What is the clinically significant ideal mesenchymal stromal cell count in the management of osteoarthritis of the knee? – Meta-analysis of randomized controlled trials

Study designMeta-analysis.ObjectivesWe aim to identify the clinically significant ideal Mesenchymal Stem Cell (MSC) count in the management of osteoarthritis of knee from Randomized Controlled Trials (RCTs) available in the literature.Materials and methodsWe conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science, and Cochrane Library till August 2021 for RCTs conducted in the management of knee osteoarthritis using MSC therapy specifying the quantity of MSCs delivered. We categorized the studies based on the MSC count utilized in them into four groups namely <1 × 10⁷ MSCs (Group I), 1-5x10⁷ MSCs (Group II), 5-10 × 10⁷ MSCs (Group III), and >10 × 10⁷ MSCs (Group IV). Visual Analog Score (VAS) for Pain, Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Knee Osteoarthritis Outcome Score (KOOS), and adverse events were the outcomes analyzed. Analysis was performed in R-platform using OpenMeta [Analyst] software.Results14 studies involving 564 patients were included for analysis. We noted incremental decrease in the VAS with increasing dosage of MSCs at 12 months [Group I,WMD = 2.641(p = 0.854); Group II, WMD = −4.853(p = 0.379); Group III, WMD = −12.154 (p = 0.316); Group IV, WMD = −15.935(p = 0.116)], and 24 months [Group I,WMD = −6(p = 0.001); Group II, WMD = −15(p = 0.001); Group IV, WMD = −20(p = 0.001)]. We also noted incremental improvement in the WOMAC, KOOS with increasing dosage of MSCs at 12 months [Group I, WMD = 7(p = 0.001); Group II, WMD = 28(p = 0.001); Group IV, WMD = 30(p = 0.001)] and [Group II, WMD = −2.562(p = 0.676); Group III, WMD = 7.670(p = 0.099); Group IV, WMD = 13.475(p = 0.261)] respectively. However, we noted significant reduction in the Lysholm score in Group IV, compared to the others at 12 months (WMD = −12.5, 95%CI[-25.883,0.883]) and 24 months (WMD = −6.6, 95%CI[-23.596,10.396]). We did not find any significant increase in the adverse events with incremental dosage of MSCs in any of the groups compared.ConclusionCompared to the four dosage groups of MSCs analyzed, Group III showed consistent significant improvement in pain and functional outcomes analyzed compared to the other groups. Hence, we recommend a cell volume of 5-10 × 10⁷ cells to be delivered to the target site to obtain superior benefits out of the procedure. However, we urge future trials of sufficient quality to validate our findings to arrive at a consensus on the ideal count of MSCs to be delivered in the cellular therapy for knee osteoarthritis.     

Perioperative intravenous S-ketamine for acute postoperative pain in adults: A systematic review and meta-analysis

