The efficacy of peri‐operative interventions to decrease postoperative delirium in non‐cardiac surgery: a systematic review and meta‐analysis.

The purpose of this meta‐analysis was to determine the efficacy of peri‐operative interventions in decreasing the incidence of postoperative delirium. An electronic search of four databases was conducted. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were adhered to. We included randomised controlled trials of non‐cardiac surgery with a peri‐operative intervention and that reported postoperative delirium, and identified 29 trials. Meta‐analysis revealed that peri‐operative geriatric consultation (OR 0.46, 95% CI 0.32–0.67) and lighter anaesthesia (OR 2.66, 95% CI 1.27–5.56) were associated with a decreased incidence of postoperative delirium. For the other interventions, the point estimate suggested possible protection with prophylactic haloperidol (OR 0.62, 95% CI 0.36–1.05), bright light therapy (OR 0.20, 95% CI 0.03–1.19) and general as opposed to regional anaesthesia (OR 0.76, 95% CI 0.47–1.23). This meta‐analysis has shown that peri‐operative geriatric consultations with multicomponent interventions and lighter anaesthesia are potentially effective in decreasing the incidence of postoperative delirium.     

Validation of a point‐of‐care prothrombin time test after cardiopulmonary bypass in cardiac surgery

Point‐of‐care coagulation monitoring can be used for the guidance of haemostasis management. However, the influence of time on point‐of‐care prothrombin time testing following protamine administration after cardiopulmonary bypass has not been investigated. Bland–Altman and error grid analysis were used to analyse the level of agreement between prothrombin time measurements from point‐of‐care and laboratory tests before cardiopulmonary bypass, and then 3 min, 6 min and 10 min after protamine administration. Prothrombin times were expressed as International Normalised Ratios. While the point‐of‐care and laboratory prothrombin time measurements showed a high level of agreement before bypass, this agreement deteriorated following protamine administration to a mean (SD) bias of ?0.22 (0.13) [limits of agreement 0.48–0.04]. Error grid analysis revealed that 35 (70%) of the paired values showed a clinically relevant discrepancy in international normalised ratio. At 3 min, 6 min and 10 min after cardiopulmonary bypass there is a clinical unacceptable discrepancy between the point‐of‐care and laboratory measurement of prothrombin time.     

Prophylactic arterial ligation following transoral robotic surgery: A systematic review and meta‐analysis

Prophylactic arterial ligation has been proposed to reduce the severity of postoperative hemorrhage following transoral robotic surgery (TORS). Previous studies have shown a trend toward a reduction in major and severe bleeding. Search strategies were implemented in multiple databases and completed in August 2018. Inclusion and exclusion criteria were designed to capture studies examining adults undergoing TORS for oropharyngeal cancer. Four retrospective studies were selected appropriate for analysis by two reviewers who independently extracted data. PRISMA guidelines were followed. A random‐effects model was used for meta‐analysis. Meta‐analysis of 619 patients in four retrospective reviews showed that the pooled RR of major and severe bleeding events was significantly lower in prophylactically ligated patients (RR, 0.28; 95% CI, 0.08‐0.92; I² = 0). Prophylactic arterial ligation of external carotid artery branches is associated with a decreased risk of major and severe bleeding events, although confounding factors remain incompletely analyzed.     

Effects of levosimendan on mortality in patients undergoing cardiac surgery: A systematic review and meta‐analysis

Purpose

We sought to determine the impact of levosimendan on mortality following cardiac surgery based on large‐scale randomized controlled trials (RCTs).

Methods

We searched PubMed, Web of Science, Cochrane databases, and ClinicalTrials.gov for RCTs published up to December 2017, on levosimendan for patients undergoing cardiac surgery.

Results

A total of 25 RCTs enrolling 2960 patients met the inclusion criteria; data from 15 placebo‐controlled randomized trials were included for meta‐analysis. Pooled analysis showed that the all‐cause mortality rate was 6.4% (71 of 1106) in the levosimendan group and 8.4% (93 of 1108) in the placebo group (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.55‐1.04; P = 0.09). There were no significant differences between the two groups in the rates of myocardial infarction (OR: 0.91; 95% CI, 0.68‐1.21; P = 0.52), serious adverse events (OR: 0.84; 95% CI, 0.66‐1.07; P = 0.17), hypotension (OR: 1.69; 95% CI, 0.94‐3.03; P = 0.08), and low cardiac output syndrome (OR: 0.47; 95% CI, 0.22‐1.02; P = 0.05).

