Patient Comfort with Various Local Infiltration Anesthetics for Minor Oculoplastic Surgery: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Although local anesthetics have been extensively studied, limited evidence is available regarding the optimal solution for maximizing patient comfort in minor oculoplastic procedures. OBJECTIVES: To determine the optimal anesthetic solution for local infiltration in minor oculoplastic surgeries to maximize patient comfort. METHODS: This systematic review with network meta-analysis of prospective studies was conducted to understand the efficacy of different local anesthetics in combination to maximize patient comfort. The study was designed according to the Cochrane Handbook for Systematic Reviews of Interventions. The population comprised patients receiving local infiltration anesthesia in minor oculoplastic surgeries. Various anesthetics with adjuvants were compared with respect to injection pain, operative bleeding, and complications. Random-effects model was performed. The primary outcome of injection pain was measured using the visual analog scale (VAS) or a preference question (which intervention was the least painful). Other outcomes were operative bleeding and complications, which were evaluated with a similar preference question. RESULTS: Eleven randomized controlled trials (RCTs) of 521 patients (917 eyes) were included. The network meta-analysis revealed that "bicarbonate-buffered lidocaine with epinephrine" led to a significant decrease in injection pain (preference question) compared to "prilocaine with felypressin" and "lidocaine with epinephrine," whereas no significant differences were detected in the analysis of injection pain measured using the VAS. CONCLUSIONS: "Bicarbonate-buffered lidocaine with epinephrine" may be the optimal anesthetic solution for local infiltration in minor oculoplastic surgeries due to reduced injection pain, operative bleeding, and postoperative swelling. However, this should be interpreted cautiously as the confidence in the evidence was very low. THE CLINICAL TRIAL REGISTRATION NUMBER: CRD42021260332 (PROSPERO).

Prophylactic antiemetic effects of dexamethasone versus 5-HT3 receptor antagonists in ear surgery: a systematic review and meta-analysis.

Background The optimal strategy for reducing the high incidence of postoperative nausea and vomiting (PONV) after otologic surgical procedures remains inconclusive. Aim of the review This study compared the prophylactic antiemetic effects of dexamethasone with 5-hydroxytryptamine 3 receptor antagonists (5-HT3-RAs) in ear surgery. Method PubMed, Embase, and Cochrane Library were searched up to October 31, 2020 for randomized controlled trials that used dexamethasone either singly or in combination with 5-HT3-RAs for PONV prophylaxis in adults undergoing ear surgery. Studies in languages other than English and those without a control group of 5-HT3-RAs were excluded. Random effects meta-analyses were performed, and risk of bias was assessed using the version 2 of the Cochrane risk-of-bias tool. Main outcome measures include incidences of early (< 6 h) and overall (0-48 h) PONV, the overall requirement for rescue antiemetics, and the occurrence of adverse events. Results Eight trials of 733 adults were included, and the overall risks of bias were generally low. Pooled risk ratios (RRs) of early and overall PONV of dexamethasone versus 5-HT3-RAs were 2.0 (95% CI 0.8-5.1, I2 = 82%), and 1.3 (95% CI 0.6-2.6, I2 = 86%). In studies comparing dexamethasone plus 5-HT3-RAs with 5-HT3-RAs alone, pooled RRs of early and overall PONV were 0.8 (95% CI 0.4-1.4, I2 = 30%), and 0.5 (95% CI 0.3-0.6, I2 = 0%), respectively. Pooled RRs of the overall need for rescue antiemetics comparing 5-HT3-RAs with dexamethasone alone and in combination with 5-HT3-RAs were 1.2 (95% CI 0.4-3.9, I2 = 73%) and 0.4 (95% CI 0.1-1.4, I2 = 61%), respectively. Common adverse events reported were headache and dizziness, and the incidences range from 0 to 10% without significant differences between the groups. Conclusion The prophylactic antiemetic effects of dexamethasone versus 5-HT3-RAs in ear surgery did not significantly differ in the early and overall postoperative phases. The combination of dexamethasone with 5-HT3-RAs showed superior overall PONV prophylactic effects to 5-HT3-RAs alone in ear surgery, but their differences in the need for rescue antiemetics remained non-significant.

Central Corneal Thickness of Healthy Lowlanders at High Altitude: A Systematic Review and Meta-Analysis.