Study objectiveTo evaluate the effectiveness and safety of S-ketamine for pain relief and analgesic consumption in surgical patients.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).SettingPerioperative setting.PatientsA total of 905 adult patients undergoing surgery using general anesthesia: 504 patients in the S-ketamine group and 401 patients in the placebo group.InterventionIntravenous S-ketamine as an adjuvant to general anesthesia compared with placebo.MeasurementsThe primary outcomes were resting and movement pain scores (VAS/NRS 0–10) and morphine consumption within 4, 12, 24 and 48 h after surgery. The secondary outcomes included postoperative complications such as nausea, vomiting, and psychotomimetic adverse events. We used the guidelines of the Recommendation Assessment, Development, and Evaluation (GRADE) system to evaluate the level of certainty for the main results.Main resultsA total of 12 studies were included. The types of surgery included abdominal surgery, thoracotomy, gynecologic surgery, arthroscopic anterior cruciate ligament repair, cardiac surgery, laparoscopic cholecystectomy, lumbar spinal fusion surgery, radical prostatectomy, and hemorrhoidectomy. There were significant improvements in resting pain scores at 4, 12 and 24 h with S-ketamine versus placebo [4 h: standardized mean difference (SMD) -1.11; 95% confidence interval (CI): −1.53, −0.68, p < 0.00001; GRADE = moderate; 12 h: SMD −0.88; 95%CI: −1.42, −0.34, p = 0.001; GRADE = moderate; 24 h: SMD -0.39; 95%CI: −0.73, −0.06, p = 0.02; GRADE = moderate]. The incidence of pain scores at 48 h showed no statistical difference between the two groups (SMD -0.27; 95%CI: −1.12, 0.58, p = 0.53, GRADE = moderate). The movement pain scores were not significantly different between the two groups at each time point (4 h: SMD −0.34; 95%CI: −0.73, 0.05, p = 0.09, GRADE = moderate; 12 h: SMD −0.42; 95%CI: −1.46, 0.63, p = 0.44, GRADE = low; 24 h: SMD −0.58; 95%CI: −1.25, 0.09, p = 0.09, GRADE = moderate; 48 h: SMD −0.49; 95%CI: −1.11, 0.14, p = 0.13, GRADE = low). At 4 and 12 h after surgery, the consumption of morphine was significantly reduced in the S-ketamine group (4 h: SMD −0.98; 95%CI: −1.37, −0.06, p < 0.00001, GRADE = moderate; 12 h: SMD −1.36; 95%CI: −2.26, −0.46, p = 0.003, GRADE = low). There were no significant differences in morphine use at 24 and 48 h between the two groups (24 h: SMD −0.70; 95%CI: −1.42, 0.02, p = 0.06, GRADE = low; 48 h: SMD −0.79; 95%CI: −2.26, 1.03, p = 0.39, GRADE = low). The risk for nausea [relative risk (RR) = 1.04; 95%CI: 0.83, 1.30, p = 0.73], vomiting (RR = 1.07; 95%CI: 0.84, 1.38, p = 0.57), and psychotomimetic adverse events (RR = 1.57; 95%CI: 0.82, 2.99, p = 0.17) showed no significant increase in the S-ketamine group.ConclusionsIntravenous S-ketamine as an adjunct to general anesthesia is effective for assisting analgesia and decreases the intensity of pain and opioid requirements in a short period of time after surgery, but it may increase the psychotomimetic adverse event rate. Overall, the level of certainty is moderate to low.     

Combined treatment of intraoperative cell-salvage and tranexamic acid for primary unilateral total hip arthroplasty: Are there added benefits?

BackgroundBlood management strategies in total hip arthroplasty (THA) are essential in reducing intraoperative blood loss, blood transfusion and associated complications. This study investigates whether using intraoperative cell-salvage (ICS) with tranexamic acid (TXA) has additional effects on blood loss and allogeneic transfusion in primary THA. Additionally, we evaluated the financial impact of using ICS on our institution.MethodsUsing an institutional database, 1171 cases of primary unilateral THA performed between May 2015 and January 2016 were identified. Subjects were separated into those who received only TXA (n = 323) and those who received TXA and ICS (n = 848). Calculated blood loss and post-operative blood transfusions were assessed using logistic regression. Drop in hematocrit was assessed using linear regression. Multivariable models adjusted for intraoperative blood transfusions, pre-operative autologous blood donation, anticoagulation medications, sex, and body mass index. Pricing data was used to calculate the costs associated with these interventions.ResultsThe likelihood of post-operative allogeneic blood transfusion was similar for the combined group relative to the TXA group (OR = 0.63; 95% CI: 0.26, 1.54), as was the likelihood of any post-operative blood transfusion (OR = 1.13; 95% CI: 0.63, 2.01). There was no correlative relationship between use of ICS and hematocrit drop when accounting for baseline hematocrit (R² = 0.118). Factoring in rental, service fees, and disposable equipment, the utilization of ICS added $146 to each case, resulting in a gross expenditure of over $123,000 during the study period.ConclusionsThe combination of ICS with TXA for primary unilateral THA did not improve blood loss or transfusion outcomes compared to TXA alone. As there was no observed clinical benefit to combined treatment, additional costs associated with routine usage of ICS may not be justifiable. Our institution would have reduced expenditures for blood loss management products by 85% during the study period if all patients had only received TXA.     

A meta-analysis of the three-dimensional reconstruction visualization technology for hepatectomy

