Role of supplemental regional blocks on postoperative neurocognitive dysfunction after major non-cardiac surgeries: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND/IMPORTANCE: Postoperative neurocognitive dysfunction (PNCD) is a frequent and preventable complication after surgery. The large high-quality evidence for the efficacy of supplemental regional analgesia blocks (RAB) for preventing PNCD is still elusive. OBJECTIVE: The objective of this meta-analysis was to evaluate the effect of RAB versus standard anesthesia care on the incidence of PNCD in adult patients undergoing major non-cardiac surgery. EVIDENCE REVIEW: PubMed, EMBASE, Scopus, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) from 2017 until June 2022. The primary outcome was the incidence of PNCD within 1 month of surgery. A random-effects model with an inverse variance method was used to pool results, and OR and mean differences were calculated for dichotomous and continuous outcomes. Various exploratory subgroup analyses were performed to explore the possibility of the association between the various patient, technique, and surgery-related factors. Grading of Recommendation, Assessment, Development, and Evaluation guidelines were used to determine the certainty of evidence. FINDINGS: Twenty-six RCTs comprizing 4414 patients were included. The RAB group was associated with a significant reduction in the incidence of PNCD with an OR of 0.46 (95% CI 0.35 to 0.59; p<0.00001; I2=28%) compared with the control group (moderate certainty). Subgroup analysis exhibited that the prophylactic efficacy of RAB persisted for both delirium and delayed neurocognitive recovery. CONCLUSIONS: Current evidence suggests that supplemental RAB are beneficial in preventing PNCD in patients after major non-cardiac surgery. PROSPERO REGISTRATION NUMBER: CRD42022338820.

The analgesic efficacy of quadratus lumborum block in caesarean delivery: a meta-analysis and trial sequential analysis.

PURPOSE: Quadratus lumborum block (QLB) has recently gained popularity for postoperative analgesia after cesarean delivery (CD) as it provides both visceral and somato-sensory blockade of the abdomen. Aim of this meta-analysis was to evaluate the analgesic potential of QLB after CD. METHODS: Electronic database from inception to December 2019 was searched systematically for randomized-controlled trials comparing QLB with injection of inactive solution in women undergoing CD. Primary outcome was consumption of morphine at 24 h. Morphine consumption at 48 h, dynamic and static pain scores at various time intervals were the secondary outcomes studied. RESULTS: Seven trials met the inclusion criteria. Morphine consumption was reduced significantly with QLB in comparison to sham or no block at 24 h (mean difference [MD] - 9.84 mg; 95% confidence interval [CI] - 18.16, - 0.50; p = 0.04; I2 = zero). Adequate "information size" for above outcome was confirmed with trial sequential analysis, ruling out any possibility of a false-positive result. QLB significantly reduced pain scores at rest (MD - 1.13; 95% CI - 1.75, - 0.56; p = 0.00) and on movement (MD - 1.48; 95% CI - 2.5, - 0.46; p = 0.01) at 6 h. However, statistically significant difference in pain scores persisted only for dynamic pain at 24 h (MD - 0.55; 95% CI - 1.04, - 0.06; p = 0.03). QLB does not provide any additional analgesic benefit to the parturient receiving intrathecal morphine. CONCLUSION: QLB significantly reduces opioid requirements in CD and may have analgesic effects lasting 24 h.

Role of Decompressive Craniectomy in Traumatic Brain Injury - A Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: Several studies have indicated that decompressive craniectomy (DC) for traumatic brain injury (TBI) is lifesaving. However, there is lack of level 1 evidence to define the role of DC in TBI. We performed a meta-analysis of all the randomized controlled trials (RCTs) published so far on the role of DC in adult patients with TBI. MATERIALS AND METHODS: A systematic literature search was performed for articles published until September of 2016 for RCTs of DC in adult patients with TBI. The primary end-point was mortality at six-months. We also evaluated the overall adverse outcomes at six months. Assessment of risk of bias of the RCTs was also performed. RESULTS: Three trials evaluating adult population satisfied the eligibility criteria. Pooled analysis involved 285 and 288 patients in DC group and control groups respectively. Patients undergoing DC for TBI had a lower mortality association of nearly 50 percent. However, patients surviving DC were more likely to have a poor neurological outcome compared to patients undergoing medical management. CONCLUSION: Based on the available RCTs on DC in TBI, the results of our meta-analysis show that there is a mortality benefit of performing a DC over the best medical management in adult patients. Furthermore, surviving following DC, a greater incidence of a poor neurological outcome is noted. In the event of small number of high-quality RCTs, our results must be interpreted with caution.

