidence in the literature for beneficial effects from the use of bowel cleansing before elective colorectal surgery. Cleansing seems to be associated with an increased risk of more anastomotic dehiscence. Further studies stratifying between rectal and colonic surgery are warranted.