This meta-analysis was conducted to systematically evaluate the short-term efficacy and safety of the three-dimensional (3D) reconstruction visualization technology (3D-RVT) technique for hepatectomy. A systematic literature search was used to gather information on the 3D reconstruction visualization technology technique for hepatectomy from retrospective cohort studies and comparative studies. The retrieval period was up to March 2022. Publications and conference papers in English were manually searched and references in bibliographies traced. After evaluating the quality of selected studies, a meta-analysis was conducted using Review Manager 5.1 software. We included 12 studies comprising 2053 patients with liver disease. Our meta-results showed that 3D-RVT significantly shortened operation times [weighted mean differences (WMD) = ?29.36; 95% confidence interval (CI): ?55.20 to ?3.51; P = 0.03], reduced intraoperative bleeding [WMD = ?93.53; 95% CI: ?152.32 to ?34.73; P = 0.002], reduced blood transfusion volume [WMD = ?66.06; 95% CI: ?109.13 to ?22.99; P = 0.003], and shortened hospital stays [WMD = ?1.90; 95% CI: ?3.05 to ?0.74; P = 0.001]. Additionally, the technique reduced the use of hepatic inflow occlusion and avoided overall postoperative complications [odds ratio (OR) = 0.60; 95% CI: 0.46 to 0.79; P < 0.001]. 3D-RVT is safe and effective for liver surgery and provides safety assessments before anatomical hepatectomy.     

Ensayo clínico para determinar si el momento de administración del ácido tranexámico en la cirugía de prótesis total de rodilla con torniquete influye en el sangrado perioperatorio

Background and objectivesThe ideal timing of tranexamic acid administration in total knee arthroplasty with tourniquet remains unclear. Our primary objective was to prove if administering it before surgical incision, instead of before releasing the tourniquet, reduces postoperative bleeding. A second objective was to determine whether a second dose reduces post-operative bleeding.Material and methodsA prospective, double-blind clinical trial was performed on 212 patients scheduled for total knee arthroplasty. They were randomised into 4 groups. Tranexamic acid was administered before the surgical incision in “pre-induction groups” (1 and 2), and just before the tourniquet release in “pre-release groups” (3 and 4). Groups 2 and 4 received a second dose 3 hours post-surgery. Main outcome was postoperative bleeding (visible blood loss and calculated total bleeding). Secondary outcomes were haemoglobin variations, complications and transfusion rate.ResultsThe mean calculated total bleeding was 1563 ml (95%CI: 1445 to 1681) in preinduction groups versus 1576 ml (95%CI: 1439 to 1713) in pre-release groups (P = .9); 1579 ml (95%CI: 1452 to 1706) in single-dose groups versus 1559 ml (95%CI: 1431 to 1686) in double-dose groups (P = .82). One patient was transfused. The mean haemoglobin at discharge was 10.4 g/dl (95%CI: 10.2 to 10.7) in singledose groups versus 10.8 (95%CI: 10.6 to 11.1) in double-dose groups (P = .06).ConclusionsThere were no differences in bleeding or transfusion regarding the time of tranexamic acid administration. The second dose had not impact on outcomes.Trial registration: EudraCT 2016-000071-24.     

Risk of fracture with thiazolidinediones: An updated meta-analysis of randomized clinical trials

ObjectiveThe use of thiazolidinediones (TZDs) has been associated with increased fracture risk. We performed a comprehensive literature review and meta-analysis to estimate the risk of fractures with TZDsMethodsWe searched MEDLINE, Embase and the Cochrane Database, from inception to May 2014. We included all randomized trials that described the risk of fractures or changes in bone mineral density (BMD) with TZDs. We pooled data with odds ratios (ORs) for fractures and the weighted mean difference in BMD. To assess heterogeneity in results of individual studies, we used Cochran's Q statistic and the I² statistic.ResultsWe included 24,544 participants with 896 fracture cases from 22 randomized controlled trials. Meta-analysis showed that the significantly increased incidence of fracture was found in women (OR = 1.94; 95%CI: 1.60–2.35; P < 0.001), but not in men (OR = 1.02; 95%CI: 0.83–1.27; P = 0.83). For women, the fracture risk was similar in rosiglitazone (OR = 2.01; 95%CI: 1.61–2.51; P < 0.001) and pioglitazone (OR = 1.73; 95%CI: 1.18–2.55; P = 0.005) treatment and appeared to be similar for participants aged < 60 years old (OR = 1.89; 95%CI: 1.51–2.36; P < 0.001) and aged ≥ 60 years old (OR = 2.07; 95%CI: 1.51–2.36; P < 0.001). There was a non-significant trend towards increased risk of fractures in different cumulative durations of TZD exposure. TZD treatment was also associated with significant changes in BMD among women at the lumbar spine(weighted mean difference: − 0.49%, 95%CI: − 0.66% to − 0.32%; P < 0.001), the femoral neck (weighted mean difference: − 0.34%, 95%CI: − 0.51% to − 0.16%; P < 0.001) and the hip(weighted mean difference: − 0.33%, 95%CI: − 0.52% to − 0.14%; P < 0.001).ConclusionsOur results suggest that TZD treatment is associated with an increased risk of fractures in women, effects of rosiglitazone and pioglitazone are similar, fracture risk is independent of age and fracture risk has no clear association with duration of TZD exposure.     