Perioperative antiemetic efficacy of dexamethasone versus 5-HT3 receptor antagonists: a meta-analysis and trial sequential analysis of randomized controlled trials.

BACKGROUND: Dexamethasone has many desirable pharmacologic properties for perioperative use. Its antiemetic potential has been a focus of many recent trials. METHODS: Trials comparing dexamethasone to 5-HT3-receptor antagonists (5HT3-RA) for 24 h postoperative vomiting incidences published till August 2017 were searched in the medical database. Comparisons for antiemetic efficiency variables (vomiting incidence, nausea incidence, rescue antiemetic need, and patients with complete response) during early (until 6 h) and late postoperative phase were made. Comparative analgesic requirements were also evaluated. RESULTS: Twenty randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar (Fixed-effects, P = 0.86, I2 = 2.94%). Trial sequential analysis (TSA) confirmed non-inferiority of dexamethasone for 24-h vomiting incidence. (α = 5%, ß = 20%, δ = 10%) with "information size" being 1619 (required > 573). Equivalence was also verified from early and delayed nausea rate as well using TSA. Pooled results did not demonstrate superiority/inferiority of 5-HT3-RAs over dexamethasone in all other antiemetic efficacy variables (early and delayed). Heterogeneity was found to be low in all of the comparisons. Linear-positive dose-response curve for dexamethasone 24-h vomiting and nausea incidence was seen (correlation coefficient being 0.21 and 0.28, respectively). Dexamethasone reduced the analgesic need (MH-odds of 0.64 (95% CI being 0.44 to 0.93) P = 0.02, I2 = 0)). Possibility of publication bias could not be ruled out (Egger's test, X-intercept = 1.41, P = 0.04). CONCLUSIONS: Dexamethasone demonstrates equal antiemetic efficacy compared to 5-HT3 receptor antagonists. The agents perform equally well both in early postoperative phase and up to 24 h after surgery. Use of dexamethasone replacing 5-HT3 RAs offers an additional advantage of lowering the opioid requirements during the perioperative period.

Evaluation of transversus abdominis plane block for renal transplant recipients - A meta-analysis and trial sequential analysis of published studies.

BACKGROUND: Patients undergoing renal transplant (RT) have altered drug/opioid pharmacokinetics. Transversus abdominis plane (TAP) block in renal transplant recipients has been recently evaluated for analgesic and opioid-sparing potential by many trials. METHODOLOGY: The studies comparing TAP-block to conventional analgesic regimens for RT were searched. Comparisons were made for total opioids consumed (as morphine-equivalents) during the first postoperative 24-h (primary objective), intraoperative, and immediate-postoperative period. Pain scores and postoperative nausea-vomiting (PONV) were also evaluated. Trial sequential analysis (TSA) was used to quantify the strength of analysis. RESULTS: Ten-trials with 258 and 237 patients in control and TAP-block group, respectively, were included. TAP-block decreased the 24-h (reported in 9-trials) opioid consumption by 14.61 ± 4.34 mg (reduction by 42.7%, random-effects, P < 0.001, I2 = 97.82%). Sample size of the present analysis (472) was well past the required "information-size" variable (396) as per the TSA for a power of 85%. Intraoperative opioid consumption also decreased by 2.06 ± 0.63 mg (reduction of 27.8%) (random effects, P < 0.001, I2 = 98.84%). Pain scores with TAP-block were significantly lower in both early and delayed postoperative phase. Odds ratio for PONV without TAP block was 1.99 ± 1.05 (Fixed-effects, P = 0.04, I2 = 0%). Publication bias was likely (Egger's test, X-intercept=7.89, P < 0.05). CONCLUSIONS: TAP-block significantly lowers the intraoperative and cumulative postoperative 24-h opioid consumption in RT recipients. Persistent and better pain control is achieved when TAP-Block is used. Benefits of TAP block extend beyond the analgesic actions alone as it also decreases the 24-h incidence of postoperative nausea vomiting as well. The technique of the block needs standardization for RT recipients.

Opioid-sparing effects of the thoracic interfascial plane blocks: A meta-analysis of randomized controlled trials.

