Influence of different volumes and frequency of programmed intermittent epidural bolus in labor on maternal and neonatal outcomes: A systematic review and network meta-analysis.

STUDY OBJECTIVE: In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined. DESIGN: Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708). SETTINGS: Labor. PATIENTS: Pregnant patients. INTERVENTIONS: Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool. MAIN RESULTS: Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials. CONCLUSIONS: Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.

Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis.

BACKGROUND: Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery. METHODS: CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis. RESULTS: We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs. CONCLUSIONS: Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.

Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis.

PURPOSE: In labour, neuraxial analgesia is the standard in the provision of pain relief. However, the optimal mode of delivering epidural solution has not been determined, and some parturients may need an alternative to epidural analgesia. We sought to conduct a systematic review and network meta-analysis to compare continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, patient-controlled epidural bolus (PCEA), fentanyl patient-controlled analgesia (PCA), and remifentanil PCA, either alone or in combination. METHODS: We searched CENTRAL, CINAHL, Ovid Embase, Ovid Medline, and Web of Science for randomized controlled trials that included nulliparous and/or multiparous parturients in spontaneous or induced labour. The maintenance epidural solution had to include a low concentration local anesthetic and an opioid. Specific subgroups in the obstetric population such as preeclampsia were excluded. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes are presented as mean differences and odds ratios, respectively, with 95% confidence intervals. RESULTS: Overall, 73 trials were included. For the first coprimary outcome, the need for rescue analgesia, CEI was inferior to PIEB and PIEB + PCEA was superior to PCEA alone, with a low certainty of evidence given the presence of serious limitations and imprecision. The second coprimary outcome, the maternal satisfaction, was improved by PIEB + PCEA compared with CEI + PCEA and PCEA alone, with a low quality of evidence in view of the presence of serious limitations and imprecision. Fentanyl PCA increased the requirement for rescue analgesia and decreased maternal satisfaction relative to many methods of delivering epidural solution. In terms of secondary outcomes, PIEB increased analgesic efficacy compared with CEI, and PCEA reduced local anesthetic consumption at the expense of inferior analgesia relative to CEI and PIEB. PIEB + PCEA was superior to CEI + PCEA in regard to the pain score at 2 h and 4 h, consumption of local anesthetic, incidence of lower lower limb motor blockade and the rate of spontaneous vaginal delivery. Fentanyl and remifentanil PCA did not provide the same level of analgesia as all epidural methods, resulted in increasing analgesic ineffectiveness with time spent in labour, and predisposed to a higher incidence of side effects such as nausea and/or vomiting and sedation. Remifentanil PCA was superior to fentanyl PCA for analgesia at an early time point, and it increased the incidence of oxygen desaturation relative to other strategies of delivering epidural solution. CONCLUSIONS: Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects. We interpret the findings of our systematic review and network meta-analysis as suggesting PIEB + PCEA to be the optimal delivery mode of epidural solution. Nevertheless, the potential differing importance of the various maternal, fetal, and neonatal outcomes in determining which is optimal has not, to our knowledge, been elucidated yet. STUDY REGISTRATION: PROSPERO (CRD42021254978); registered 27 May 2021.