Tranexamic Acid Does Not Reduce the Risk of Transfusion in Rheumatoid Arthritis Patients Undergoing Total Joint Arthroplasty

BackgroundPatients with rheumatoid arthritis (RA) receive transfusions more often than patients with osteoarthritis following lower extremity total joint arthroplasty (TJA), but mitigating factors are not described. Tranexamic acid (TXA) is widely used to reduce blood loss in patients undergoing TJA, but its effect on transfusion rates in patients with RA has not been studied.MethodsWe retrospectively reviewed data from a prospectively collected cohort of patients with RA undergoing TJA. Disease activity measured by Clinical Disease Activity Index, patient-reported outcome measures, and serologies was obtained. Baseline characteristics were summarized and compared. Transfusion requirements and TXA usage were obtained from chart review. Logistic regression was used to determine factors associated with transfusion in RA patients undergoing TJA.ResultsThe cohort included 252 patients, mostly women with longstanding RA and end-stage arthritis requiring TJA. In multivariate analysis, 1 g/dL decrease in baseline hemoglobin (odds ratio [OR] = 0.394, 95% confidence interval [CI] [0.232, 0.669], P = .001), 1-minute increase in surgical duration (OR = 1.022, 95% CI [1.008, 1.037], P = .003), and 1-point increase in Clinical Disease Activity Index (OR = 1.079, 95% CI [1.001, 1.162]) were associated with increased risk of transfusion. TXA use was not associated with decreased risk of postoperative transfusion.ConclusionsPreoperative health optimization should include assessment and treatment of anemia in RA patients before TJA, as preoperative hemoglobin level is the main risk factor for postoperative transfusion. Increased disease activity and increased surgical time were independent risk factors for postoperative transfusion but are less modifiable. While TXA did not decrease transfusion risk in this population, a prospective trial is needed to confirm this.Level of EvidenceIV.     

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

IntroductionTopical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.MethodsA total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.ResultsThere was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760–1.795) in the TXA group and 1.078 L (IQR: 0.797–1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40–140) in the TXA group and 70 mL (IQR: 30–168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).ConclusionA 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.     

Tranexamic acid in burn surgery: A systematic review and meta-analysis

Burn injury causes a coagulopathy that is poorly understood. After severe burns, significant fluid losses are managed by aggressive resuscitation that can lead to hemodilution. These injuries are managed by early excision and grafting, which can cause significant bleeding and further decrease blood cell concentration. Tranexamic acid (TXA) is an anti-fibrinolytic that has been shown to reduce surgical blood losses; however, its use in burn surgery is not well established. We performed a systematic review and meta-analysis to investigate the influence TXA may have on burn surgery outcomes. Eight papers were included, with outcomes considered in a random-effects model meta-analysis. Overall, when compared to the control group, TXA significantly reduced total volume blood loss (mean difference (MD) = −192.44; 95% confidence interval (CI) = −297.73 to − 87.14; P = 0.0003), the ratio of blood loss to burn injury total body surface area (TBSA) (MD = −7.31; 95% CI = −10.77 to −3.84; P 0.0001), blood loss per unit area treated (MD = −0.59; 95% CI = −0.97 to −0.20; P = 0.003), and the number of patients receiving a transfusion intraoperatively (risk difference (RD) = −0.16; 95% CI = −0.32 to − 0.01; P = 0.04). Additionally, there were no noticeable differences in venous thromboembolism (VTE) events (RD = 0.00; 95% CI = −0.03 to 0.03; P = 0.98) and mortality (RD = 0.00; 95% CI = −0.03 to 0.04; P = 0.86). In conclusion, TXA can potentially be a pharmacologic intervention that reduces blood losses and transfusions in burn surgery without increasing the risk of VTE events or mortality.     