BACKGROUND: Thoracic interfascial plane blocks and modification (PECS) have recently gained popularity for analgesic potential during breast surgery. We evaluate/consolidate the evidence on opioid-sparing effect of PECS blocks in comparison with conventional intravenous analgesia (IVA) and paravertebral block (PVB). MATERIALS AND METHODS: Prospective, randomized controlled trials comparing PECS block to conventional IVA or PVB in patients undergoing breast surgery published till June 2017 were searched in the medical database. Comparisons were made for 24-h postoperative morphine consumption and intraoperative fentanyl-equivalent consumption. RESULTS: Final analysis included nine trials (PECS vs. IVA 4 trials and PECS vs. PVB 5 trials). PECS block showed a decreased intraoperative fentanyl consumption over IVA by 49.20 mcg (95% confidence interval [CI] =42.67-55.74) (I2 = 98.47%, P < 0.001) and PVB by 15.88 mcg (95% CI = 12.95-18.81) (I2 = 95.51%, P < 0.001). Postoperative, 24-h morphine consumption with PECS block was lower than IVA by 7.66 mg (95% CI being 6.23-9.10) (I2 = 63.15, P < 0.001) but was higher than PVB group by 1.26 mg (95% CI being 0.91-1.62) (I2 = 99.53%, P < 0.001). Two cases of pneumothorax were reported with PVB, and no complication was reported in any other group. CONCLUSIONS: Use of PECS block and its modifications with general anesthesia for breast surgery has significant opioid-sparing effect intraoperatively and during the first 24 h after surgery. It also has higher intraoperative opioid-sparing effect when compared to PVB. During the 1st postoperative day, PVB has slightly more morphine sparing potential that may however be associated with higher complication rates. The present PECS block techniques show marked interstudy variations and need standardization.

Haloperidol Versus 5-HT3 Receptor Antagonists for Postoperative Vomiting and QTc Prolongation: A Noninferiority Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials.

Haloperidol is an antipsychotic with well-known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta-analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5-HT3 -receptor antagonists (5-HT3 -RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar in groups (fixed effects, P = 0.52, I2 = 0%). Trial-sequential analysis confirmed noninferiority of haloperidol over 5-HT3 -RAs (α = 5%, ß = 20%, δ = 10%), with "information size" being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5-HT3 -RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, P = 0.23, I2 = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial-sequential analysis showed statistical equivalence (α = 5%, ß = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X-intercept = 2.07, P = 0.10). We conclude that haloperidol is equivalent to the well-established 5-HT3 -RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5-HT3 -RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting.

Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Meta-analysis.

BACKGROUND: In this meta-analysis, we explore the role of repetitive transcranial magnetic stimulation (rTMS), a noninvasive neuromodulation technique in the treatment of chronic pain. METHODS: Studies comparing rTMS and conventional treatment for chronic pain were searched. The comparison was made for decrease in the pain scores with and without (sham) the use of rTMS after a follow-up interval of 4-8 weeks. All reported pain scores were converted into a common scale ranging from "0" (no pain) to "10" (worst pain). RESULTS: Nine trials with 183 patients in each of the groups were included in the analysis. The decrease in pain scores with rTMS was 1.12 (95% confidence interval [CI] being 1.46-0.78) (fixed effects, I2 = 0%, P < 0.001) and in sham-rTMS was 0.28 (95% CI being 0.49-0.07) (Fixed effects, I2 = 0, P = 0.01). The pooled mean drop in pain scores with rTMS therapy was higher by 0.79 (95% CI being 0.26-1.33) (fixed effects, I2 = 0, P < 0.01). The duration and frequency of rTMS were highly variable across trials. Publication bias was unlikely (Egger's test, X-intercept = 0.13, P = 0.75). CONCLUSIONS: Use of rTMS improves the efficacy of conventional medical treatment in chronic pain patients. This treatment is not associated with any direct adverse effects. However, the duration and frequency of rTMS therapy is presently highly variable and needs standardization.

Comparison of the Recovery Profile between Desflurane and Sevoflurane in Patients Undergoing Bariatric Surgery-a Meta-Analysis of Randomized Controlled Trials.