PURPOSE: Central corneal thickness, a marker of corneal hydration and metabolism, was reported to increase at high elevations. This study aimed to assess the effect of chronic high-altitude exposure on the central corneal thickness of healthy lowlanders with unoperated corneas, and determine if a relationship exists between exposure time and corneal edema formation. MATERIALS AND METHODS: The PubMed, Embase, Scopus, Cochrane Library, and Airiti Library databases were searched up to 2017 January 31 for prospective cohort studies performed above 2500 m in healthy lowlanders with measurements of the central corneal thickness. Subjects with prior eye surgery, contact lens, and non-hypobaric hypoxic exposure were excluded. RESULTS: Seven studies of 207 adults were included. The pooled effect of high-altitude exposure on the central corneal thickness for < 12 hours, 3-5 days, 6-7 days, and > 10 days was a mean difference of 13.4 (95% confidence interval: 5.1-21.6) µm with moderate heterogeneity (p < 0.05, I2 = 59%), 19.3 (95% confidence interval: 9.7-29) µm with low heterogeneity (p = 0.88, I2 = 0%), 20.4 (95% confidence interval: 10.3-30.5) µm with low heterogeneity (p = 0.73, I2 = 0%), and 30.8 (95% confidence interval: 20.4-41.2) µm with low heterogeneity (p = 0.69, I2 = 0%), respectively. Baseline differences between pre-exposure and post-exposure were not statistically significant. Regression analysis revealed a significant linear relation between high-altitude exposure time and corneal edema formation that exceeded 5% after 10 days. CONCLUSIONS: High-altitude exposure induces central corneal thickening with significant linear progression over time, whereas it takes over 10 days to reach clinical significance in healthy lowlanders with unoperated corneas, and changes in central corneal thickness are reversible after descent to lower elevations.

The effect of acetazolamide on sleep apnea at high altitude: a systematic review and meta-analysis.

BACKGROUND: Acetazolamide has been investigated for treating sleep apnea in newcomers ascending to high altitude. This study aimed to assess the effect of acetazolamide on sleep apnea at high altitude, determine the optimal therapeutic dose, and compare its effectiveness in healthy trekkers and obstructive sleep apnea (OSA) patients. METHODS: PubMed, Embase, Scopus, Cochrane Library, and Airiti Library databases were searched up to July 2015 for randomized controlled trials (RCTs) performed above 2500 m in lowlanders and that used acetazolamide as intervention in sleep studies. Studies including participants with medical conditions other than OSA were excluded. RESULTS: Eight studies of 190 adults were included. In healthy participants, the pooled mean effect sizes of acetazolamide on Apnea-Hypopnea Index (AHI), percentage of periodic breathing time, and nocturnal oxygenation were 34.66 [95% confidence interval (CI) 25.01-44.30] with low heterogeneity ( p = 0.7, I2 = 0%), 38.56% (95% CI 18.92-58.19%) with low heterogeneity ( p = 0.24, I2 = 28%), and 4.75% (95% CI 1.35-8.15%) with high heterogeneity ( p < 0.01, I2 = 87%), respectively. In OSA patients, the pooled mean effect sizes of acetazolamide on AHI and nocturnal oxygenation were 13.18 (95% CI 9.25-17.1) with low heterogeneity ( p = 0.33, I2 = 0%) and 1.85% (95% CI 1.08-2.62%) with low heterogeneity ( P = 0.56, I2 = 0%). CONCLUSIONS: Acetazolamide improves sleep apnea at high altitude by decreasing AHI and percentage of periodic breathing time and increasing nocturnal oxygenation. Acetazolamide is more beneficial in healthy participants than in OSA patients, and a 250 mg daily dose may be as effective as higher daily doses for healthy trekkers.

Obstructive sleep apnea rather than diabetes or obesity associated with proteinuria in late mid-aged male workers: a decision tree analysis.

BACKGROUND: Both proteinuria and obstructive sleep apnea (OSA) are associated with cardiovascular events and consequent mortality. To examine whether age, OSA, diabetes, and obesity are potential predictors of proteinuria, a data-driven analysis was performed to delineate a potential categorical classification algorithm. METHODS: In this cross-sectional community-based cohort study, demographic data, blood pressure, serum biochemical analyses, proteinuria via single dipstick urinalysis, and overnight polysomnographies were measured in 300 males with sedentary work styles. RESULTS: Sixty-one (20.3 %) of all these participants had proteinuria. Logistic regression analysis showed that glycated hemoglobin (HbA1c), duration of arterial oxygen saturation <90 %, age, and log high-sensitivity C-reactive protein, but not apnea-hypopnea index (AHI), were responsible for 16.7 % of the variance of proteinuria's presence. A decision tree analysis showed that subjects over 49 years old had a higher risk for proteinuria than those subjects of 49 years old, or less. In the over 49-year-old group, subjects with an AHI >21 events/h had a higher risk for proteinuria; whereas in the 49-year-old and less group, subjects with HbA1c >7 %, or with HbA1c ≤7, and body mass index (BMI) >27.4 kg/m(2) had a higher risk for proteinuria than their counterparts. CONCLUSIONS: AHI was the major determinant responsible for the presence of proteinuria in late mid-aged male workers, while HbA1c and BMI were found in the junior subgroup. By algorithmic analysis, this study provides a comprehensive hierarchical model for better understanding of the correlates of proteinuria and sleep apnea.

