Souvik Maitra

Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis

Though once considered the gold standard, epidural anaesthesia has complications that may be significant and include hypotension, urinary retention, partial or patchy block and, in rare cases, devastating neurological injuries also. Paravertebral block (PVB) is an alternative technique for unilateral surgical procedures like thoracotomy, which may offer similar analgesic effectiveness and a more favourable side-effect profile than epidural analgesia. This systematic review and meta-analysis of published randomized clinical trials aims to compare thoracic paravertebral with thoracic epidural analgesia (TEA) in thoracotomy for lung surgery. Five hundred and forty-one patients from 12 clinical trials have been included in this systematic review and meta-analysis. We found that visual analogue scale (VAS) scores at rest and during activity/coughing at 4-8, 24 and 48 h postoperatively were similar in both the PVB and TEA groups. Considering studies not included in the previous meta-analysis, a VAS score on activity at 48 h is significantly better in the PVB group (mean difference 0.40 cm; 95% confidence interval [95% CI] 0.77, 0.02; Mantel-Haenszel (M-H) fixed). Hypotension (odds ratio 0.13; 95% CI 0.06, 0.31; M-H fixed) and urinary retention are more common in the epidural analgesia group. So, we conclude that thoracic PVB may be as effective as thoracic epidural analgesia for post-thoracotomy pain relief and is also associated with fewer complications.

Evaluation of i-gel(™) airway in children: a meta-analysis.

I‐gel™ is a relatively newer addition in the pediatric anesthesia practice. Its comparison with the other laryngeal mask airway repor‐ted a wide range of results. Randomized controlled trials where i‐gel™ has been compared with other laryngeal masks (laryngeal mask airway ProSeal™ and laryngeal mask airway Classic™) in children for airway management device during general anesthesia has been included in this meta‐analysis.

Comparison of laryngeal mask airway Supreme and laryngeal mask airway Pro-Seal for controlled ventilation during general anaesthesia in adult patients: systematic review with meta-analysis.

BACKGROUND Laryngeal mask airway (LMA) Supreme is a newly introduced single-use supraglottic device, which shares common features of both the LMA Pro-Seal and the intubating LMA (ILMA). Clinical studies have compared the safety and efficacy of the LMA Supreme over the ‘gold standard’ LMA Pro-Seal in different patient populations. However, the clinical relevance of the potential advantage which one device may offer over the other remains unclear. OBJECTIVE To quantify the potential advantage that the LMA Supreme may offer over the LMA Pro-Seal on oropharyngeal leak pressures in adult patients. DESIGN A systematic review and meta-analysis of randomised controlled trials. DATA SOURCE Three authors independently searched PubMed, PubMed Central, Scopus, Central Register of Clinical Trials of the Cochrane Collaboration, Google Scholar and Directory of open access journals. ELIGIBILITY CRITERIA Randomised trials comparing the LMA Supreme and the LMA Pro-Seal in adults in supine position, reporting on safety outcomes and published in English. RESULTS Seven randomised controlled trials met the eligibility criteria and were included in the meta-analysis. Pooled data from 666 patients showed that the LMA Supreme provided lower oropharyngeal leak pressures than the LMA Pro-Seal [mean difference −2.48 cmH2O, 95% confidence interval (CI) −4.45 to −0.52]. First insertion success rate was higher for the LMA Supreme than for the LMA Pro-Seal when a muscle relaxant was not used [relative risk 1.17, 95% CI 1.03 to 1.35; number needed to treat (NNT) 6, 95% CI 4 to 12]. Time taken to insert the LMA was similar for the two devices. Complications associated with the use of either of the devices are infrequent and similar. CONCLUSION Although the single-use LMA Supreme provides lower oropharyngeal leak pressures in comparison with the LMA Pro-Seal for controlled ventilation in supine adult patients, the clinical relevance of this small difference may be debatable and should be weighed against the potential risks of transmission of communicable diseases with the LMA Pro-Seal.

High-frequency ventilation does not provide mortality benefit in comparison with conventional lung-protective ventilation in acute respiratory distress syndrome: a meta-analysis of the randomized controlled trials.