RéSUMé: OBJECTIF: Pendant le travail obstétrical, l'analgésie neuraxiale constitue la norme de soins pour soulager la douleur. Néanmoins, le mode optimal d'administration de la solution péridurale n'a pas été déterminé et certaines parturientes pourraient avoir besoin d'une alternative à l'analgésie péridurale. Nous avons cherché à réaliser une revue systématique et une méta-analyse en réseau pour comparer l'analgésie péridurale par perfusion continue (APPC), l'administration programmée de bolus périduraux (PIEB), l'APPC intégrée par ordinateur, l'analgésie péridurale contrôlée par la patiente (l'APCP), l'analgésie contrôlée par la patiente (ACP) de fentanyl et l'ACP de rémifentanil, soit seules ou en combinaison. MéTHODE: Nous avons effectué des recherches dans les bases de données CENTRAL, CINAHL, Ovid Embase, Ovid Medline et Web of Science pour en tirer les études randomisées contrôlées incluant des parturientes nullipares et/ou multipares en travail spontané ou induit. La solution péridurale de maintien devait inclure un anesthésique local à faible concentration et un opioïde. Des sous-groupes spécifiques dans la population obstétricale, comme par exemple les parturientes atteintes de prééclampsie, ont été exclus. Une méta-analyse en réseau a été réalisée à l'aide d'une méthode fréquentiste, et les résultats continus et dichotomiques sont présentés sous forme de différences moyennes et de rapports de cotes, respectivement, avec des intervalles de confiance à 95 %. RéSULTATS: Au total, 73 études ont été incluses. Concernant le premier critère d'évaluation coprincipal, soit le besoin d'analgésie de secours, l'APPC était inférieure à la PIEB, et la PIEB + APCP était supérieure à l'APCP seule, avec un faible niveau de fiabilité des données probantes compte tenu de la présence de limitations et d'imprécisions importantes. Le deuxième critère d'évaluation coprincipal, soit la satisfaction maternelle, a été amélioré avec la PIEB + APCP comparativement à l'APPC + APCP et à l'APCP seule, avec une faible qualité de données probantes compte tenu de la présence de limitations et d'imprécisions importantes. L'ACP à base de fentanyl a augmenté le besoin d'analgésie de secours et diminué la satisfaction maternelle par rapport à de nombreuses méthodes d'administration de la solution péridurale. En termes de critères d'évaluation secondaires, la PIEB a amélioré l'efficacité analgésique par rapport à l'APPC, et l'APCP a diminué la consommation d'anesthésiques locaux au détriment d'une analgésie inférieure par rapport à l'APPC et à la PIEB. La PIEB + APCP était supérieure à l'APPC + APCP en ce qui a trait aux scores de douleur à 2 h et 4 h, à la consommation d'anesthésiques locaux, à l'incidence de bloc moteur des membres inférieurs et au taux d'accouchement vaginal spontané. Les ACP de fentanyl et de rémifentanil n'ont pas fourni le même niveau d'analgésie que toutes les méthodes péridurales et ont entraîné une augmentation de l'inefficacité analgésique avec le temps passé en travail actif, en plus de prédisposer les parturientes à une incidence plus élevée d'effets secondaires tels que les nausées et/ou vomissements et la sédation. L'ACP de rémifentanil était supérieure à l'ACP de fentanyl en début d'analgésie mais a augmenté l'incidence de désaturation en oxygène par rapport aux stratégies de livraison de la solution péridurale. CONCLUSION: L'ACP à base d'opioïdes n'a pas fourni le même niveau d'analgésie que les méthodes péridurales, avec une incidence plus élevée d'effets secondaires. Nous interprétons les résultats de notre revue systématique et de notre méta-analyse en réseau comme suggérant que la PIEB + APCP constitue le mode d'administration optimal de la solution péridurale. Néanmoins, la différence potentielle en importance des divers devenirs maternels, fœtaux et néonataux pour déterminer la modalité optimale n'a pas encore été élucidée, à notre connaissance. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021254978); enregistrée le 27 mai 2021.

Influence of perioperative dexmedetomidine on the incidence of postoperative delirium in adult patients undergoing cardiac surgery.

BACKGROUND: Delirium is a common neurocognitive complication after cardiac surgery. The aim of this systematic review was to determine whether the administration of dexmedetomidine in the perioperative period decreases the incidence of postoperative delirium in adult patients undergoing cardiac surgery. METHODS: Central, CINAHL, Ovid Embase, Ovid Medline, and Web of Science databases were searched for RCTs of adult patients undergoing cardiac surgery where participants received i.v. dexmedetomidine or control in the perioperative period. The methods included systematic review, meta-analysis, and trial sequential analysis. The primary outcome was the incidence of postoperative delirium. Dichotomous outcomes were presented as risk ratio (RR) using the Mantel-Haenszel method, and continuous variables were presented as mean difference with the inverse variance method. RESULTS: Thirty trials, comprising 4090 patients, were included. With unselected inclusion of trials, dexmedetomidine vs control was associated with decreased incidence of postoperative delirium (12.4% vs 16.2%; RR=0.62; 95% confidence interval 0.44-0.86; P=0.005; I2=61%). If trials at high risk of bias were excluded, the incidence of postoperative delirium was not significantly different between groups (RR=0.71; 95% confidence interval 0.49-1.03; P=0.070; I2=58%). Postoperative delirium was not a reliably determined outcome across trials because of methodological and reporting limitations, including the heterogeneity of delirium diagnostic approach. Trial sequential analysis revealed that the optimal information size was not reached, and the Z-curve did not cross the trial sequential boundaries for benefit or futility. With respect to safety concerns, dexmedetomidine was not significantly associated with incident bradycardia or hypotension, or with the duration of mechanical ventilation. CONCLUSIONS: When trials at high risk of bias were excluded, the use of perioperative dexmedetomidine was not associated with decreased incidence of postoperative delirium. PROSPERO REGISTRATION NUMBER: CRD 42021252779.

