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Journal of clinical anesthesia 03/2012; 24(2):165. · 1.32 Impact Factor
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Journal of clinical anesthesia 08/2011; 23(6):435-6. · 1.32 Impact Factor
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ABSTRACT: To determine if the use of ultrasound guidance (vs non-ultrasound techniques) improves the success rate of nerve blocks.
Meta-analysis of randomized controlled trials (RCTs) in the published literature.
University medical center.
16 RCTs of patients undergoing elective surgical procedures were studied. Patients underwent ultrasound-guided or non-ultrasound techniques (nerve stimulation, surface landmark) for peripheral nerve blocks. Success rates were measured.
Ultrasound guidance (vs all non-ultrasound techniques) was associated with a significant increase in the success rate of nerve blocks [relative risk (RR) = 1.11 (95% confidence interval [CI]: 1.06 to 1.17, P < 0.0001]). When compared with nerve stimulator techniques only, ultrasound guidance was still associated with an increase in the success rate (RR = 1.11 [95% CI: 1.05 to 1.17, P = 0.0001]). For specific blocks, ultrasound guidance (vs all non-ultrasound) was associated with a significant increase in successful brachial plexus (all) nerve blocks (RR = 1.11 [95% CI: 1.05 to 1.20, P = 0.0001]), sciatic popliteal nerve block (RR = 1.22 [95% CI: 1.08 to 1.39, P = 0.002]) and brachial plexus axillary nerve block (RR = 1.13 [95% CI: 1.00 to 1.26, P = 0.05]) but not brachial plexus infraclavicular nerve block (RR = 1.25 [95% CI: 0.88 to 1.76, P = 0.22]).
Ultrasound-guided peripheral nerve block is associated with an increased overall success rate when compared with nerve stimulation or other methods. Ultrasound-guided techniques also increase the success rate of some specific blocks.
Journal of clinical anesthesia 03/2011; 23(2):90-6. · 1.32 Impact Factor
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ABSTRACT: The overall benefits of epidural analgesia are controversial, in part because of the varying quality of methodology in published randomized controlled trials (RCTs). We performed a systematic review of available RCTs to examine the methodological quality of epidural analgesia trials. Current instruments for evaluating the quality of methodology are generic; thus, we also developed a specific assessment tool named Epidural Analgesia Trial Checklist (EATC).
The National Library of Medicine's PubMed database was searched (1966 to January 2006) for RCTs of epidural analgesia. All RCTs that had epidural infusion analgesia in at least 1 study arm and as primary intervention for randomization were included. Two independent reviewers were given blinded full-text paper versions of each article and reviewed all articles for inclusion in this study. Study characteristics were extracted from accepted RCTs, and reviewers completed the standardized 7-item Jadad score, 22-item Consolidated Standards of Reporting Trials (CONSORT) checklist, and 8-item EATC for evaluation of methodological quality.
A total of 321 articles met all inclusion criteria. The overall median (first, third quartiles) Jadad, CONSORT, and EATC scores were 2 (1, 3), 10 (8, 11), and 4 (3, 6) (of maximum scores of 5, 22, and 8), respectively. For all assessments, we found significantly higher methodological study quality for articles with a larger study population size, those written by a first author affiliated with an anesthesiology department, and studies published after release of the CONSORT statement with a significant overall increase in methodological quality over time. There was no effect on methodological quality with regard to region of publication or number of centers. There was relatively high interrater agreement when using the EATC (κ = 0.92). The items most frequently lacking from the studies captured using the EATC were appropriate description/definition of adverse effects (11.8% of all studies properly reported this), proper presentation of visual analog scale (VAS) pain scores (31.2%), and assessment of VAS pain both at rest and with activity (39.9%).
Methodology scores for epidural analgesia RCTs have improved over time. The EATC seems to correlate well with other commonly used generic assessments for methodological RCT quality and be useful for assessing methodological quality of epidural RCTs. Future epidural analgesia RCTs should focus on improving appropriate description/definition of adverse effects, proper presentation of VAS pain scores, and assessment of VAS pain both at rest and with activity.
Regional anesthesia and pain medicine 11/2010; 35(6):549-55. · 4.16 Impact Factor
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ABSTRACT: The management of postoperative pain in the elderly represents a considerable challenge because these patients are generally at higher risk for postoperative complications. There are several analgesic options, some of which may influence perioperative morbidity in this high-risk group of patients. Although use of regional analgesia, particularly epidural analgesia is associated with some benefits, including a decrease in perioperative morbidity, there are side effects and complications (eg, medication-related side effects, epidural hematoma, infection) from these and other techniques, and the clinician should evaluate the benefits and risks of each technique on an individual basis. Nevertheless, the available data suggest that use of regional analgesic techniques (ie, epidural and paravertebral catheters) is associated with a decrease in perioperative pulmonary complications.
Thoracic Surgery Clinics 08/2009; 19(3):353-61.