The role of tranexamic acid in reducing post-operative bleeding and seroma formation in breast surgery: A meta-analysis

IntroductionTranexamic acid (TXA) reduces blood loss and blood transfusion requirements in surgery. Seroma and haematoma formation occur as complications of breast surgery. We aimed to perform a meta-analysis evaluating TXA in reducing post-operative haematoma and seroma formation for breast surgery.MethodsA systematic review was performed in accordance with PRISMA guidelines. Results were expressed as dichotomous variables pooled as odds ratios (OR) with corresponding 95% confidence intervals (CIs) using the Mantel–Haenszel method.ResultsSeven studies including 1446 patients were included. There were 1830 breast surgery procedures performed with TXA administered in 797 cases (43.6%). There was a significant reduction in haematoma rates in the TXA group (TXA: 3.184% (22/691) vs Control: 6.787% (64/943), OR: 0.41, 95% CI: 0.20–0.86, P = 0.020). Based on surgical procedure, haematoma rates were similar for TXA and control groups in cancer surgery (P = 0.230). Haematoma rates reduced following TXA use in cosmetic procedures (TXA: 3.807% (15/394) vs. Control: 9.091% (34/374), OR: 0.41, 95% CI: 0.22–0.75, P = 0.004). Haematoma rates were also reduced in procedures where axillary lymph node dissection (ALND) was not performed; in the TXA group, 3.379% (22/651) developed a haematoma versus 6.623% (60/906) in the control group (OR: 0.45, 95% CI 0.27–0.77, P = 0.003). TXA administration did not impact seroma formation or infection rates.ConclusionPerioperative administration of TXA may impact the incidence of haematoma in breast surgery, particularly in cosmetic procedures and procedures without ALND. Well-designed randomised studies are required to determine its true efficacy. TXA has no effect on seroma formation or infection in breast surgery.     

The use of phenylephrine to obtund oxytocin-induced hypotension and tachycardia during caesarean section

BackgroundOxytocin causes clinically significant hypotension and tachycardia. This study examined whether prior administration of phenylephrine obtunds these unwanted haemodynamic effects.MethodsForty pregnant women undergoing elective caesarean section under spinal anaesthesia were randomised to receive either an intravenous 50 μg bolus of phenylephrine (Group P) or saline (Group S) immediately before oxytocin (3 U over 15 s). Systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate were recorded using a continuous non-invasive arterial pressure device. Baseline values were averaged for 20 s post-delivery. Between-group comparisons were made of the mean peak changes in blood pressure and heart rate, and the mean percentage changes from baseline, during the 150 s after oxytocin administration.ResultsThe mean ± SD peak percentage change in systolic blood pressure was −16.9 ± 2% in Group P, and −19.0 ± 1.9% in Group S and the estimated mean difference was 2.1% (95% CI −3.5% to 7.8%; P=0.44); corresponding changes in heart rate were 13.5 ± 2.3% and 14.0 ± 1.5% and the mean estimated difference was 0.5% (95% CI −6.0% to 5%; P=0.87). The mean percentage change from the baseline measurements during the 150 s period of measurement was greater for Group S than Group P: systolic blood pressure −5.9% vs −3.4% (P=0.149); diastolic blood pressure −7.2% vs −1.5% (P=0.014); mean arterial pressure −6.8% vs −1.5% (P=0.007); heart rate 2.1% vs −2.4% (P=0.033).ConclusionIntravenous phenylephrine 50 μg immediately before 3 U oxytocin during elective caesarean section does not prevent maternal hypotension and tachycardia.     

Enhancing recovery after minimally invasive surgery in children: A systematic review of the literature and meta-analysis

ObjectiveEnhanced recovery after surgery (ERAS) has been widely implemented after minimally invasive surgeries (MIS) in adults. The aim of this study was to evaluate the current evidence available on ERAS after MIS in children.MethodsUsing a defined search strategy (PubMed, Cochrane, Scopus), we performed a systematic review of the literature, searching for studies reporting on ERAS after MIS (thoracoscopy, laparoscopy, retroperitoneoscopy) in children (1975–2019). This study was registered with PROSPERO-international prospective register of systematic reviews. A meta-analysis was conducted using comparative studies for length of stay (LOS), complication rates, and readmission rates.ResultsOf 180 abstracts screened, 20 full-text articles were analyzed, and 9 were included in our systematic review (1 randomized controlled trial, 3 prospective, and 5 retrospective studies), involving a total number of 531 patients. ERAS has been applied to laparoscopy for digestive (n = 7 studies) or urologic surgeries (n = 1), as well as thoracoscopy (n = 1). Mean LOS was decreased in ERAS children compared to controls (6 studies, −1.12 days, 95%IC: −1.5 to −0.82, p < 0.00001). There was no difference in complication rates between ERAS children and control children (5 studies, 13% vs 14%, OR = 0.84, 95%CI: 0.49–1.44, p = 0.52). The 30-day readmission rate was decreased in ERAS children compared to controls (6 studies, 4% vs 10%, OR = 0.34, 95%CI: 0.18–0.66, p = 0.001).ConclusionsAlthough the evidence regarding ERAS in MIS is scarce, these protocols seem safe and effective, by decreasing LOS and 30-day readmission rate, without increasing post-operative complication rates.     

Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials

AimThe objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages.MethodsA systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri?operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events’ incidence. A subgroup analysis was performed with respect to TXA dosage.ResultsOut of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between “single” and “multiple doses” studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg.ConclusionsThis meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes.     

Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis

Study objectivePrevious studies reported that controlled low central venous pressure (CVP) can reduce blood loss during liver resection. This systematic review and meta-analysis sought to explore the efficacy and safety of low CVP in patients undergoing hepatectomy.DesignA systematic review and meta-analysis of randomized controlled trials (RCTs).Review methodsRCTs were searched in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical database, Chinese Scientific Journals Database, and Wanfang database from inception to April 30, 2021. Subgroup analyses were performed based on different surgical methods (open hepatectomy vs laparoscopic hepatectomy) and published countries (China vs other countries). The quality of evidence was assessed by Grading of Recommendations, Assessment, Development, and Evaluation.Main resultsEighteen RCTs containing 1285 participants (626 patients in the low CVP group and 659 patients in the control group) were included in this study. The forest plot showed that low CVP effectively reduced blood loss during liver resection compared with the control group (MD = −311.92 mL, 95% CI [−429.03, −194.81]; P < 0.001, I² = 96%). Furthermore, blood transfusion volume (MD = −158.85 mL, 95% CI [−218.30, −99.40]; P < 0.001, I² = 55%) and the number of patients requiring transfusion (RR 0.41, 95% CI 0.27–0.65, P < 0.001, I² = 0%) were decreased in the low CVP group. Subgroup analyses showed similar results. Notably, the alanine transaminase level was significantly lower in the low CVP group during the first five postoperative days. However, no significant differences were observed for other postoperative liver function indicators (aspartate aminotransferase, total bilirubin, serum albumin, and prothrombin time), renal function indicators (blood urea nitrogen and serum creatinine) and perfusion parameters (heart rate, mean arterial pressure, and urine volume). The incidence of complications was similar between the two groups.ConclusionThe findings of this study showed that low CVP is effective and safe during hepatectomy. Therefore, this technique is recommended to reduce blood loss during hepatectomy.PROSPERO registration number: CRD42021232829.     

Do patients prefer optional follow-up for simple upper extremity fractures: A pilot study

IntroductionWe aimed to evaluate the results of offering patients optional follow-up for simple upper extremity fractures. Specifically this study tested if there is a difference in (1) upper extremity disability, (2) return to work, and (3) satisfaction with delivered care at 2–6 months after enrollment between patients who choose and do not choose a return visit for an adequately aligned metacarpal, distal radius, or radial head fracture. Additionally we assessed if there was a difference in overall evaluation of the visit at enrollment between those patients and what factors were associated with returning after initially choosing not to schedule a follow-up visit.Patients and methodsWe prospectively enrolled all adult patients (n = 120) with adequately aligned metacarpal fractures, non-or minimally displaced distal radius fractures, and isolated non- or minimally displaced radial head fractures of whom 82 (68%) were available at 2–6 months after enrollment. Subjects chose to have a scheduled (n = 56) or optional (n = 64) return visit. Subsequently, we recorded patient demographics and overall evaluation of the visit. Between two and six months after enrollment we measured QuickDASH, satisfaction with care, and current employment status.ResultsAccounting for potential differences in baseline characteristics by multivariable analysis, return choice was not associated with QuickDASH (β regression coefficient [β] −0.53, 95% confidence interval [CI] −7.4 to 6.4, standard error [SE] 3.5, P = 0.88), return to work (odds ratio [OR] −1.3, 95%CI −3.5 to 0.95, SE 1.1, P = 0.26), satisfaction with care (β −0.084, 95%CI −0.51 to 0.35, SE 0.22, P = 0.70), or overall evaluation of the initial visit (β 0.18, 95%CI −0.38 to 0.73, SE 0.28, P = 0.53). Of the 64 people choosing optional follow-up, 11 patients returned (17%). The only factor independently associated with returning after initially not choosing to return was greater disability at enrollment (OR 1.05, 95%CI 1.0050–1.098, SE 0.024, P = 0.029).ConclusionsA majority of patients prefer optional follow-up for simple upper extremity fractures with a good prognosis. Hand surgeons can consider offering patients with low-risk hand fractures an optional second visit. Eliminating unnecessary visits, tests and imaging could lower the cost of care.Level of evidenceTherapeutic level II.     

Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis

Study objectiveErector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery.DesignA meta-analysis of randomized controlled trials.SettingPerioperative setting.PatientsPatients undergoing lumbar spine surgery under general anesthesia.InterventionsWe searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery.MeasurementsThe primary outcome was opioid consumption in the first 24 h after surgery.Main resultsTwelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = −14.55; 95% confidence interval (CI), −21.03 to −8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0−10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = −1.24 days; 95% CI, −2.31 to −0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed.ConclusionsESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required.PROSPERO registration number: CRD42021233362.     

The protective effects of dexmedetomidine on ischemic brain injury: A meta-analysis

BackgroundIntracranial lesions, trauma or surgery-related damage activate immune inflammation and neuroendocrine responses, causing ischemic brain injury. Studies have shown that inflammatory cascade mediated by neuroendocrine hormones and proinflammatory mediators is implicated in the pathophysiology of ischemic brain injury. Alpha2-adrenoceptor agonists, dexmedetomidine, is widely used as neuroprotectants in anesthesia practice. However, it is still lack of a comprehensive meta-analysis to evaluate the neuroprotection of dexmedetomidine against ischemic brain injury via suppressing these two physiological responses.MethodSearched the Cochrane Library, Pub-Med, EMBASE, EBSCO, Ovid, Chinese biological and medical database (CBM). Related literatures published in English or Chinese before January 2017 were enrolled. We assessed the quality of eligible studies and synthesized predefined outcomes with a random-effects model or fixed-effects model.ResultNineteen Randomized Controlled Trials including 879 patients were included. Findings for meta-analysis of various outcomes were summarised. Primary results shown that compared with placebo, dexmedetomidine reduced a surge of TNF-α [SMD = − 2.34, 95%CI (− 3.25, − 1.44)], IL-6 [SMD = − 2.44, 95%CI (− 3.40, − 1.47)], S100-β [SMD = − 2.73, 95%CI (− 3.65, − 1.82)], NSE [SMD = − 1.69, 95%CI (− 2.77, − 0.61)], cortisol [SMD = − 2.48, 95%CI (− 3.38, − 1.58)] and glucose [SMD = − 1.44, 95%CI (− 1.85, − 1.04)]; maintained the level of SOD [SMD = 1.36, 95%CI (0.62, 2.10)]; decreased the rise in CRP level at postoperative one day. In response to stress reaction, dexmedetomidine attenuated the stress-related increasing of MAP, HR and intracranial pressure without significant effects on cerebral oxygen metabolism.ConclusionAlpha2-adrenoceptor agonists, dexmedetomidine, could reduce the release of inflammatory mediators and neuroendocrine hormones as well as maintain intracranial homoeostasis, alleviating ischemic brain injury and exerting an effect on brain protection.     

The effect of tranexamic acid on wound complications in primary total Hip Arthroplasty: A meta-analysis

BackgroundAllogeneic blood transfusion has been linked with an increase in the risk of surgical site infections (SSIs) through the mechanism of immunomodulation. However, no studies to date have investigated the direct relationship between blood conserving strategies including antifibrinolytics and wound complications after total hip arthroplasties (THA).MethodsA systematic review and meta-analysis of published randomised controlled trials (RCTs) to investigate the effect of tranexamic acid (TXA) on wound complications after THAs has been conducted.ResultsWe identified 25 clinical trials which were suitable for detailed data extraction. There were no trials which utilised TXA in revision THA. All studies reported on wound complications including a total of 1608 patients. Using TXA led to a 2% reduction in the risk of developing wound complications compared to the control group with no significant statistical heterogeneity among the study groups (Risk Difference −0.02, 95%, confidence interval CI -0.04 to −0.00, P = 0.01, Heterogeneity I² = 0%). However, there was no significant difference in clinical outcomes in terms of antibiotic treatment or surgical intervention among the study groups. TXA also reduced intraoperative, postoperative and total blood loss and led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion with no significant differences in deep venous thrombosis, pulmonary embolisms, or other complications between the study groups.ConclusionTXA reduced blood loss and transfusion rates after primary THA surgery. It also reduced wound complication rates but the clinical significance of this needs further investigation through well designed and adequately powered RCTs.     