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis.

BACKGROUND: Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis. METHODS: We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the  grading of recommendations, assessment, development, and evaluation system. RESULTS: Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr. CONCLUSIONS: Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr. TRIAL REGISTRATION: PROSPERO (CRD42021238916); registered 25 February 2021.

RéSUMé: CONTEXTE: La laparotomie médiane est associée à une douleur sévère. L'analgésie péridurale est la norme de soins établie, mais plusieurs modalités alternatives d'anesthésie régionale sont aujourd'hui disponibles. Dans cette revue systématique et méta-analyse en réseau, nous avons cherché à comparer les techniques d'anesthésie régionale continue et par injection unique. MéTHODE: Nous avons inclus les études randomisées contrôlées portant sur des adultes devant bénéficier d'une laparotomie avec une simple incision médiane sous anesthésie générale et qui ont reçu une anesthésie neuraxiale ou régionale pour la douleur. Une méta-analyse en réseau a été réalisée avec une méthode fréquentiste, et les résultats continus et dichotomiques ont été présentés sous forme de différences moyennes et de rapports de cotes, respectivement, avec des intervalles de confiance à 95 %. La qualité des données probantes a été évaluée avec le système GRADE (Grading of Recommendations Assessment, Development and Evaluation). RéSULTATS: Au total, 36 études portant sur 2056 patients ont été incluses. Aucune des études n'a évalué le bloc du plan des muscles érecteurs du rachis ou du carré des lombes. Les blocs de la gaine des grands droits et du plan des muscles transverses de l'abdomen ont été combinés en blocs de la paroi abdominale (BPA). Concernant le critère d'évaluation principal de score de douleur au repos à 24 heures, avec une différence minimale cliniquement pertinente (DMCP) de 1, l'analgésie péridurale était cliniquement supérieure au BPA de contrôle et par injection unique; l'analgésie péridurale était statistiquement mais non cliniquement supérieure à l'infiltration continue de la plaie; et aucune différence statistique ou clinique n'a été constatée entre le BPA de contrôle et par injection unique. Pour le deuxième critère d'évaluation principal portant sur la consommation cumulative de morphine à 24 heures, avec une DMCP de 10 mg, la péridurale et le BPA continu étaient cliniquement supérieurs au groupe contrôle; la péridurale était cliniquement supérieure à l'infusion continue de la plaie, au BPA par injection unique, à l'infiltration par injection unique de la plaie et à la rachianesthésie; et le BPA continu était cliniquement supérieur au BPA par injection unique. La qualité des données probantes était faible compte tenu d'importantes limites et d'imprécisions. De plus, le BPA par injection unique n'a fourni aucun avantage analgésique cliniquement pertinent au-delà de deux heures; l'infiltration continue de la plaie était cliniquement supérieure de 8 à 12 heures à l'infiltration de la plaie en injection unique; et une équivalence clinique a été observée entre la péridurale, le BPA continu et l'infiltration continue de la plaie en ce qui avait trait au score de douleur au repos, et entre la péridurale et l'infiltration continue de la plaie en ce qui touchait à la consommation cumulative de morphine à 48 heures. CONCLUSION: Les BPA par injection unique n'étaient cliniquement efficaces pour procurer une analgésie qu'au début de la période postopératoire. Les modalités d'anesthésie régionale continue ont augmenté la durée de l'analgésie par rapport aux modalités équivalentes par injection unique. L'analgésie péridurale est demeurée cliniquement supérieure aux techniques alternatives d'anesthésie régionale continue pendant les 24 premières heures, mais a atteint l'équivalence, au moins en ce qui concerne la douleur statique, avec les BPA et les infiltrations de lésions continus à 48 heures. Enregistrement de l'étude : PROSPERO (CRD42021238916); enregistrée le 25 février 2021.

Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis.

BACKGROUND: Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. METHODS: CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. RESULTS: Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat. CONCLUSIONS: Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.

Infiltration between the popliteal artery and the capsule of the knee (IPACK) block in knee surgery: a narrative review.