Conclusion

Levosimendan did not result in a reduction in mortality in adult cardiac surgery patients. Well designed, adequately powered, multicenter trials are necessary to determine the role of levosimendan in adult cardiac surgery.     

Mean platelet volume,platelet distribution width and platelet count in erectile dysfunction: A systematic review and meta‐analysis

The aim of this study was to investigate the relationship between mean platelet volume (MPV), platelet distribution width (PDW), platelet count (PC) and erectile dysfunction (ED). We searched for observational studies from PubMed, EMBASE, Web of Science and CNKI up to 31 March 2016. Two reviewers independently selected the studies and extracted the data. MPV, PDW, and PC and mean differences in these platelet indices between healthy subjects and ED patients were explored using the Comprehensive Meta‐Analysis software package. Seven studies including 795 patients and 524 healthy subjects met the inclusion criteria. The MPV was significantly larger in patients with ED than controls with the standardised mean difference of 0.596 fL (95% CI: 0.378, 0.815, p < 0.001). In ED patients, the pooled mean difference in MPV between vasculogenic ED patients and nonvasculogenic ED patients was 0.706 fL in case–control studies (95% CI: 0.410, 1.002, p < 0.001). There was no significant difference in PDW and PC between healthy subjects and ED patients. The available data suggest that larger MPV was associated with ED. Patients with vasculogenic ED tend to have higher MPV than nonvasculogenic ED patients. Further studies are needed to assess whether increased MPV in ED patients is associated with increased cardiovascular disease.     

Diagnostic point‐of‐care ultrasound: applications in obstetric anaesthetic management

Complications during pregnancy are not frequent, but may occur abruptly. Point‐of‐care ultrasound is a non‐invasive, non‐ionising diagnostic tool that is available at the bed‐side when complications occur. This review covers the use of ultrasound in various clinical situations. Gastric ultrasound can identify stomach contents that put the woman at risk for pulmonary aspiration. In the future, this tool will probably be used routinely before induction of anaesthesia to determine the presence of stomach contents above a particular risk threshold. Difficult tracheal intubation, and the potential for ‘can't intubate, can't oxygenate’, is more frequent in pregnant women. Point‐of‐care ultrasound of the airway allows accurate identification of the cricothyroid membrane, permitting rapid and safer establishment of front‐of‐neck airway access. Combined cardiac and lung ultrasound can determine the potential risk:benefit of fluid administration in the pregnant patient. Such prediction is of critical importance, given the tendency of pregnant women to develop pulmonary oedema. Combined echocardiography and lung ultrasound can be combined with ultrasound of the leg veins to differentiate between the various causes of acute respiratory failure, and guide treatment in this situation. Finally, as shown in the general population, multi‐organ point‐of‐care ultrasound allows early diagnosis of the main causes of circulatory failure and cardiac arrest at the bed‐side. As the importance of point‐of‐care ultrasound in critical patients is increasingly recognised, it is emerging as an important tool in the therapeutic armoury of obstetric anaesthetists.     

The effect of antiplatelet therapy on survival and cardiac allograft vasculopathy following heart transplantation: A systematic review and meta‐analysis

Cardiac allograft vasculopathy (CAV) is mediated by endothelial inflammation, platelet activation and thrombosis. Antiplatelet therapy may prevent the development of CAV. This systematic review and meta‐analysis summarizes and appraises the evidence on the effect of antiplatelet therapy after heart transplantation (HT). CENTRAL(Ovid), MEDLINE(Ovid), Embase(Ovid) were searched from inception until April 30, 2020. Outcomes included CAV, all‐cause mortality, and CAV‐related mortality. Data were pooled using random‐effects models. Seven observational studies including 2023 patients, mean age 52 years, 22% female, 47% with ischemic cardiomyopathy followed over a mean 7.1 years proved eligible. All studies compared acetylsalicylic acid (ASA) to no treatment and were at serious risk of bias. Data from 1911 patients in 6 studies were pooled in the meta‐analyses. The evidence is very uncertain about the effect of ASA on all‐cause or CAV‐related mortality. ASA may reduce the development of CAV (RR 0.75, 95% CI: 0.44–1.29) based on very low certainty evidence. Two studies that conducted propensity‐weighted analyses showed further reduction in CAV with ASA (HR 0.31, 95% CI: 0.13–0.74). In conclusion, there is limited evidence that ASA may reduce the development of CAV. Definitive resolution of the impact of antiplatelet therapy on CAV and mortality will require randomized clinical trials.     