Background:Despite implementation of lung-protective ventilation strategy, acute respiratory distress syndrome is associated with significant mortality, which necessitates the evaluation of ventilatory modes other than conventional lung-protective strategy. This meta-analysis of the randomized controlled trials has been undertaken to know whether high-frequency oscillatory ventilation (HFOV) provides any mortality benefit over conventional ventilation in adult patients with acute respiratory distress syndrome. Methods:Published randomized controlled trials comparing HFOV with conventional lung-protective ventilation in adult patients with acute respiratory distress syndrome were included in this meta-analysis. Results:A total 1,759 patient data from seven randomized controlled trials have been analyzed here. Primary outcome of the review is in-hospital/30-day mortality and secondary outcomes are duration of intensive care unit stay, duration of mechanical ventilation, requirement of additional treatment, and complications associated with the interventions. HFOV does not offer any in-hospital/30-day mortality benefit (386 of 886 in HFOV vs. 368 of 873 in conventional ventilation; risk ratio, 0.96; 95% CI, 0.77 to 1.19; P = 0.70) over conventional ventilation. It may also prolong the duration of mechanical ventilation (mean difference, 1.18 days; 95% CI, 0.00 to 2.35 days; P = 0.05). Duration of intensive care unit stay (mean difference, 1.24 days; 95% CI, −0.08 to 2.56 days; P = 0.06) and requirement of neuromuscular blocker is similar between two treatment arm. Incidence of refractory hypoxemia is significantly less (risk ratio, 0.60; 95% CI, 0.39 to 0.93; P = 0.02) with the use of HFOV. HFOV is not associated with increased incidence of barotrauma and refractory hypotension. Conclusion:HFOV should not be used routinely in all adult patients with acute respiratory distress syndrome as primary ventilation strategy in place of conventional lung-protective ventilation.

Quadratus lumborum block: an effective method of perioperative analgesia in children undergoing pyeloplasty

Informed written consent was obtained from the parents of all children. Quadratus lumborum (QL) block is a new addition into the league of truncal nerve block techniques that has been found to provide analgesia for abdominal surgeries in both adults and children. We used posterior transmuscular approach of QL block for pyeloplasty in children. Quadratus lumborum block was used in 5 children aged between 3 and 5 years, weighing 12 to 18 kg, undergoing pyeloplasty under general anesthesia as part of multimodal analgesic technique. After induction of general anesthesia and endotracheal intubation, block was given in lateral position with side to be blocked kept up. A linear ultrasonographic (US) probe (Sonosite M-Turbo; Sonosite Inc, Bothell, WA) was kept just above the iliac crest; and initially, tapering end of 3 anterior abdominal wall muscles and anterior end of QL muscle were identified. Then we moved the US probe dorsally to identify the posterior end of QL, psoas major (PM) muscle, and attachment of QL with transverse process of fourth lumbar vertebra. A 23G needle was inserted in-plane from the anterior to posterior direction under US guidance through the QL muscle as described by Börglum et al [1]. We used 0.5 mL/kg of 0.2% ropivacaine and deposited local anesthetic (LA) between QL and PM after penetrating ventral fascia QL muscle (Fig. 1). We used only 2 μg/kg fentanyl at time of induction, and no more opioid was required during surgery. At the end of surgery, intravenous paracetamol was given at a dose of 15 mg/kg. In the postoperative period, pain was assessed by Wong-Baker Faces scale; and intravenous morphine at a dose of 50 μg/kg was prescribed when pain score was N2 in the Wong-Baker Faces scale. Median time to administer morphine was 5 hours, and longest duration obtained was 8 hours in 1 child. Various approaches of this nerve block have been described in literature. Visoiu and Yakovleva [2] injected 10 mL LA between the anterior border of QL muscle and its fascia in a 5-year-old child for colostomy. Kadam [3] had similarly used anterior technique for QL block in an adult patient for laparotomy. In the anterior approach to QL block, probably LA spreads anteriorly towards transversus abdo-

Intravenous Paracetamol Reduces Postoperative Opioid Consumption after Orthopedic Surgery: A Systematic Review of Clinical Trials

Postoperative pain management is one of the most challenging jobs in orthopedic surgical population as it comprises of patients from extremes of ages and with multiple comorbidities. Though effective, opioids may contribute to serious adverse effects particularly in old age patients. Intravenous paracetamol is widely used in the postoperative period with the hope that it may reduce opioid consumption and produce better pain relief. A brief review of human clinical trials where intravenous paracetamol was compared with placebo or no treatment in postoperative period in orthopedic surgical population has been done here. We found that four clinical trials reported that there is a significant reduction in postoperative opioid consumption. When patients received an IV injection of 2 g propacetamol, reduction of morphine consumption up to 46% has been reported. However, one study did not find any reduction of opioid requirement after spinal surgery in children and adolescent. Four clinical trials reported better pain scores when paracetamol has been used, but other three trials denied. We conclude that postoperative intravenous paracetamol is a safe and effective adjunct to opioid after orthopedic surgery, but at present there is no data to decide whether paracetamol reduces opioid related adverse effects or not.