BACKGROUND: The infiltration between the popliteal artery and the capsule of the knee (IPACK) block has been described as an alternative analgesic strategy for knee pain. OBJECTIVE: Our aim was to perform a narrative review to examine the place and value that the IPACK block has in comparison to and in conjunction with other regional anesthesia modalities. EVIDENCE REVIEW: Following an extensive search of electronic databases, we included anatomical studies, letters, comparative observational studies, and non-randomized and randomized controlled trials that examined the IPACK block in relation to surgery on the knee under general or neuraxial anesthesia. FINDINGS: In all, 35 articles were included. Cadaveric studies demonstrated the potential for injected dye to spread to the nerves responsible for the innervation of the posterior as well as anteromedial and anterolateral aspects of the knee. Of the comparative observational studies (n=15) and non-randomized (n=1) and randomized controlled trials (n=13), 2 and 27 were conducted in the context of anterior cruciate ligament reconstruction and knee replacement surgery, respectively. The role of the IPACK block with each different permutation of regional anesthesia techniques was investigated by a small number of studies. Clinical studies, in the setting of knee replacement surgery, revealed variation in the manner in which the IPACK block was performed, and indicated the possible superiority of distal injection at the level of the femoral condyles for the management of posterior knee pain. Evidence suggested the following: the IPACK block in combination with single shot adductor canal block (ACB) may be beneficial for analgesic and functional outcomes; in conjunction with single shot or continuous ACB, the IPACK block might be superior to local infiltration analgesia (LIA); and functional outcomes may be improved with the supplementation of continuous ACB and LIA with the IPACK block. The IPACK block did not commonly result in the occurrence of foot drop. Relative to tibial nerve block (TNB), the IPACK block reduced the occurrence of foot drop and increased the proportion of patients who were able to be discharged on the third postoperative day. CONCLUSIONS: The IPACK block was potentially complementary to the ACB and might be preferable to the TNB as a motor-sparing regional anesthesia technique in knee surgery. Definitive recommendations were not reached in the presence of the heterogeneous and limited evidence base.

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients: A systematic review with meta-analysis and trial sequential analysis of randomised controlled trials.

BACKGROUND: Central neuraxial modalities can occasionally be challenging to perform, particularly if the underlying anatomy is altered or obscured. OBJECTIVES: To compare the efficacy, efficiency and the safety of preprocedural ultrasound to landmark palpation in the nonobstetric adult population. DESIGN: Systematic review of randomised controlled trials with meta-analysis and trial sequential analysis. DATA SOURCES: Systematic search of Central, CINAHL, Embase, Global Health, MEDLINE, Scopus and Web of Science to 13th February 2020. ELIGIBILITY CRITERIA: Randomised controlled trials of nonobstetric adult patients having diagnostic and/or therapeutic neuraxial procedures using standard preprocedural ultrasound interpreted by the operator as the intervention and conventional landmark palpation as the comparator. KEY DEFINITIONS: A skin puncture was defined as the insertion or reinsertion of the needle through the skin; needle redirection was the backward followed by the forward movement of the needle without its removal from the skin; first skin puncture referred to a single skin puncture with or without needle redirections; and first pass was a single skin puncture with no needle redirection. RESULTS: In all, 18 randomised controlled trials with 1800 patients were included. The first pass success rate was not different between landmark and ultrasound methods [risk ratio 1.46; 95% confidence interval (CI), 0.99 to 2.16; P = 0.06, I2 = 76%; moderate quality of evidence] and the trial sequential analysis demonstrated the futility of further randomisation of patients in modifying this finding. Preprocedural ultrasound increased the total time taken (mean difference 110.8 s; 95% CI, 31.01 to 190.65; P = 0.006; I2 = 96%; moderate quality of evidence). Subgroup analyses revealed no influence of the predicted difficulty of the neuraxial procedure on outcomes. Compared with the landmark method, ultrasound increased the first skin puncture success rate (risk ratio 1.36; 95% CI, 1.18 to 1.57; P < 0.001; I2 = 70%), and decreased the need for three or more skin punctures (risk ratio 0.46; 95% CI, 0.33 to 0.64; P < 0.001; I2 = 29%) and the number of needle redirections (mean difference -1.24; 95% CI, -2.32 to -0.17; P = 0.020; I2 = 83). The incidence of bloody tap was reduced with the use of ultrasound (risk ratio 0.61; 95% CI, 0.40 to 0.93; P = 0.020; I2 = 42%). CONCLUSIONS: The use of preprocedural ultrasound for neuraxial procedures in the nonobstetric adult population did not enhance the first pass success rate and increased the total time taken to a clinically insignificant extent. Improvement in secondary outcomes, including other markers of efficacy, should be interpreted with caution.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis.

STUDY OBJECTIVE: Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery. DESIGN: Systematic review and network meta-analysis. SETTING: Operating room, postoperative recovery room and ward. PATIENTS: Patients scheduled for breast surgery under general anesthesia. INTERVENTIONS: Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced. MEASUREMENTS: Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status. MAIN RESULTS: In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques. CONCLUSIONS: In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis.