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ABSTRACT: The objective of the study was to identify the effect of atrial natriuretic peptide (ANP) on uterine contractility, production of ANP, and natriuretic peptide receptor (NPR) expression in human myometrial tissue.
In an institutional review board-approved study, gravid human myometrium was obtained from patients undergoing cesarean section. Uterine contractility was examined using isometric force tension studies. After regular uterine contractions were obtained with oxytocin, ANP was added in increasing concentrations. ANP concentration was measured from myometrial tissue using radioimmunoassay (RIA). Primary myometrial cell culture was performed and treated with nifedipine vs oxytocin. RIA was performed on these cells and the cell culture media. Western blot analysis was performed on uterine tissue samples for natriuretic peptide receptors.
With increasing concentration of ANP (starting at 3 pM), myometrial contraction frequency decreased. ANP was identified in primary cultured myometrial cells and cell culture media. Myometrial ANP concentration increased with advancing gestational age. The concentration of ANP decreased within myometrial cells treated with oxytocin. The amount of ANP in the cell culture media increased from cells treated with nifedipine. Western blot identified NPR-A, -B, and -C in myometrial tissue. NPR-A expression was significantly increased in preterm samples.
ANP has a dose dependent effect on uterine relaxation. ANP is present in human myometrial cells and appears to be secreted by myometrial cells. The concentration of ANP may vary with gestational age and modulators of uterine contractility. NPR-A, -B, and -C receptor proteins are present in myometrial tissue. NPR-A levels may correlate with gestational age.
American journal of obstetrics and gynecology 09/2008; 199(4):429.e1-6. · 3.28 Impact Factor
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ABSTRACT: To perform a meta-analysis of available randomized trials investigating the analgesic efficacy of periprostatic block with local anesthetic.
The National Library of Medicine's PubMed database was searched for the time period 1966 to August 16, 2005 for all relevant articles. Inclusion criteria included subjects undergoing prostate biopsy, trials that were randomized with one arm of the randomization using local anesthetic for periprostatic block before prostate biopsy, and where the assessment of biopsy pain was measured and available in a form compatible for statistical analysis in our meta-analysis.
Our search resulted in 107 abstracts, of which a total of 16 articles met all inclusion criteria. There were 660 subjects who received local anesthetics for a periprostatic block and 616 subjects who did not. The weighted mean difference between the groups indicates that subjects receiving local anesthetic periprostatic block would have a statistically lower pain score compared with those who did not (weighted mean difference in visual analogue pain of -1.66 [95% confidence interval -2.03 to -1.29]).
Our meta-analysis suggests that periprostatic block with local anesthetic for prostate biopsy might result in significantly lower levels of pain during the biopsy procedure. Because periprostatic block with local anesthetic is relatively easy to administer and does not seem to be associated with increased morbidity, clinicians performing prostate biopsies should consider using this technique on a routine basis.
Urology 07/2006; 67(6):1224-8. · 2.43 Impact Factor
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ABSTRACT: Extended-release epidural morphine (EREM) is a single-dose, extended-release epidural morphine formulation intended to provide postoperative pain relief over a 48-hour period. There have been a few randomized controlled trials investigating the use and safety of EREM versus intravenous patient-controlled analgesia with opioids (IV-PCA); however, the adverse event of respiratory depression of this treatment is unclear. The authors have undertaken a meta-analysis to examine this issue.
A systematic literature search of the National Library of Medicine's PubMed database was conducted for terms related to EREM. Only randomized controlled trials, in the English language, assessing the rates of respiratory depression of EREM to IV-PCA were included for analysis. Data on pertinent study characteristics and relevant outcomes were extracted from accepted articles. Meta-analysis was performed using the Review Manager 4.2.7 (The Cochrane Collaboration, 2004). A random effects model was used.
The authors' literature search yielded three articles which met all inclusion criteria. All studied doses of EREM were evaluated. Pooled estimates (odds ratio) were made for rates of adverse events of respiratory depression. Use of EREM was associated with significantly higher odds of respiratory depression compared to IV-PCA (odds ratio = 5.74; 95% confidence interval: 1.08, 30.54, p = 0.04). Even when examining only Food and Drug Administration approved dosages for EREM, the use of EREM was associated with significantly higher odds of respiratory depression when compared with IV-PCA (odds ratio = 5.80; 95% confidence interval: 1.05, 31.93, p = 0.04).
Although perioperative single-dose epidural EREM (versus IV-PCA) was effective for postoperative pain relief for up to 48 hours, it is associated with significantly higher odds of respiratory depression. Further examination of the issue of respiratory depression of epidural EREM may be warranted.
Journal of opioid management 5(5):301-5.
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ABSTRACT: Although the addition of a background infusion for intravenous patient-controlled analgesia (IV-PCA) has been identified as a risk factor for the development of respiratory depression, this has not clearly been examined in a systematic fashion. The authors undertook a systematic review and meta-analysis of available randomized controlled trials (RCTs) to examine whether the addition of a background or continuous infusion to an IV-PCA regimen would be associated with an increased risk of respiratory depression.
