Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis.

Background and Aims: Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid receptor agonist properties, has been successfully used to manage post-anaesthesia shivering. Methods: After registering the review with the International Prospective Register of Systematic Reviews (PROSPERO), we searched PubMed/Medline, Scopus, Ovid, Cochrane Library and clinicaltrials.gov with keywords for randomised controlled trials. The risk of bias-2 (RoB-2) scale was used to assess the quality of evidence. We also used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines to evaluate the strength of evidence and trial sequential analysis to validate the conclusions. Results: Of the 240 articles, 10 were considered eligible for review (700 patients, 350- nalbuphine, 350- control or placebo). When compared to placebo, the success rate of nalbuphine controlling shivering was significantly better (risk ratio [RR]: 2.37, 95% confidence interval [CI]:1.91, 2.94; P = 0.04, I² = 94%), but comparable to the control group drugs (opioids, dexmedetomidine, ondansetron, pethidine). Compared to placebo, shivering recurrence was significantly less with nalbuphine than with placebo (RR: 0.47, 95% CI: 0.26, 0.83; P = 0.01, I² = 61%), but comparable with the control group. The incidence of postoperative nausea/vomiting (PONV) was significantly less with nalbuphine when compared to the control group (RR: 0.67, 95% CI: 0.47, 0.95; P = 0.02, I² = 37%), but PONV in the nalbuphine group was comparable to placebo (RR: 1.20, 95% CI: 0.68, 2.12; P = 0.54, I² = 0%). Other outcomes, like the grade of shivering and hypotension, were comparable between the nalbuphine and control groups. Conclusion: Nalbuphine successfully controls post-anaesthesia shivering and reduces the recurrence of shivering.

Analgesic Efficacy and Outcomes of Ultrasound-guided Erector Spinae Plane Block in Patients Undergoing Bariatric and Metabolic Surgeries: A Systematic Review.

Erector spinae plane block (ESPB) has been used as an intervention for providing postoperative analgesia in patients undergoing bariatric and metabolic surgeries. After registering the protocol in PROSPERO, randomized controlled trials and nonrandomized observational studies were searched in various databases till July 2022. The primary outcome was 24-h opioid consumption; the secondary outcomes were intraoperative opioid use, pain scores, time to rescue analgesia, and complications. The risk of bias and Newcastle-Ottawa scale were used to assess the quality of evidence. From the 695 studies identified, 6 studies were selected for analysis. The 24-h opioid consumption was significantly lesser in ESPB group when compared to control (mean difference [MD]: -10.67; 95% confidence interval [CI]: -21.03, -0.31, I² = 99%). The intraoperative opioid consumption was significantly less in the ESPB group (MD: -17.75; 95% CI: -20.36, -15.13, I² = 31%). The time to rescue analgesia was significantly more in the ESPB group (MD: 114.36; CI: 90.42, 138.30, I² = 99%). Although pain scores were significantly less at 6 and 24 h in ESPB group (MD: -2.00, 95% CI: -2.49, -1.51; I² = 0% and MD: -0.48; 95% CI: -0.72, -0.24; I² = 48%), at zero and 12 h, the pain scores were comparable (MD: -1.53, 95% CI: -3.06, -0.00, I² = 97% and MD: -0.80; 95% CI: -1.80, 0.20, I² = 88%). Bilateral ESPB provides opioid-sparing analgesia and better pain scores when compared to control. These results should be interpreted with caution due to high heterogeneity among the included studies.

Analgesic efficacy and safety of duloxetine premedication in patients undergoing hysterectomy - A systematic review.

Background and Aims: Patients undergoing hysterectomy by open or laparoscopic approach experience moderate to severe postoperative pain. A multimodal analgesic approach is recommended for these patients. This study reviews the analgesic efficacy of duloxetine, a selective serotonin and norepinephrine reuptake inhibitor used as an adjuvant for opioid-sparing postoperative analgesia. Methods: After registering the protocol in the international prospective register of systematic reviews (PROSPERO), databases like PubMed, Ovid, Scopus, Cochrane Library and clinicaltrials.gov were searched for randomised controlled trials using relevant keywords to find studies in which duloxetine premedication was compared to a placebo in patients undergoing hysterectomy. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to assess the quality of evidence. Results: The qualitative systematic review included five of the 88 studies identified. The overall risk of bias in the included studies was very high. In all the studies, 60 mg oral duloxetine was used, and the control group was placebo. In two studies, duloxetine premedication was administered 2 h before and 24 h after surgery. In the other three studies, a single dose of 60 mg duloxetine was only administered 2 h before surgery. A pooled meta-analysis was not performed due to fewer studies that fulfilled the inclusion criteria and even fewer studies with consistent reporting of various outcomes. Conclusion: The evidence is insufficient to advocate routine duloxetine premedication in patients undergoing hysterectomy.

Erector spinae plane block for postoperative analgesia in cardiac surgeries- A systematic review and meta-analysis.