PURPOSE: The incidence of difficult and failed intubation is higher in obstetrical patients than in the general population because of anatomic and physiologic changes in pregnancy. Videolaryngoscopy improves the success rate of intubation and reduces complications when compared with direct laryngoscopy in adults; however, it is not known whether this extends to obstetrical surgery. The aim of this study was to examine the efficacy, efficiency, and safety of videolaryngoscopy compared with direct laryngoscopy in obstetrics. SOURCE: Central, CINAHL, Embase, MEDLINE and Web of Science databases were searched from inception to 27 May 2020 with no restrictions. Inclusion criteria included randomized-controlled trials (RCTs), observational studies, case series, and case reports that reported the application of videolaryngoscopy to intubate the trachea in pregnant patients having general anesthesia. PRINCIPAL FINDINGS: Overall, four RCTs with 428 participants, nine observational studies, and 35 case reports/series with 100 participants were included. On meta-analysis of three trials, the co-primary outcomes of first-attempt success rate (risk ratio, 1.02; 95% confidence intervals [CI], 0.98 to 1.06; P = 0.29; I2 = 0%) and time to tracheal intubation (mean difference, 1.20 sec; 95% CI, -6.63 to 9.04; P = 0.76; I2 = 95%) demonstrated no difference between videolaryngoscopy and direct laryngoscopy in parturients without difficult airways. Observational studies and case reports underline the role of videolaryngoscopy as a primary choice when difficulty with tracheal intubation is expected or as a rescue modality in difficult or failed intubations. CONCLUSIONS: Evidence for the utility of videolaryngoscopy continues to evolve but supports its increased adoption in obstetrics where videolaryngoscopes should be immediately available for use as a first-line device. TRIAL REGISTRATION: PROSPERO (CRD42020189521); registered 6 July 2020.

RéSUMé: OBJECTIF: L'incidence des intubations difficiles et de leur échec est plus élevée chez les patientes obstétricales que dans la population générale en raison des changements anatomiques et physiologiques liés à la grossesse. Chez l'adulte, la vidéolaryngoscopie améliore le taux de réussite de l'intubation et réduit les complications par rapport à la laryngoscopie directe; cependant, nous ne savons pas si ces avantages s'étendent également à la population obstétricale. L'objectif de cette étude était d'examiner l'efficacité, l'efficience et la sécurité de la vidéolaryngoscopie par rapport à la laryngoscopie directe en obstétrique. SOURCE: Les bases de données Central, CINAHL, Embase, MEDLINE et Web of Science ont été recherchées de leur création jusqu'au 27 mai 2020 sans restriction. Les critères d'inclusion comprenaient les études randomisées contrôlées (ERC), les études observationnelles, les séries de cas et les présentations de cas rapportant l'application de la vidéolaryngoscopie pour intuber la trachée de patientes enceintes recevant une anesthésie générale. CONSTATATIONS PRINCIPALES: Quatre ERC comptant 428 participantes, neuf études observationnelles et 35 présentations/séries de cas comptant 100 participantes ont été incluses. En effectuant une méta-analyse de trois études, les critères d'évaluation co-primaires du taux de réussite de l'intubation à la première tentative (risque relatif, 1,02; intervalle de confiance [IC] 95 %, 0,98 à 1,06; P = 0,29; I2 = 0 %) et le temps jusqu'à l'intubation endotrachéale (différence moyenne, 1,20 sec; IC 95 %, -6,63 à 9,04; P = 0,76; I2 = 95 %) n'ont démontré aucune différence entre la vidéolaryngoscopie et la laryngoscopie directe chez les parturientes ne présentant pas de difficultés au niveau des voies aériennes. Les études observationnelles et les présentations de cas soulignent le rôle de la vidéolaryngoscopie comme premier choix lorsque des difficultés sont anticipées pour l'intubation endotrachéale ou comme modalité de sauvetage dans les cas d'intubations difficiles ou ratées. CONCLUSION: Les données probantes concernant l'utilité de la vidéolaryngoscopie continuent d'évoluer mais appuient son adoption accrue en obstétrique, où des vidéolaryngoscopes devraient être immédiatement disponibles pour être utilisés comme dispositif de première ligne. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42020189521); enregistrée le 6 juillet 2020.

Carbetocin compared with oxytocin in non-elective Cesarean delivery: a systematic review, meta-analysis, and trial sequential analysis of randomized-controlled trials.