Comparison of high-flow nasal oxygen therapy with conventional oxygen therapy and noninvasive ventilation in adult patients with acute hypoxemic respiratory failure: A meta-analysis and systematic review ☆ ☆☆ ★

PURPOSE The role of high-flow nasal oxygen (HFNO) therapy in adult patients with acute hypoxemic respiratory failure is controversial. METHODS This meta-analysis of prospective randomized controlled trials (RCTs) has been designed to compare HFNO with noninvasive ventilation (NIV) and conventional oxygen therapy in such patients. RESULTS Initial database searching revealed 336 RCTs, of which 7 were included in this meta-analysis. Five RCTs compared HFNO with standard oxygen therapy, one compared HFNO with NIV, and one compared all three. HFNO did not decrease the requirement of higher respiratory support compared with control group. HFNO was associated with improved respiratory rate and dyspnea score, and better comfort in 3 RCTs, whereas other studies did not find any difference. CONCLUSION High-flow nasal oxygen does not offer any benefit over NIV or conventional oxygen therapy in terms of requirement of higher respiratory support.

Analgesic efficacy of transversus abdominis plane block in providing effective perioperative analgesia in patients undergoing total abdominal hysterectomy: A randomized controlled trial

Background and Aims: Transversus abdominis plane (TAP) block has been shown to provide postoperative pain relief following various abdominal and inguinal surgeries, but few studies have evaluated its analgesic efficacy for intraoperative analgesia. We evaluated the efficacy of TAP block in providing effective perioperative analgesia in total abdominal hysterectomy in a randomized double-blind controlled clinical trial. Materials and Methods: A total of 90 adult female patients American Society of Anesthesiologists physical status I or II were randomized to Group B (n = 45) receiving TAP block with 0.25% bupivacaine and Group N (n = 45) with normal saline followed by general anesthesia. Hemodynamic responses to surgical incision and intraoperative fentanyl consumption were noted. Visual analog scale (VAS) scores were assessed on the emergence, at 1, 2, 3, 4, 5, 6 and 24 h. Time to first rescue analgesic (when VAS ≥4 cm or on demand), duration of postoperative analgesia, incidence of postoperative nausea-vomiting were also noted. Results: Pulse rate (95.9 ± 11.2 bpm vs. 102.9 ± 8.8 bpm, P = 0.001) systolic and diastolic BP were significantly higher in Group N. Median intraoperative fentanyl requirement was significantly higher in Group N (81 mcg vs. 114 mcg, P = 0.000). VAS scores on emergence at rest (median VAS 3 mm vs 27 mm), with activity (median 8 mm vs. 35 mm) were significantly lower in Group B. Median duration of analgesia was significantly higher in Group B (290 min vs. 16 min, P = 0.000). No complication or opioid related side effect attributed to TAP block were noted in any patient. Conclusion: Preincisional TAP block decreases intraoperative fentanyl requirements, prevents hemodynamic responses to surgical stimuli and provides effective postoperative analgesia.

Epidural anesthesia and analgesia in the neonate: a review of current evidences

The role of single shot spinal anesthesia has been established in ex-premature infants at risk of apnea. However, use of epidural anesthesia in neonates is on the rise. In this systematic analysis, we have reviewed the current evidence on the safety and efficacy of the use of single shot and continuous epidural anesthesia/analgesia in neonates. Current clinical practice is guided by evidence based mostly on non-randomized studies, prospective/retrospective case series and surveys. Single shot caudal blockade as a sole technique has been used in neonates mainly for inguinal hernia repair and circumcision. Use of continuous epidural anesthesia through the caudal route or caudo-thoracic advancement of the catheter for major thoracic and abdominal surgery offers good perioperative analgesia. Other observed benefits are early extubation, attenuation of stress response, early return of bowel function and reduction of general anesthesia-related postoperative complications. However, risk of procedure-related and drug-related complications to the developing neural structure remains a serious concern.

Clonidine for management of chronic pain: A brief review of the current evidences

Clonidine, an alpha-2 adrenergic receptor agonist, has well-established role in acute perioperative pain management. However, recently it has found increasing use in chronic pain conditions as well. In this review, we systematically searched and analyzed the clinical studies from “PubMed,” “PubMed central” and “Scopus” database for use of clonidine in the chronic pain. Quantitative meta-analysis was not possible as clonidine has been used in various patient populations through different routes. However, qualitative analysis of nearly thirty clinical studies provides some evidence that clonidine administered through epidural, intrathecal and local/topical route may be effective in chronic pain conditions where neuropathy is a predominant component. It may also be effective where opioids are of limited use due to inadequate pain relief or adverse effects.