Ultrasound-guided erector spinae plane block (ESPB) has been used in many studies for providing opioid-sparing analgesia after various cardiac surgeries. We performed a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of ESPB in cardiac surgeries. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar to identify the studies in which ESPB was compared with the control group/sham block in patients undergoing cardiac surgeries. The primary outcomes were postoperative opioid consumption and postoperative pain scores. The secondary outcomes were intraoperative opioid consumption, ventilation time, time to the first mobilization, length of ICU and hospital stay, and adverse events. Out of 607 studies identified, 16 studies (n = 1110 patients) fulfilled inclusion criteria and were used for qualitative and quantitative analysis. Although, 24-hr opioid consumption were comparable in both groups group (MD, -18.74; 95% CI, -46.85 to 9.36, P = 0.16), the 48-hr opioid consumption was significantly less in ESPB group than control ((MD, -11.01; 95% CI, -19.98 to --2.04, P = 0.02). The pain scores at various time intervals and intraoperative opioid consumption were significantly less in ESPB group. Moreover, duration of ventilation, time to the first mobilization, and length of ICU and hospital were also less in ESPB group (P < 0.00001, P < 0.00001, P < 0.00001, and P < 0.0001, respectively). This systematic review and meta-analysis demonstrated that ESPB provides opioid-sparing perioperative analgesia, facilitates early extubation and mobilization, leads to early discharge from ICU and hospital, and has lesser pruritus when compared to control in patients undergoing cardiac surgeries.

Application of Enhanced Recovery After Surgery Pathways in Patients Undergoing Laparoscopic Cholecystectomy With and Without Common Bile Duct Exploration: A systematic review and meta-analysis.

Many researchers have implemented enhanced recovery after surgery (ERAS) pathways for laparoscopic cholecystectomy (LC) and found it effective over conventional care. This review investigates the efficacy and safety of such pathways compared to conventional practices. PubMed Central/Medline, Scopus, Ovid and clinicaltrials. gov were searched using relevant keywords to identify studies in which ERAS pathways for LC were compared to conventional pathways. The primary outcome was length of stay (LOS) from the day of surgery and the secondary outcomes were pain scores, postoperative nausea/vomiting (PONV), readmissions (within 30 days after surgery), complications (medical and surgical), time to first flatus and cost. Out of 590 articles identified, six studies (n = 1,489 patients) fulfilled the inclusion criteria and were used for qualitative and quantitative analysis. On pooled analysis, LOS, time to first flatus, PONV and pain scores were significantly less in the ERAS group than in the conventional one, while readmission and complications were comparable in both groups.

Ultrasound-guided transversalis fascia plane block for postoperative analgesia: A systematic review and meta-analysis.

Ultrasound-guided transversalis fascia plane block (TFPB) has been used for providing postoperative analgesia after various lower abdominal surgeries like iliac crest bone harvesting, inguinal hernia repair, caesarean section and appendicectomy. After registering the protocol in PROSPERO, various databases like PubMed/Medline, Ovid, CENTRAL and clinicaltrials.gov were searched for randomized controlled trials and observational, comparative studies till October 2022. The risk of bias (RoB-2) scale was used to assess the quality of evidence. The database searched identified 149 articles. Out of these, 8 studies were identified for qualitative analysis and 3 studies were TFPB was compared to control in patients undergoing caesarean section were selected for quantitative analysis. At 12 hours, pain scores were significantly less in TFPB group when compared to control on movement with no heterogeneity. At other times, the pain scores were comparable. 24-hr opioid consumption was significantly less in TFPB group when compared to control with significant heterogeneity. Time to rescue analgesia was significantly less in TFPB group when compared to control with significant heterogeneity. Number of patients requiring rescue analgesia were significantly less in TFPB group when compared to control with no heterogeneity. Postoperative nausea/vomiting (PONV) was significantly less in TFPB group when compared to control with minimal heterogeneity. In conclusion, TFPB is a safe block which provides opioid-sparing postoperative analgesia and a delayed time to rescue analgesia with no significant difference in pain scores and lesser PONV postoperatively when compared to control in patients undergoing caesarean section.

Efficacy and safety of oral tizanidine premedication as pre-emptive analgesia in adult patients undergoing elective surgeries- A systematic review.

Tizanidine is a centrally acting α2 agonist which has been used as a premedication due to its opioid-sparing and sympatholytic properties. This systematic review assessed the safety and feasibility of oral tizanidine. After registering the protocol with PROSPERO (CRD42022368546), randomized controlled trials and non-randomized observational studies were searched in various databases. The primary outcome was intraoperative opioid use; the secondary outcomes were 24-hr opioid consumption, pain scores, time to rescue analgesia, and adverse events. The risk of bias scale was used to assess the quality of evidence. Out of 202 studies identified, five studies fulfilled the inclusion criteria. Intraoperative opioid consumption was significantly less in the tizanidine group (MD: -2.40; 95% CI: -4.22, -0.59; P = 0.010; I2 = 0 %). The 24-hr opioid consumption was comparable between both groups (MD: -42.53, 95% CI: -91.45, 6.39; P = 0.09; I2 = 99%). Time to rescue analgesia was comparable between both groups (MD: 308.22; 95% CI: -263.67, 880.11, P = 0.29, I2 = 100%). Pain scores at 6 and 12 hours were comparable (MD: -1.37; 95% CI: -3.68, 0.94; P = 0.24; I2 = 97%) and (MD: -1.76; 95% CI: -4.06, 0.53; P = 0.13; I2 = 95%); however, at 24 hours the scores were better in the tizanidine group (MD: -1.10; 95% CI: -1.50, -0.69; P < 0.0001 I2 = 0%). Although dry mouth was significantly more in the tizanidine group (MD: 5.35; 95% CI: 1.72, 16.62; P = 0.004; I2 = 0%), postoperative nausea/vomiting and dizziness were comparable. Tizanidine reduces intraoperative opioid consumption without significant adverse events. However, it does not provide effective opioid-sparing analgesia or reduced opioid requirement in the first 24 hours after surgery.