Cardiac Fas-dependent and mitochondria-dependent apoptosis after chronic cocaine abuse.

To evaluate whether chronic cocaine abuse will increase cardiac Fas-dependent and mitochondria-dependent apoptotic pathways, thirty-two male Wistar rats at 3-4 months of age were randomly divided into a vehicle-treated group (phosphate-buffered saline, PBS, 0.5 mL, SQ per day) and a cocaine-treated group (Cocaine, 10 mg/kg, SQ per day). After 3 months of treatment, the excised left ventricles were measured by H&E staining, Western blotting, DAPI staining and TUNEL assays. More cardiac TUNEL-positive apoptotic cells were observed in the Cocaine group than the PBS group. Protein levels of TNF-alpha, Fas ligand, Fas death receptor, FADD, activated caspase-8, and activated caspase-3 (Fas-dependent apoptosis) extracted from excised hearts in the Cocaine group were significantly increased, compared to the PBS group. Protein levels of cardiac Bax, cytosolic cytochrome c, t-Bid-to-Bid, Bak-to-Bcl-xL, Bax-to-Bcl-2 ratio, activated caspase-9, and activated caspase-3 (mitochondria-dependent apoptosis) were significantly increased in the Cocaine group, compared to the PBS group. Chronic cocaine exposure appeared to activate the cardiac Fas-dependent and mitochondria-dependent apoptosis, which may indicate a possible mechanism for the development of cardiac abnormalities in humans with chronic cocaine abuse.

Chronic methamphetamine exposure induces cardiac fas-dependent and mitochondria-dependent apoptosis.

Very limited information regarding the influence of chronic methamphetamine exposure on cardiac apoptosis is available. In this study, we evaluate whether chronic methamphetamine exposure will increase cardiac Fas-dependent (type I) and mitochondria-dependent (type II) apoptotic pathways. Thirty-two male Wistar rats at 3-4 months of age were randomly divided into a vehicle-treated group [phosphate-buffered saline (PBS) 0.5 ml SQ per day] and a methamphetamine-treated group (MA 10 mg/kg SQ per day) for 3 months. We report that after 3 months of exposure, abnormal myocardial architecture, more minor cardiac fibrosis and cardiac TUNEL-positive apoptotic cells were observed at greater frequency in the MA group than in the PBS group. Protein levels of TNF-α, Fas ligand, Fas receptor, Fas-associated death domain, activated caspase-8, and activated caspase-3 (Fas-dependent apoptosis) extracted from excised hearts were significantly increased in the MA group, compared to the PBS group. Protein levels of cardiac Bak, t-Bid, Bak to Bcl-xL ratio, activated caspase-9, and activated caspase-3 (mitochondria-dependent apoptosis) were significantly increased in the MA group, compared with the PBS group. The results from this study reveal that chronic methamphetamine exposure will activate cardiac Fas-dependent and mitochondria-dependent apoptotic pathways, which may indicate a possible mechanism for developing cardiac abnormalities in humans with chronic methamphetamine abuse.

Effects of 17beta-estradiol on cardiac apoptosis in ovariectomized rats.