PURPOSE: Carbetocin has been shown to reduce the requirement for additional uterotonics in women exclusively undergoing elective Cesarean delivery (CD). The aim of this review was to determine whether this effect could also be demonstrated in the setting of non-elective CD. METHODS: Medline, Embase, CINAHL, Web of Science and Cochrane databases were searched for randomized-controlled trials (RCTs) in any language comparing carbetocin to oxytocin. Studies with data on women undergoing non-elective CD, where carbetocin was compared with oxytocin, were included. The primary outcome was the need for additional uterotonics. Secondary outcomes included incidence of blood transfusion, estimated blood loss (mL), incidence of postpartum hemorrhage (PPH; > 1000 mL) and mean hemoglobin drop (g·dL-1 RESULTS: Five RCTs were included, with a total of 1,214 patients. The need for additional uterotonics was reduced with carbetocin compared with oxytocin (odds ratio, 0.30; 95% CI, 0.11 to 0.86; I2, 90.60%). Trial sequential analysis (TSA) confirmed that the information size needed to show a significant reduction in the need for additional uterotonics had been exceeded. No significant differences were shown with respect to any of the secondary outcomes, but there was significant heterogeneity between the studies. CONCLUSIONS: Carbetocin reduces the need for additional uterotonics in non-elective CD compared with oxytocin. TSA confirmed that this analysis was appropriately powered to detect the pooled estimated effect. Further trials utilizing consistent core outcomes are needed to determine an effect on PPH. TRIAL REGISTRATION: PROSPERO CRD42019147256, registered 13 September 2019.

RéSUMé: OBJECTIF: Il a été démontré que la carbétocine réduisait les besoins en utérotoniques supplémentaires exclusivement chez les femmes subissant un accouchement par césarienne planifié. L'objectif de ce compte rendu était de déterminer si cela pouvait également être démontré dans le cas d'un accouchement par césarienne non planifié. MéTHODE: Les bases de données Medline, Embase, CINAHL, Web of Science et Cochrane ont été passées en revue pour en extraire les études randomisées contrôlées (ERC), toutes langues confondues, comparant la carbétocine à l'ocytocine. Les études comportant des données concernant des femmes subissant un accouchement par césarienne non planifié et comparant la carbétocine à l'ocytocine ont été incluses. Le critère d'évaluation principal était le besoin d'utérotoniques supplémentaires. Les critères secondaires comprenaient l'incidence de transfusion sanguine, la perte de sang estimée (mL), l'incidence d'hémorragie postpartum (HPP; > 1000 mL) et la baisse moyenne du taux d'hémoglobine (g·dL−1). RéSULTATS: Cinq ERC ont été retenues, incluant 1214 patientes au total. Les besoins en utérotoniques supplémentaires étaient plus faibles lors de l'utilisation de carbétocine par rapport à l'ocytocine (rapport de cotes, 0,30; IC 95 %, 0,11 à 0,86; I2, 90,60 %). L'analyse séquentielle des essais a confirmé que la taille des informations démontrant une réduction significative du besoin d'utérotoniques supplémentaires avait été dépassée. Aucune différence significative n'a été démontrée en ce qui touchait nos critères d'évaluation secondaires, mais l'hétérogénéité des études était considérable. CONCLUSION: La carbétocine réduit le besoin d'utérotoniques supplémentaires lors d'un accouchement par césarienne non planifié comparativement à l'ocytocine. L'analyse séquentielle des essais a confirmé que cette analyse disposait de suffisamment de puissance pour détecter l'effet estimé pondéré. Des études supplémentaires portant sur des critères constants sont nécessaires afin de déterminer un effet sur l'HPP. ENREGISTREMENT DE L'éTUDE: PROSPERO CRD42019147256, enregistrée le 13 septembre 2019.

Impact of parallel processing of regional anesthesia with block rooms on resource utilization and clinical outcomes: a systematic review and meta-analysis.

