Leigh D White

Ultrasound-guided radial artery cannulation in adult and paediatric populations: a systematic review and meta-analysis

BACKGROUND Ultrasound is a well-validated adjunct to central venous cannulation; however, previous reviews of ultrasound-guided radial artery cannulation have been inconclusive. The aim of this study was to assess the use of ultrasound in radial artery cannulation in adult and paediatric populations. METHODS A systematic search of five major databases for all relevant articles published until November 2015 was conducted. Randomized controlled trials of radial artery cannulation with and without ultrasound guidance were included. All studies were assessed for level of evidence and risk of bias. Studies were grouped in adult and paediatric populations for each outcome. A meta-analysis was performed to analyse the data. RESULTS Eleven randomized controlled trials (six adult and five paediatric) were found. In both the adult and paediatric populations, there was high-level evidence for significantly improved first-attempt success rate and number of attempts with the use of ultrasound guidance. CONCLUSIONS This is the first level one systematic review to demonstrate strong evidence for the use of ultrasound guidance in radial artery cannulation in adult and paediatric populations. In the adult population, ultrasound use significantly increased first-attempt success rate, which subsequently resulted in a significant reduction in the number of attempts. The benefits of ultrasound were also shown in the paediatric population, with a significant increase in first-attempt success rate and reduction in the number of attempts. The use of ultrasound as an adjunct to radial arterial cannulation should now be considered best practice.

The role of infrapatellar fat pad resection in total knee arthroplasty

We read with interest the correspondence from Bai et al 1 and the response from Pan et al 2 regarding ‘A longitudinal study of the association between infrapatellar fat pad maximal area and changes in knee symptoms and structure in older adults’. Both correspondents raise valid points, but we would like to highlight further evidence concerning the effect of the infrapatellar fat pad (IPFP) preservation on outcomes post open total knee arthroplasty (TKA). Since the Van Beeck et al study3 in 2013, there have been a number of studies reporting on …

Intubation using apnoeic oxygenation to prevent desaturation: A systematic review and meta-analysis

Purpose: To determine whether or not apnoeic oxygenation reduces the incidence of hypoxaemia during endotracheal intubation. Materials and methods: A systematic search of six databases for all relevant studies until November 2016 was performed. All study designs using apnoeic oxygenation during intubation were eligible for inclusion. All studies were assessed for level of evidence and risk of bias. A meta‐analysis was performed on all data using Revman 5.3. Results: Seventeen studies including 2422 patients were retrieved. Overall there was a significant reduction in the incidence of desaturation (RR = 0.65; p < 0.00001), critical desaturation (RR = 0.61, p = 0.002) and safe apnoea time (WMD = 1.73 min, p < 0.00001). There was no significant difference in mortality (RR = 0.77, p = 0.08). Conclusions: In patients whom are being intubated for any indication other than respiratory failure, apnoeic oxygenation at any flow rate 15 L or greater is likely to reduce their incidence of desaturation (< 90%) and critical desaturation (< 80%). However, further high quality RCTs are required given the high degree of heterogeneity in many of the outcomes and subgroup analyses. HIGHLIGHTSThis review summarises a growing body of literature surrounding apnoeic oxygenation during intubation.Meta‐analysis of seventeen studies including 2,422 patients.Overall there was a significant reduction in the incidence of desaturation, critical desaturation and an increase in safe apnoea time.

Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis

Background: Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting. Aim: To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval. Methods: We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta‐analysis of the pooled data. Results: Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004). Conclusion: Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first‐pass success rate in this setting.

Apnoeic oxygenation during intubation in the intensive care unit: A systematic review and meta-analysis