Early and clear recovery from anesthesia is the crux for preventing perioperative complications in the obese undergoing bariatric surgery. Volatile inhalation agents by virtue of high lipid solubility are expected to produce residual anesthetic effects. Prospective randomized trials comparing desflurane and sevoflurane used for anesthesia maintenance (electroencephalograph guided) during bariatric surgery published till 1st of July 2017 were searched in the medical database. Comparisons were made for surrogate markers of recovery from anesthesia that included time to eye-opening (TEo), time to tracheal-extubation (TEx), and Aldrete scores on immediately shifting to recovery (Ald-I). Five trials were included in the final analysis. Patients receiving desflurane began to respond faster by opening eyes on command (five trials) by 3.80 min (95%CI being 1.83-5.76) (random effects, P < 0.01, I2 = 78.61%), and tracheal extubation was also performed earlier (four trials) by 4.97 min (95%CI being 1.34-8.59). This meant a reduction of 37% in TEo and 33.60% in TEx over sevoflurane. Ald-I scores were higher/better with desflurane by 0.52 (95%CI being 0.19-0.84) (Fixed-effects, P < 0.01, I2 = 6.67%). Publication bias is likely for TEo (Egger's Test, X-intercept = - 8.57, P = 0.02). No airway-related complications were reported with desflurane's expedited recovery. Use of desflurane compared to sevoflurane for maintenance of anesthesia in morbidly obese patients allows attaining verbal contact faster, and tracheal extubating can be performed earlier without compromising safety. The benefits of better recovery extend into the immediate postoperative phase with patients being more awake upon shifting to the recovery.

Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis.

BACKGROUND/AIMS: The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures. MATERIALS AND METHODS: Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates. RESULTS: A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006-0.001) and 0.001 (95% CI being 0.000-0.001), respectively. CONCLUSIONS: The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy.

Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis.

BACKGROUND: Opioid-sparing analgesia for bariatric surgery in morbidly obese can potentially prevent catastrophic airway complications. Our meta-analysis attempts to consolidate the evidence on dexmedetomidine evaluating its analgesic and safety profile. METHODS: Trails comparing perioperative dexmedetomidine infusion to conventional analgesic regimens for bariatric surgery were searched. Comparisons were made for 24-hour and postanesthesia care unit (PACU) morphine consumed, PACU pain scores, postoperative nausea and vomiting pain scores, and heartrate. Meta-regression was performed for length of stay to evaluate various analgesic control subgroups. RESULTS: Six trials were included in the final analysis. Dexmedetomidine infusion (reported in 5 intraoperative subgroups and 2 postoperative subgroups) decreased 24-hour morphine by 18.13±6.11 mg (random effects: P<.001, I2 = 95.48%). Despite the small number of included studies, the sample size for avoiding a false positive result was adequate as the trial sequential analysis found the present sample size (362) to be well past the required "sample size" (n = 312) for 85% power. Meta-regression for infusion dose on morphine consumption difference found a predictability of 49% (coefficient = 39.93, random-effects, Tau2 = 396.08), and predictability of the model improved to 68% on inclusion of time of initiation of infusion. The dexmedetomidine group had lower PACU morphine consumption (by 6.91±1.19, I2 = 34.37%), lower pain scores (scale of 0-10±2.27, I2 = 88.14%), lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I2 = 0%), and lower heart rate (73.25 versus. 83.50) (mean difference =±10.15 I2 = 94.04%). No adverse events were reported across trials. CONCLUSION: Perioperative dexmedetomidine infusion in obese patients undergoing bariatric surgery is a promising and safe alternative. Both intraoperative or postoperative infusions lead to significant opioid sparing in early and extend postoperative recovery phase. Morbidly obese patients receiving perioperative dexmedetomidine infusions have overall better pain control and lower incidence of postoperative nausea-vomiting. All the aforementioned merits come with a stable hemodynamic profile and without any reported major adverse events.

Role of Periarticular Liposomal Bupivacaine Infiltration in Patients Undergoing Total Knee Arthroplasty-A Meta-analysis of Comparative Trials.