Block rooms allow parallel processing of surgical patients with the purported benefits of improving resource utilization and patient outcomes. There is disparity in the literature supporting these suppositions. We aimed to synthesize the evidence base for parallel processing by conducting a systematic review and meta-analysis. A systematic search was undertaken of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Health Service (NHS) National Institute for Health Research Centre for Reviews and Dissemination database, and Google Scholar for terms relating to regional anesthesia and block rooms. The primary outcome was anesthesia-controlled time (ACT; time from entry of the patient into the operating room (OR) until the start of surgical prep plus surgical closure to exit of patient from the OR). Secondary outcomes of interest included other resource-utilization parameters such as turnover time (TOT; time between the exit of one patient from the OR and the entry of another), time spent in the postanesthesia care unit (PACU), OR throughput, and clinical outcomes such as pain scores, nausea and vomiting, and patient satisfaction. Fifteen studies were included involving 8888 patients, of which 3364 received care using a parallel processing model. Parallel processing reduced ACT by a mean difference (95% CI) of 10.4 min (16.3 to 4.5; p<0.0001), TOT by 16.1 min (27.4 to 4.8; p<0.0001) and PACU stay by 26.6 min (47.1 to 6.1; p=0.01) when compared with serial processing. Moreover, parallel processing increased daily OR throughout by 1.7 cases per day (p<0.0001). Clinical outcomes all favored parallel processing models. All studies showed moderate-to-critical levels of bias. Parallel processing in regional anesthesia appears to reduce the ACT, TOT, PACU time and improved OR throughput when compared with serial processing. PROSPERO CRD42018085184.

Two-Stage Technique Used to Manage Severe Upper Airway Obstruction and Avoid Surgical Tracheostomy: A Case Report.

Severe upper airway obstruction is commonly managed with surgical tracheostomy under local anesthesia. We present a 49-year-old woman with postradiotherapy laryngeal fixation and transglottic stenosis for dilation of a pharyngeal stricture who refused elective tracheostomy. A 2-stage technique was used, which involved an awake fiberoptic intubation, followed by the transtracheal insertion of a Cricath needle and ventilation using an ejector-based Ventrain device. We discuss management aspects of this clinical scenario and the principles by which the Ventrain works.

The effect of virtual endoscopy on diagnostic accuracy and airway management strategies in patients with head and neck pathology: a prospective cohort study.

PURPOSE: There is growing evidence to suggest a deficiency in anesthesiologists' diagnosis of airway pathology and subsequent airway management planning, and conventional instruments have not shown increases in safety. Virtual endoscopy (VE) is a tool that can detail intraluminal anatomical "fly-through" information in a format visually similar to the flexible endoscopic views familiar to anesthesiologists. We aimed to determine the effect of VE on diagnostic accuracy and airway management strategies when compared with conventional tools. METHODS: Clinical scenarios, along with computerized tomography (CT) imaging, were presented to 20 anesthesiologists, and structured questions were asked regarding diagnosis of airway pathology and airway management strategy. Virtual endoscopy videos were then provided and the questions were repeated. Following the CT and VE presentations, the anesthesiologists' responses involving diagnostic accuracy and airway management strategy were compared between the CT and VE techniques. Answers relating to the utility of VE were also sought. RESULTS: Diagnostic accuracy was 54.1% with CT alone and increased to 67.7% when VE was added (P = 0.007). In 48% of cases, the addition of VE to clinical history and CT led to changes in airway management strategy (P < 0.001), and 90.6% of these changes were deemed more cautious (P < 0.001). CONCLUSION: Virtual endoscopy improves the accuracy in diagnosis of airway pathology when compared with CT alone. Furthermore, it leads to more conservative and potentially safer airway management strategies in patients with head and neck pathology.

Effect of magnesium sulfate on oxytocin-induced contractility in human myometrium: an in vitro study.

PURPOSE: The purpose of this study was to determine the contractile patterns induced by oxytocin in myometrium exposed to magnesium sulfate (MgSO4). We hypothesized that MgSO4 pretreatment would reduce oxytocin-induced myometrial contractions in both oxytocin-naïve and oxytocin-desensitized myometrium. METHODS: In this prospective in vitro study, myometrial samples were obtained from 26 women undergoing elective Cesarean deliveries. Samples were divided into six groups. Four groups were apportioned to no pretreatment (control group), oxytocin 10-5 M pretreatment (desensitization group), MgSO4 3.5 mM pretreatment, and MgSO4 3.5 mM + oxytocin 10-5M pretreatment. This was followed by dose-response testing to oxytocin 10-10 to 10-5M in all four groups. Two additional groups included MgSO4 3.5 mM pretreatment and MgSO4 3.5 mM + oxytocin 10-5 M pretreatment, followed by dose-response testing to oxytocin along with MgSO4 3.5 mM. The outcomes were motility index (MI), as defined by the amplitude (g) × frequency of myometrial contractions (c) over ten minutes, and area under the curve (AUC). RESULTS: In oxytocin-naïve myometrium, the mean (standard error [SE]) MI was not affected by MgSO4 pretreatment [3.31 (0.20) √g⋅c/10 min] as compared with control (P = 0.88), even when MgSO4 was continued during dose-response testing [2.50 (0.19) √g⋅c/10 min; P = 0.41]. In the oxytocin-desensitized model, mean (SE) MI was not affected by MgSO4 pretreatment [2.60 (0.21) √g⋅c/10 min; P = 0.68], but when MgSO4 was continued during the dose-response period, the MI was significantly reduced compared with control [1.89 (0.13) √g⋅c/10 min; P < 0.001]. The results for AUC were similar to MI, except for a significant reduction in oxytocin-naïve myometrium when MgSO4 was continued during dose-response testing (P = 0.02). CONCLUSION: Magnesium sulfate pretreatment does not impair oxytocin-induced myometrial contractility in oxytocin-naïve or desensitized myometrium unless it is continued during oxytocin dose-response testing. These results suggest that its tocolytic effect is likely dependent on an extracellular mechanism. The study was registered with ClinicalTrials.gov, number NCT02647268.