Studies were identified by searching the National Library of Medicine's PubMed database (1966 to November 30, 2008). Inclusion criteria were a clearly defined analgesic technique of demand-only IV-PCA versus IV-PCA utilizing both a demand dose and background infusion, opioid medication used, and randomized trials. Data were abstracted and analyzed with the RevMan 4.2.7 (The Cochrane Collaboration, 2004).
The search yielded 687 abstracts from which the original articles were obtained and data abstracted with a total of 14 articles analyzed. There were 402 subjects in the continuous IV-PCA with demand group versus the 394 subjects in the demand-only IV-PCA group. Addition of a background infusion to the demand dose for IV-PCA with opioids was associated with a significant increased risk for respiratory depression (odds ratio [OR] = 4.68, 95% confidence interval [CI]: 1.20-18.21). Subgroup analysis revealed that this increased risk was seen in adult but not in pediatric patients.
Our meta-analysis indicates that the addition of a continuous or background infusion to the demand dose for IV-PCA is associated with a higher incidence of respiratory events than demand IV-PCA alone in adult but not in pediatric patients; however, our overall results should be interpreted with caution due to the relatively small sample size and the wide range of definitions for respiratory depression in studies examined.
Journal of opioid management 6(1):47-54.
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ABSTRACT: Intravenous patient-controlled analgesia (IV PCA) with tramadol is an accepted method to deliver postoperative analgesia outside North America; however, the analgesic efficacy of this analgesic agent when compared with IVPCA with opioids is uncertain. As such, the authors undertook a systematic review to compare the analgesic efficacy of IVPCA tramadol with that of IVPCA with opioids.
The authors used the National Library of Medicine's Medline database to search for terms related to tramadol and patient-controlled analgesia. Inclusion criteria were randomized controlled trials (RCTs) comparing IVPCA tramadol with IVPCA opioid and RCTs published in the English language. Relevant data were abstracted from accepted studies. Meta-analysis was performed using RevMan 4.2.10 (The Cochrane Collaboration, 2004). A random effects model was used.
A total of 190 abstracts were obtained from the above search, and a total of 12 RCTs met the above inclusion criteria. There was no difference in weighted visual analog scale pain scores between IVPCA tramadol versus IVPCA opioid at 48 hours postoperatively or risk of sedation or fatigue. IVPCA tramadol was associated with a higher odds of postoperative nausea and vomiting [odds ratio (OR) = 1.52, 95% confidence interval (CI) = 1.07-2.14) but a lower odds of pruritus (OR = 0.43, 95% CI = 0.19-0.98).
IVPCA tramadol appears to produce similar pain scores when compared with that from IVPCA opioids; however, the side effect profile is different between the two groups. Because of the relatively small sample size, no determination of the relative "safety" (eg, respiratory depression) of one regimen over the other can be made, and larger RCTs would be needed for such a determination.
Journal of opioid management 6(2):141-7.
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ABSTRACT: Pruritus may be a significant problem for patients in the postoperative period. There are many options for the treatment of pruritus including intravenous (IV) naloxone. However, it is not clear whether the use of IV naloxone may also affect analgesia or other opioid-related side effects. The authors have performed a systematic review to further examine this issue.
Systematic literature searches of the National Library of Medicine's PubMed and EMBASE databases were conducted using terms related to postoperative use of IV naloxone. Only randomized controlled trials comparing IV naloxone used either as a continuous infusion or part of an IV patient-controlled analgesia (PCA) regimen after surgical procedures were considered. The data on pertinent study characteristics and relevant outcomes were extracted from accepted articles. There was no restriction on language for inclusion. Meta-analysis was performed using the Review Manager 4.2.10 (The Cochrane Collaboration, 2004). A random effects model was used.
The literature searches yielded eight articles that met all inclusion criteria. There were a total of 424 subjects in the naloxone group and 376 in the saline group. The authors found that the use of naloxone was associated with a decreased risk for pruritus (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.21-0.79, p = 0.006] and nausea [OR = 0.62, 95% CI = 0.43-0.89, p = 0.009]. However, the use of IV naloxone (vs no naloxone) did not significantly influence the risk of postoperative emesis [OR = 0.97, 95% CI = 0.70-1.33, p = 0.83], opioid consumption [OR = 0.29, 95% CI = -3.54-4.13, p = 0.88], or sedation [OR = 0.82, 95% CI = 0.38-1.74, p = 0.60]. Finally, the use of IV naloxone did not appear to be associated with any significant change in visual analog score pain scores at 24 hours postoperatively (weighted mean difference = -0.14, 95% CI = -0.50-0.23, p = 0.46).
Our pooled analysis examining the analgesic efficacy of IV naloxone (either as a continuous infusion or IV PCA) revealed that naloxone was associated with a decrease in pruritus and nausea without any increase in pain scores. When compared with controls, the use of IV naloxone was not associated with any significant changes in opioid consumption or with the risk of sedation or emesis.
Journal of opioid management 7(4):321-7.