ABSTRACT Hypoxaemia increases the risk of cardiac arrest and mortality during intubation. The reduced physiological reserve and reduced efficacy of pre‐oxygenation in intensive care patients makes their intubation particularly dangerous. Apnoeic oxygenation is a promising means of preventing hypoxaemia in this setting. We sought to ascertain whether apnoeic oxygenation reduces the incidence of hypoxaemia when used during endotracheal intubation in the intensive care unit (ICU). A systematic review of five databases for all relevant studies published up to November 2016 was performed. Eligible studies investigated apnoeic oxygenation during intubation in the ICU, irrespective of design. All studies were assessed for risk of bias and level of evidence. A meta‐analysis was performed on all data using Revman 5.3. Six studies including 518 patients were retrieved. The study found level 1 evidence of a significant reduction in the incidence of critical desaturation (RR = 0.69, CI = 0.48–1.00, p = 0.05) and a significant increase in the lowest SpO2 value by 2.83% (CI = 2.28–3.38, p < 0.00001). There was a significant reduction in ICU stay (WMD = −2.89, 95%CI = −3.25 to −2.51, p < 0.00001). There was no significant difference between groups regarding mortality (RR = 0.77, 95%CI = 0.59–1.03, p = 0.08), first pass intubation success (RR = 1.17, 95%CI = 0.67 to 2.03, p = 0.58), arrhythmia during intubation (RR = 0.58, 95%CI = 0.08 to 4.29, p = 0.60), cardiac arrest during intubation (RR = 0.33, 95%CI = 0.01 to 7.84, p = 0.49) and duration of ventilation (WMD = −1.97, 95%CI = −5.89 to 1.95, p = 0.32). Apnoeic oxygenation reduces patient hypoxaemia during intubation performed in the ICU. This meta‐analysis found evidence that apnoeic oxygenation may significantly reduce the incidence of critical desaturation and significantly raises the minimum recorded SpO2 in this setting. We recommend apnoeic oxygenation be incorporated into ICU intubation protocol.

The Impact of an Intact Infrapatellar Fat Pad on Outcomes after Total Knee Arthroplasty

Background. The infrapatellar fat pad (IPFP) is currently resected in approximately 88% of Total Knee Arthroplasties (TKAs). We hypothesised that an intact IPFP would improve outcomes after TKA. Methods. Patients with an intact IPFP participated in this cross-sectional study by completing two surveys, at 6 and 12 months after TKA. Both surveys included questions regarding kneeling, with the Oxford Knee Score also included at 12 months. Results. Sixty patients participated in this study. At 6 and 12 months, a similar number of patients were able to kneel, 40 (66.7%) and 43 (71.7%), respectively. Fifteen (25.0%) patients were unable to kneel due to knee pain at 6 months; of these, nine (15%) were unable to kneel at 12 months. Moreover, at 12 months, 90.0% of the patients reported minimal or no knee pain. There was no correlation between the inability to kneel and knee pain (). There was a significant correlation between the inability to kneel and reduced overall standardised knee function scores (). Conclusions. This was the first study to demonstrate improved kneeling and descending of stairs after TKA with IPFP preservation. These results in the context of current literature show that IPFP preservation reduces the incidence of knee pain 12 months after TKA.

Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis

AbstractThe infiltration of local anaesthetic agents has been shown to reduce post-tonsillectomy pain. A number of recent studies have shown that the addition of agents such as clonidine and dexamethasone improve the efficacy of nerve blocks and spinal anaesthesia. The aim of this review was to determine whether additives to local anaesthetic agents improve post-tonsillectomy outcomes. Four major databases were systematically searched for all relevant studies published up to August 2016. All study designs with a control group receiving local anaesthetic infiltration and an intervention receiving the same infiltration with an added agent were included in this review. These studies were then assessed for level of evidence and risk of bias. The data were then analysed both qualitatively and where appropriate by meta-analysis. We reviewed 11 randomised controlled trial (RCTs) that included 854 patients. Due to inconsistencies in the methods used to report outcomes, both quantitative and qualitative comparisons were required to analyse the extracted data. Overall, we found that dexamethasone, magnesium, pethidine and tramadol reduce post-operative pain and analgesia use, with dexamethasone in particular significantly reducing post-operative nausea and vomiting and magnesium infiltration significantly reducing the incidence of laryngospasm. This systematic review of RCTs provides strong evidence that the use of dexamethasone and magnesium as additives to local anaesthetics reduces post-tonsillectomy pain and analgesia requirement. There is limited evidence that pethidine and tramadol have a similar effect on pain and analgesia requirement. The studies in this pooled analysis are sufficiently strong to make a level one recommendation that the addition of magnesium to local anaesthetics reduces the incidence of laryngospasm, a potentially lethal post-operative complication. Review level of evidence: 1.

Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomised controlled trials

&NA; Buprenorphine appears to have a ceiling effect on respiratory depression, but not analgesia in healthy young patients. However, the efficacy and side‐effects of buprenorphine in the setting of acute pain are poorly characterized. The aim of this study was to characterize the analgesic efficacy and adverse effects of buprenorphine compared with morphine in the acute pain setting. A systematic review of five databases was performed. Randomised controlled trials (RCTs) comparing buprenorphine with morphine in acute pain management were included. Studies performed outside of the hospital setting were excluded. The a priori primary outcomes included pain, respiratory depression, and sedation. Secondary outcomes included requirement for rescue analgesia, time to rescue analgesia, nausea, vomiting, dizziness, hypotension, and pruritus. Twenty‐eight RCTs with 2210 patients met the inclusion criteria. There was no difference in pain [visual analogue scale weighted mean difference (WMD)=−0.29; 95% confidence interval (CI)=−0.62 to 0.03; I2=99%; P=0.07], incidence of respiratory depression [odds ratio (OR)=2.07; 95% CI=0.78–5.51; I2=30%; P=0.14], or sedation (OR=1.44; 95% CI=0.76–2.74; I2=23%; P=0.26). There was only one secondary outcome with an overall significant difference; buprenorphine use was associated with significantly less pruritus (OR=0.31; 95% CI=0.12–0.84; I2=6%; P=0.02). Whilst a theoretical ceiling effect may exist with respect to buprenorphine and respiratory depression, in a clinical setting, it can still cause significant adverse effects on respiratory function. However, given that buprenorphine is an equally efficacious analgesic agent, it is a useful alternative opioid because of its ease of administration and reduced incidence of pruritus.

Iconography : Sublingual buprenorphine versus intravenous or intramuscular morphine in acute pain: A systematic review and meta-analysis of randomized control trials

Intro Buprenorphine is a potent analgesic agent with several unique and favourable features such as its sublingual formulation. The aim of this study is to compare the effectiveness of sublingual versus intramuscular and intravenous buprenorphine in acute pain. Methods Five major databases were systematically searched until April 2018. All randomized control trials comparing sublingual buprenorphine with intravenous or intramuscular morphine in acute pain were included in this review. These studies were assessed for level of evidence and risk of bias. The data was then analyzed both qualitatively and where appropriate by meta‐analysis. The primary outcomes were analgesic effect up to six hours and rescue analgesia requirement. The secondary outcomes were incidence of respiratory depression, nausea, vomiting, dizziness and hypotension. Results Nine studies comparing sublingual and intramuscular or intravenous buprenorphine were identified and included 826 patients. There was no difference in pain at any time point before six hours or need for rescue analgesia between the two agents. There was no difference in secondary outcomes between the two agents. Discussion Sublingual buprenorphine offers an effective alternative to intravenous or intramuscular analgesia in acute pain. Sublingual buprenorphine appears to be a viable option in patients where intravenous access is difficult or not favourable.

Antiarrhythmics in Cardiac Arrest: A Systematic Review and Meta-Analysis

INTRODUCTION It is widely accepted that antiarrhythmics play a role in cardiopulmonary resuscitation (CPR) universally, but the absolute benefit of antiarrhythmic use and the drug of choice in advanced life support remains controversial. AIM To perform a thorough, in-depth review and analysis of current literature to assess the efficacy of antiarrhythmics in advanced life support. MATERIAL AND METHODS Two authors systematically searched through multiple bibliographic databases including CINAHL, SCOPUS, PubMed, Web of Science, Medline(Ovid) and the Cochrane Clinical Trials Registry. To be included studies had to compare an antiarrhythmic to either a control group, placebo or another antiarrhythmic in adult cardiac arrests. These studies were independently screened for outcomes in cardiac arrest assessing the effect of antiarrhythmics on return of spontaneous circulation (ROSC), survival and neurological outcomes. Data was extracted independently, compared for homogeneity and level of evidence was evaluated using the Cochrane Collaborations tool for assessing the risk of bias. The Mantel-Haenszel (M-H) random effects model was used and heterogeneity was assessed using the I2 statistic. RESULTS AND DISCUSSION The search of the literature yielded 30 studies, including 39,914 patients. Eight antiarrhythmic agents were identified. Amiodarone and lidocaine, the two most commonly used agents, showed no significant effect on any outcome either against placebo or each other. Small low quality studies showed benefits in isolated outcomes with esmolol and bretylium against placebo. The only significant benefit of one antiarrhythmic over another was demonstrated with nifekalant over lidocaine for survival to admission (p=0.003). On sensitivity analysis of a small number of high quality level one RCTs, both amiodarone and lidocaine had a significant increase in survival to admission, with no effect on survival to discharge. CONCLUSIONS This systematic review and meta-analysis suggests that, based on current literature and data, there has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes. Given the side effects of some of these agents, we recommend further research into their utility in current cardiopulmonary resuscitation guidelines.