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study.

BACKGROUND: The use of phenylephrine as the first-line agent for prevention and treatment of maternal hypotension during cesarean delivery (CD) may reduce cardiac output, posing a theoretical risk to mother and fetus. Norepinephrine has been suggested as a potential alternative, because its ß-adrenergic effects might result in greater heart rate and cardiac output than phenylephrine. The use of norepinephrine to prevent and treat hypotension during CD is new, and its use as a bolus has not been fully determined in this context. The purpose of this study was to determine the effective norepinephrine dose, when given as intermittent intravenous (IV) boluses, to prevent postspinal hypotension in 90% of women undergoing elective CD (ED90). METHODS: This was a prospective, double-blind sequential allocation dose-finding study, using the biased coin up-and-down design. Forty-term pregnant women undergoing elective CD under spinal anesthesia received a set intermittent norepinephrine bolus of either 3, 4, 5, 6, 7, or 8 µg every time their systolic blood pressure (SBP) fell to below 100% of baseline. The primary outcome was the success of the norepinephrine regimen to maintain SBP at or above 80% of baseline, from induction of spinal anesthesia to delivery of the fetus. Secondary outcomes included nausea, vomiting, hypertension (SBP > 120% of baseline), bradycardia (<50 bpm), upper sensory level of anesthesia to ice cold and umbilical artery and vein blood gases. The ED90 and 95% confidence intervals (CIs) were estimated using both truncated Dixon and Mood and isotonic regression methods. RESULTS: The estimated ED90 of norepinephrine was 5.49 µg (95% CI, 5.15-5.83) using the truncated Dixon and Mood method and 5.80 µg (95% CI, 5.01-6.59) using the isotonic regression method. CONCLUSIONS: The use of intermittent IV norepinephrine boluses to prevent spinal-induced hypotension in elective CD seems feasible and was not observed to be associated with adverse outcomes. Practically, we suggest an ED90 dose of 6 µg. Further work is warranted to elucidate the comparative effects of intermittent IV bolus doses of phenylephrine and norepinephrine, in terms of efficacy and safety.

Teamwork Assessment Tools in Obstetric Emergencies: A Systematic Review.

INTRODUCTION: Team-based training and simulation can improve patient safety, by improving communication, decision making, and performance of team members. Currently, there is no general consensus on whether or not a specific assessment tool is better adapted to evaluate teamwork in obstetric emergencies. The purpose of this qualitative systematic review was to find the tools available to assess team effectiveness in obstetric emergencies. METHODS: We searched Embase, Medline, PubMed, Web of Science, PsycINFO, CINAHL, and Google Scholar for prospective studies that evaluated nontechnical skills in multidisciplinary teams involving obstetric emergencies. The search included studies from 1944 until January 11, 2016. Data on reliability and validity measures were collected and used for interpretation. A descriptive analysis was performed on the data. RESULTS: Thirteen studies were included in the final qualitative synthesis. All the studies assessed teams in the context of obstetric simulation scenarios, but only six included anesthetists in the simulations. One study evaluated their teamwork tool using just validity measures, five using just reliability measures, and one used both. The most reliable tools identified were the Clinical Teamwork Scale, the Global Assessment of Obstetric Team Performance, and the Global Rating Scale of performance. However, they were still lacking in terms of quality and validity. CONCLUSIONS: More work needs to be conducted to establish the validity of teamwork tools for nontechnical skills, and the development of an ideal tool is warranted. Further studies are required to assess how outcomes, such as performance and patient safety, are influenced when using these tools.