Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis

Abstract Background The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) in intubated COVID-19 patients. Methods Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded. Results Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO2/FiO2 ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO2) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO2) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p= 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p= 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p= 0.28; evidence: very low). Conclusion Prone ventilation improved PaO2/FiO2 ratio and SpO2 in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.

The use of cerebral oximetry in cardiac surgery: A systematic review and meta-analysis of randomized controlled trials.

High prevalence of cerebral desaturation is associated with postoperative neurological complications in cardiac surgery. However, the evidence use of cerebral oximetry by correcting cerebral desaturation in the reduction of postoperative complications remains uncertain in the literature. This systematic review and meta-analysis aimed to examine the effect of cerebral oximetry on the incidence of postoperative cognitive dysfunction in cardiac surgery. Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception until April 2021. All randomized controlled trials comparing cerebral oximetry and blinded/no cerebral oximetry in adult patients undergoing cardiac surgery were included. Observational studies, case series, and case reports were excluded. A total of 14 trials (n = 2,033) were included in this review. Our pooled data demonstrated that patients with cerebral oximetry were associated with a lower incidence of postoperative cognitive dysfunction than the control group (studies = 4, n = 609, odds ratio [OR]: 0.15, 95% confidence interval [CI]: 0.04 to 0.54, P = 0.003, I2 = 88%; certainty of evidence = very low). In terms of postoperative delirium (OR: 0.75, 95%CI: 0.50-1.14, P = 0.18, I2 = 0%; certainty of evidence = low) and postoperative stroke (OR: 0.81 95%CI: 0.37-1.80, P = 0.61, I2 = 0%; certainty of evidence = high), no significant differences (P > 0.05) were reported between the cerebral oximetry and control groups. In this meta-analysis, the use of cerebral oximetry monitoring in cardiac surgery demonstrated a lower incidence of postoperative cognitive dysfunction. However, this finding must be interpreted with caution due to the low level of evidence, high degree of heterogeneity, lack of standardized cognitive assessments, and cerebral desaturation interventions.

Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis.

BACKGROUND: The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) in intubated COVID-19 patients. METHODS: Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded. RESULTS: Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO2/FiO2 ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO2) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO2) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low). CONCLUSION: Prone ventilation improved PaO2/FiO2 ratio and SpO2 in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.

The Use of Cerebral Oximetry in Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: The evidence on the use of cerebral oximetry during surgery to minimize postoperative neurologic complications remains uncertain in the literature. The present authors aimed to assess the value of cerebral oximetry in the prevention of postoperative cognitive dysfunction, postoperative delirium, and postoperative stroke in adults undergoing surgery. DESIGN: A systematic review and meta-analysis. SETTING: The surgery room. PARTICIPANTS: Adult patients (ages ≥18 years) undergoing surgery. INTERVENTIONS: Cerebral oximetry monitoring. MEASUREMENTS AND MAIN RESULTS: Databases of Ovid MEDLINE, Ovid EMBASE, and CENTRAL were systematically searched from their inception until December 2020 for randomized controlled trials comparing cerebral oximetry monitoring with either blinded or no cerebral oximetry monitoring in adults undergoing surgery. Observational studies, case reports, and case series were excluded. Seventeen studies (n = 2,120 patients) were included for quantitative meta-analysis. Patients who were randomized to cerebral oximetry monitoring had a lower incidence of postoperative cognitive dysfunction (studies = seven, n = 969, odds ratio [OR] 0.23, 95% confidence interval [CI] 0.11-0.48, p = 0.0001; evidence = very low). However, no significant differences were observed in the incidence of postoperative delirium (studies = five, n = 716, OR 0.81, 95% CI 0.53-1.25, p = 0.35; evidence = high), and postoperative stroke (studies = seven, n = 1,087, OR 0.72, 95% CI 0.30-1.69, p = 0.45; evidence = moderate). CONCLUSION: Adult patients with cerebral oximetry monitoring were associated with a significant reduction of postoperative cognitive dysfunction. However, given the low certainty of evidence and substantial heterogeneity, more randomized controlled trials using standardized assessment tools for postoperative cognitive dysfunction and interventions of correcting cerebral desaturation are warranted to improve the certainty of evidence and homogeneity.

l-carnitine and l-acetylcarnitine supplementation for idiopathic male infertility.

Fifteen percent of couples are globally estimated to be infertile, with up to half of these cases attributed to male infertility. Reactive oxidative species (ROS) are known to damage sperm leading to impaired quantity and quality. Although not routinely assessed, oxidative stress is a common underlying pathology in infertile men. Antioxidants have been shown to improve semen analysis parameters by reducing ROS and facilitating repair of damage caused by oxidative stress, but it remains unclear whether they improve fertility. Carnitines are naturally occurring antioxidants in mammals and are normally abundant in the epididymal luminal fluid of men. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of carnitine supplementation for idiopathic male infertility. We searched ClinicalKey, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, PubMed and ScienceDirect for relevant studies published from 1 January 2000 to 30 April 2020. Of the articles retrieved, only eight randomised controlled trials were identified and included. Analysis showed that carnitines significantly improve total sperm motility, progressive sperm motility and sperm morphology, but without effect on sperm concentration. There was no demonstrable effect on clinical pregnancy rate in the five studies that included that outcome, although patient numbers were limited. Therefore, the use of carnitines in male infertility appears to improve some sperm parameters but without evidence of an increase in the chance of natural conception. LAY SUMMARY: Although male infertility affects 1:15 men, there is no obvious reason in the vast majority of cases. Reactive oxidative species (ROS) are highly active molecules containing oxygen and are natural byproducts of normal metabolism. However, high concentrations of ROS have been shown to damage sperm, which negatively impacts a couple's ability to conceive. Carnitines are natural antioxidants found in the body that counterbalance the damaging effects of ROS. We conducted a comprehensive review of published studies to assess whether carnitine supplements are safe and effective in improving sperm quality and pregnancy rates. Our analysis shows that carnitines improve sperm swimming and production of normal-shaped sperm cells but do not affect sperm count or pregnancy rates, although there are only a few studies and scientific evidence is limited. Whilst it is possible that carnitines may benefit male infertility, more evidence is required regarding chances of pregnancy after carnitine therapy.