BACKGROUND: Over last 2 years, many trials have evaluated newly approved liposomal bupivacaine for periarticular infiltration in total knee arthroplasty (TKA) with mixed results. Our meta-analysis attempts to consolidate the results and make evidence-based conclusions. METHODS: Trails comparing periarticular infiltration of liposomal bupivacaine to conventional analgesic regimens for total knee arthroplasty published till June 2016 were searched in medical database. Comparisons were made for length of stay (LOS), postoperative pain scores, range of motion, and opioid consumption. Meta-regression was performed for LOS to evaluate various analgesic control subgroups. RESULTS: Sixteen trials were included in the final analysis. Liposomal bupivacaine group showed a shorter LOS (reported in 13 subgroups) than control group by 0.17 ± 0.04 days (random effects, P < .001, I2 = 84.66%). Meta-regression for various types of control showed a predictability (R2) of 73%, τ2 = 0.013 (random effects, P < .001, I2 = 45.16). Only femoral block subgroup attained statistically significant shorter LOS on splitting the control group. Numeric pain scores were lower for pooled control group and local anesthetic infiltration subgroup in immediate postoperative phase. Second postoperative day analgesia was statistically superior to overall clubbed controls and femoral block subgroup. Superiority and/or inferiority of liposomal bupivacaine could not be proven for opioid consumption and range of motion because of a small pooled sample size. Publication bias is likely for LOS (Egger test, X intercept = 2.42, P < .001). CONCLUSION: Liposomal bupivacaine infiltration has questionable clinical advantage, as it marginally shortens patient's hospital stay especially in comparison with patients receiving analgesic femoral nerve block. Compared with conventional regimens, it can provide slightly superior yet sustained (till second postoperative day) perioperative analgesia. High heterogeneity suggests need for standardization of infiltration techniques for better predictability of results.

Efficiency and Safety Effects of Applying ERAS Protocols to Bariatric Surgery: a Systematic Review with Meta-Analysis and Trial Sequential Analysis of Evidence.

Application of the enhanced recovery after surgery (ERAS) to the bariatric surgical procedures is at its early stages with little consolidated evidence. This meta-analysis evaluates present literature and indicates pathways for development of evidence-based standardized ERAS protocols for bariatric surgery. Comparative trials between ERAS and conventional bariatric surgery published till June 2016 were searched in the medical database. Comparisons were made for length of stay (LOS), readmission, complications (major/minor), and reoperation rates. Trial sequential analysis (TSA) for the strength of meta-analysis was performed for the primary outcome LOS. Five subgroups with a total of 394 and 471 patients in ERAS and conventional group respectively were included. LOS was shorter in ERAS group by 1.56 ± 0.18 days (random-effects, p < 0.001, I 2 = 93.07 %). The sample size in ERAS was well past the "information size" variable which was calculated to be 189 as per the TSA for power 85%. MH odds ratio [1.41 (95% CI 1.13 to1.76)] was higher for minor complications in the ERAS group (fixed effects, I 2 = 0, p < 0.001). Superiority/inferiority of ERAS could not be established for major or overall complications, readmission, and anastomotic leak rates. No publication bias was found in the included trials (Egger's test, X-intercept = 6.14, p = 0.66). Evaluation based on Cochrane collaboration recommendations suggested that all the five included trials had a high risk of methodological bias. ERAS protocols for bariatric procedures allow faster return to home for patients. The present bariatric ERAS protocols have high heterogeneity and would benefit from standardization. Minor complication rates increase with implementation of ERAS, however without any significant effect on overall patient morbidity. Further randomized trials comparing ERAS with conventional care are required to consolidate these findings.

Association between Type of Sedation and the Adverse Events Associated with Gastrointestinal Endoscopy: An Analysis of 5 Years' Data from a Tertiary Center in the USA.

BACKGROUND/AIMS: The landscape of sedation for gastrointestinal (GI) endoscopic procedures and the nature of the procedures themselves have changed over the last decade. In this study, an attempt is made to analyze the frequency and etiology of all major adverse events associated with GI endoscopy. METHODS: All adverse events extracted from the electronic database and local registry were analyzed. Although the data analysis was retrospective, the adverse events themselves were documented prospectively. These events were evaluated after subdivision into propofol-based anesthesia and intravenous conscious sedation groups. RESULTS: Cardiorespiratory events, including cardiac arrest, were the most common adverse events during esophagogastroduodenoscopy, while bleeding was more frequent in patients undergoing colonoscopy. Pancreatitis was the most frequent adverse event in patients undergoing endoscopic retrograde cholangiopancreatography. The frequencies of most adverse events were significantly higher in patients anesthetized with propofol. Automatic regression modeling showed that the type of sedation, the American Society of Anesthesiologists physical status classification, and the procedure type were some of the predictors of immediate life-threatening complications. CONCLUSIONS: Clearly, our regression modeling suggests a strong association between the type of sedation as well as various patient factors and the frequency of adverse events. The possible reasons for our results are the changing demographics, the worsening comorbidities of the patient population, and the increasing technical complexity of these procedures. Although extensive use of propofol has increased patient satisfaction and procedure acceptability, its use is also associated with more frequent adverse events.