Is gabapentin effective and safe in open hysterectomy? A PRISMA compliant meta-analysis of randomized controlled trials

BackgroundPain management after open hysterectomy has been investigated for years. Owing to the effect of significant analgesic, gabapentin was often administrated for pre-emptive analgesia. However, the relationship between gabapentin and postoperative pain after open hysterectomy is still controversial. This meta-analysis was applied to assess the efficacy of pre-emptive use of gabapentin in open hysterectomy.MethodsThis meta-analysis of randomized controlled trials (RCTs) was performed to compare the use of gabapentin with placebo in open hysterectomy regarding (1) the mean difference (MD) of postoperative opioid requirements; (2) the changes of visual analogue scale (VAS) scores in two groups; and (3) incidence rate of adverse effects. Systematic searches of all related literatures was conducted using the following databases: MEDLINE, EMBASE, ClinicalTrials.gov and Web of Science. Only randomized controlled trials (RCTs) for open hysterectomy were included. The MD of postoperative opioid requirements and VAS scores, relative risk (RR) of incidence rate of adverse effects in the gabapentin group versus placebo group were extracted throughout the study.ResultsFourteen trials were included in this meta-analysis. The total opioid consumption at 24 h was a less in gabapentin group. (MD = − 11.61, 95% CI: − 16.71 to − 6.51, P = 0.00) The visual analogue scale (VAS) score at 4, 12 and 24 h were less in the gabapentin group. (MD = − 16.83, 95% CI: − 22.88 to − 10.77, P = 0.00), (MD = − 17.45, 95% CI: − 21.83 to − 13.08, P = 0.00), (MD = − 9.83, 95% CI: − 13.31 to − 6.35, P = 0.00) The incidence rate of vomiting and nausea were significantly less in gabapentin groups. (RR 0.13, 95% CI 0.45 to 0.73, P = 0.00), (RR 0.67, 95% CI 0.49 to 0.93, P = 0.02). Compared with placebo, gabapentin achieved higher patient satisfaction. (MD = 20.43, 95% CI: 12.42 to 28.44, P < 0.00).ConclusionThis meta-analysis suggested that the employment of gabapentin was efficacious in reduction of postoperative opioid consumption, VAS score and some side effects after open hysterectomy.     

Analgesic efficacy of PECS and serratus plane blocks after breast surgery: A systematic review,meta-analysis and trial sequential analysis

Study objectiveTo determine whether pectoral nerves (PECS) blocks provide effective postoperative analgesia when compared with no regional technique in patients undergoing breast surgery.DesignSystematic review, meta-analysis and trial sequential analysis.SettingOperating room, postoperative recovery area and ward, up to 24 postoperative hours.PatientsPatients undergoing breast surgery under general anaesthesia with either PECS block or no regional technique.InterventionsWe searched five electronic databases for randomized controlled trials comparing PECS block with no block or sham injection.MeasurementsThe primary outcome was rest pain scores (analogue scale, 0–10) at 2 h, analysed according to surgery (mastectomy vs other breast surgery) and regional technique (PECS 2 vs other blocks), among others. Secondary outcomes included morphine equivalent consumption, and rate of postoperative nausea and vomiting at 24 h.Main resultsSixteen trials including 1026 patients were identified. Rest pain scores at 2 h were decreased in the PECS blocks group, with a mean (95%CI) difference of −1.5 (−2.0, −1.0); I2 = 93%; p < 0.001, with no differences between surgery (mastectomy, mean difference [95%CI]: −1.8 [−2.4, −1.2], I² = 91%, p < 0.001; other breast surgery, mean difference [95%CI]: −1.1 [−2.1, −0.1], I² = 94%, p = 0.03; p for subgroup difference = 0.25), and regional technique (PECS 2, mean differences [95%CI]: −1.6 [−2.3, −1.0], I² = 94%, p < 0.001; other blocks, mean differences [95%CI]: −1.3 [−2.4, −0.1], I² = 74%, p = 0.04; p for subgroup difference = 0.57). The rate of postoperative nausea and vomiting was reduced from 30.8% (95%CI: 25.7%, 36.3%) to 18.7% (95%CI, 14.4%, 23.5%; p = 0.01). Similarly, secondary outcomes were significantly improved in the PECS blocks group. The overall quality of evidence was moderate-to-high.ConclusionsThere is moderate-to-high level evidence that PECS blocks provide postoperative analgesia after breast surgery when compared with no regional technique and reduce rate of PONV. This might provide the most benefit to those at high-risk of postoperative pain.