OBJECTIVES: Cardiac apoptosis was found in ovariectomized rats without ischemia. Limited information regarding the protective effects of 17beta-estradiol (E2) on cardiac Fas-dependent and mitochondria-dependent apoptotic pathways after post-menopause or bilateral oophorectomy in women was available. METHODS: Forty-eight female Wistar rats at 6-7 months of age were divided into sham-operated group (Sham, n = 16) and bilateral ovariectomized group (n = 32). After 4 weeks of operation, rats in ovariectomized group were injected intraperitoneally with either saline (OVX, n = 16) or 10 microg/kg/day 17beta-estradiol (E2) for 10 weeks (OVX-E2, n = 16). The excised hearts were measured by Hematoxylin-eosin staining, DAPI staining, positive TUNEL assays, and Western Blotting. RESULTS: 17beta-estradiol (E2) decreased OVX-induced cardiac widely dispersed TUNEL-positive apoptotic cells. 17beta-estradiol (E2) decreased OVX-induced TNF-alpha, Fas ligand (Fas L), Fas death receptors (Fas), Fas-associated death domain (FADD), activated caspase 8, and activated caspase 3 (Fas pathways). 17beta-estradiol (E2) decreased OVX-induced proapoptotic t-Bid, Bax, Bax-to-Bcl2 ratio, Bax-to-BclXL ratio, activated caspase 9, and activated caspase 3 as well as increased anti-apoptotic Bcl2 and Bcl-XL relative to OVX (mitochondria pathway). CONCLUSIONS: Our findings suggest that chronic 17beta-estradiol (E2) treatment can prevent ovariectomy-induced cardiac Fas-dependent and mitochondria-dependent apoptotic pathways in rat models. The findings may provide one of possible mechenisms of 17beta-estradiol (E2) for potentially preventing cardiac apoptosis after bilateral ovariectomy or menopause.

Retrospective analysis of surgery postponed or cancelled in the operating room.

STUDY OBJECTIVE: To analyze the reasons for postponement or cancellation of surgery in the operating room (OR), and to determine the effect on patient outcomes. DESIGN: Retrospective analysis. SETTING: University-affiliated hospital. MEASUREMENTS: Over a 5-year period, 45,663 surgeries requiring anesthesia occurred. Surgery was postponed or cancelled in the OR for 67 patients (0.15%). Airway problems, change in medical condition, and change in surgical condition were the reasons recorded. Each patient's surgical result was audited using medical charts and telephone calls for at least 6 months. MAIN RESULTS: 33 cases (49.3%) were postponed from one day to 6 months (range, one to 165 days; median, 8 days). The scheduled surgeries for 21 (31.3%) patients were never performed; and 9 patients (13.4%) died during their hospitalization (range, one to 20 days; mean, 12.7 days). CONCLUSIONS: Surgery was postponed or cancelled in the OR mainly for changes in medical condition (70.2%); either medical risk outweighed the benefits of surgery, or alternative treatments were used.

The relation between oxygen consumption and the equilibrated inspired oxygen fraction in an anesthetic circle breathing system: a mathematic formulation & laboratory simulations.

Measuring a patients' oxygen consumption (VO2) is valuable in critical care and during anesthesia. Up to now, there has been no satisfactory equation describing the relation between the VO2, the fresh gas, and F(I)O(2) in a semi-closed circle breathing system. By adopting a "volume-weighted average concentration" approach and stepwise calculations, we have proposed an equation. We constructed a model with known simulated O(2) consumption ((SIM)VO2) to test our equation and two other previous methods (Biro's and Azami's). After 32 different laboratory scenarios, the %-error of the calculated VO2 ((CAL)VO2) from our method is -4.0 +/- 2.9%, which is significantly better than those from Azami's method (-8.8 +/- 6.2%, p < 0.01) and from Biro's method (-27.4 +/- 5.1%, p < 0.01). We also produce a Bland-Altman analysis of our (CAL)VO2 and (SIM)VO2. The 95% limits of agreement are -18.6-3.3 mL/min with a mean bias of -7.7 mL/min, which shows a good agreement. Our equation also explains the difference between F(I)O(2) and the oxygen concentration of the fresh gas in a semi-closed circle breathing system.

The effects of low-dose fentanyl on emergence agitation and quality of life in patients with moderate developmental disabilities.

STUDY OBJECTIVE: To analyze whether emergence agitation could be reduced by using a low dosage of fentanyl without causing an increase in postoperative adverse effects and/or affecting the patient's quality of life after discharge. DESIGN: Randomized, controlled crossover trial. SETTING: University medical center. PATIENTS: One hundred ten ASA physical status I and II ambulatory patients with moderate developmental disabilities who received anesthesia for dental care. INTERVENTIONS: During their first visit, patients were randomly treated either with a placebo or a 1- to 1.5-microg/kg dose of fentanyl before inserting a reinforced laryngeal mask airway and treated with the remaining method during their second visit 6 to 12 months later. MEASUREMENTS: Measured variables included anesthetic and emergence period, the occurrence of emergence agitation, and postanesthetic adverse effects such as nausea and vomiting. After discharge, the patient's quality of life was evaluated based on disturbances in daily activity, eating habit, and sleeping behavior. Results were analyzed by Student t test and McNemar test (P < 0.05). MAIN RESULTS: Between the two treatments, there was a significant difference in the frequency of emergence agitation (P = 0.04) but no postoperative adverse effects such as postoperative nausea and vomiting. We also found no significant disturbances in the patient's quality of life according to daily activity, eating habits, or sleeping behavior. CONCLUSION: Emergence agitation may be reduced by using 1 to 1.5 microg/kg of fentanyl during induction while maintaining anesthesia by sevoflurane in patients with moderate developmental disabilities undergoing dental care, without causing an increase in postoperative adverse effects and affecting the patient's life quality after discharge.