A systematic review and meta‐regression analysis of prophylactic gabapentin for postoperative pain

We searched MEDLINE, Embase, CINAHL, AMED and CENTRAL databases until December 2014 and included 133 randomised controlled trials of peri‐operative gabapentin vs placebo. Gabapentin reduced mean (95% CI) 24‐h morphine‐equivalent consumption by 8.44 (7.26–9.62) mg, p < 0.001, whereas more specific reductions in morphine equivalents were predicted (R² = 90%, p < 0.001) by the meta‐regression equation: 3.73 + (?0.378 × control morphine consumption (mg)) + (?0.0023 × gabapentin dose (mg)) + (?1.917 × anaesthetic type), where ‘anaesthetic type’ is ‘1’ for general anaesthesia and ‘0’ for spinal anaesthesia. The type of surgery was not independently associated with gabapentin effect. Gabapentin reduced postoperative pain scores on a 10‐point scale at 1 h, 2 h, 6 h, 12 h and 24 h by a mean (95% CI) of: 1.68 (1.35–2.01); 1.21 (0.88–1.55); 1.28 (0.98–1.57); 1.12 (0.91–1.33); and 0.71 (0.56–0.87), respectively, p < 0.001 for all. The risk ratios (95% CI) for postoperative nausea, vomiting, pruritus and sedation with gabapentin were: 0.78 (0.69–0.87), 0.67 (0.59–0.76), 0.64 (0.51–0.80) and 1.18 (1.09–1.28), respectively, p < 0.001 for all. Gabapentin reduced pre‐operative anxiety and increased patient satisfaction on a 10‐point scale by a mean (95% CI) of 1.52 (0.78–2.26) points and 0.89 (0.22–1.57) points, p < 0.001 and p = 0.01, respectively. All the effects of gabapentin may have been overestimated by statistically significant small study effects.     

Examining the effects of HIV self‐testing compared to standard HIV testing services: a systematic review and meta‐analysis

Introduction : HIV self‐testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV‐positive persons, linkage to care, social harm, and risk behaviour. Methods : We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta‐analyses of studies reporting comparable outcomes were conducted using a random‐effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE. Results : After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral‐fluid rapid tests for HIVST and were among men. Meta‐analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta‐analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12–15‐month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta‐analysis of two RCTs showed HIVST also doubled the likelihood of an HIV‐positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk‐taking behaviour appeared to be minimal. Conclusions : HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV‐positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.     

The effect of ondansetron on the efficacy of postoperative tramadol: a systematic review and meta‐analysis of a drug interaction

Several studies have investigated the presence of a drug interaction between tramadol and ondansetron that reduced the efficacy of tramadol postoperatively. Most of these studies were small and the results inconsistent, so we performed a systematic review and meta‐analysis of randomised controlled trials comparing the cumulative dose of tramadol administered by patient‐controlled analgesia within the first 24 h after surgery between subjects receiving tramadol alone and those who received tramadol with ondansetron. Six studies, with a total of 340 participants, met the selection criteria and were included in the meta‐analysis. There was an increased tramadol requirement in patients receiving ondansetron. The standardised mean difference in tramadol requirements, expressed in terms of standard deviations (95% CI), was 1.03 (0.54–1.53) (p < 0.001) at 4 h, 0.66 (0.06–1.25) (p = 0.03) at 8 h, 0.86 (0.41–1.31) (p < 0.001) at 12 h and 0.45 (0.01–0.90) (p = 0.046) at 24 h postoperatively, where the mean pooled standard deviations were 79.5, 157.7, 238.1 and 289.4 mg at 4, 8, 12 and 24 h, respectively. There was a significant linear time effect over the 24 h, indicating that the effect of ondansetron on tramadol consumption diminished with time. The results support the presence of a drug interaction between tramadol and ondansetron in the early postoperative period that potentially decreases the effectiveness of tramadol.