Improving the success rate of laryngeal mask airway insertion during etomidate induction by using fentanyl or succinylcholine.

BACKGROUND: Smooth and successful insertion of a laryngeal mask airway (LMA) during etomidate induction requires a proper mouth opening and efforts to minimize airway reflexes such as gagging, coughing, or laryngospasm. We hypothesized that the concurrent use of fentanyl or succinylcholine with etomidate, the induction agent, could reduce the occurrence of airway reflexes and increase the success rate of LMA. METHODS: Sixty adult patients, ASA class I-II, scheduled for surgery under general anesthesia, were randomly allocated into three groups: group I in which patients were given etomidate 0.3 mg/kg alone; group 2 in which patients were given fentanyl 2 microg/kg and etomidate 0.3 mg/kg; groups 3 in which patients were give etomidate 0.3 mg/kg and succinylcholine 1 mg/kg. All patients were premedicated with atropine 0.01 mg/kg. When induction of anesthesia began we recorded the time from administering the designated regiminal agent or agents to the time of relaxation of jaw (the ease of mouth opening) and checked the patient for any excitatory movement after administering the induction agents. After inserting the LMA, we checked for signs of airway reflexes. Student's t test, Chi-square and Fisher's exact test were used to analyze the data. A value of P < 0.05 was considered significant. RESULTS: There were no significant differences in demographic data among the the three groups. The concurrent use of fentanyl or succinylcholine with etomidate during induction could significantly reduce the occurrence of excitatory movements and airway reflexes after LMA insertion, and increase the success rate of LMA insertion in comparison with using etomidate alone. Comparing the two adjutant agents, the concurrent use of succinylcholine could provide a significantly better jaw relaxation, shorten the time to insert the LMA and increase the success rate of LMA insertion. CONCLUSIONS: As an induction agent to facilitate insertion of LMA, etomidate alone was far from perfect. The concurrent use of 2 microg/kg of fentanyl with etomidate might significantly reduce the occurrence of airway reflexes in response to LMA insertion and increase the success rate of insertion. However, concurrent use of 1 mg/kg succinylcholine with etomidate might provide better results in terms of shortened time for the LMA insertion, jaw relaxation, and the success rate of LMA insertion than that of fentanyl.

Evaluation of airway leakage using reinforced laryngeal mask during dental anesthesia with spontaneous breathing.

BACKGROUND: The purpose of this study was to evaluate whether manipulation or position change of the head during dental procedures for handicapped patients (mentally retarded) using a reinforced laryngeal mask airway for ventilation would lead to air leak. METHODS: All patients had a reinforced laryngeal mask airway inserted after induction of anesthesia; anesthesia was maintained with sevoflurane. Normal saline stained with methylene blue was instilled into the oral cavity of the patient. Then, the patient's laryngeal region was checked for blue staining with a fiberoptic bronchoscope. After dental treatment, the laryngeal region was checked again under fiberoptic bronchoscopy. The staining results were recorded and analyzed. RESULTS: In one of 51 patients (1.96%), the laryngeal region was stained blue after the flexible laryngeal mask airway was inserted. In ten of 51 (19.6%) patients, the laryngeal area was stained blue after the dental procedure. One of the ten patients who had a leak because the laryngeal mask was pulled out during the dental procedure. And in another one patient endotracheal tube was placed in lieu of laryngeal mask due to severe leakage. No oxygen desaturation below 90% occurred in all patients. No major complications such as fever or aspiration pneumonia were reported. CONCLUSIONS: The use of a reinforced laryngeal mask airway eliminates the complications due to endotracheal intubation and enhances the progress of the dental procedure. Although leakage may happen during dental manipulation, it usually does not raise serious problem. No serious complications such as aspiration were found in our cases. So a reinforced laryngeal mask airway may be considered to be another safe choice for maintenance of a patent airway in handicapped patients during dental procedures.