RESUMO
In the article entitled "Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: a meta-analysis of randomized controlled trials" Can J Anesth 2018; 65: 529-42, we wish to clarify the following items.
RESUMO
BACKGROUND: Perioperative IV dextrose infusions have been investigated for their potential to reduce the risk of postoperative nausea and vomiting. In this meta-analysis, we investigated the use of an intraoperative or postoperative infusion of dextrose for the prevention of postoperative nausea and vomiting. METHODS: Our group searched PubMed, Embase, Cochrane library, and Google Scholar for relevant randomized controlled trials examining the use of perioperative IV dextrose for prevention of postoperative nausea and vomiting. The primary outcome was the incidence of postoperative nausea and vomiting (both in the postanesthesia care unit and within the first 24 h of surgery). Secondary outcomes included postoperative antiemetic administration and serum glucose level. RESULTS: Our search yielded a total of 10 randomized controlled trials (n = 987 patients) comparing the use of a perioperative dextrose infusion (n = 465) to control (n = 522). Perioperative dextrose infusion was not associated with a significant reduction in postoperative nausea and vomiting in the postanesthesia care unit (risk ratio = 0.91, 95% CI, 0.73-1.15; P = .44) or within the first 24 h (risk ratio = 0.76, 95% CI, 0.55-1.04; P = .09) of surgery. Although the use of dextrose was associated with a significant reduction in antiemetic administration within the first 24 h (risk ratio = 0.55, 95% CI, 0.45-0.69; P < .001), it also increased postoperative plasma glucose levels compared to controls. CONCLUSIONS: The use of perioperative dextrose did not result in a statistically significant association with postoperative nausea and vomiting. When utilized, plasma glucose monitoring is recommended to assess for postoperative hyperglycemia. Further prospective trials are necessary to examine the potential impact of timing of administration of a dextrose infusion on incidence of postoperative nausea and vomiting and rescue antiemetic requirements.
Assuntos
Antieméticos/administração & dosagem , Glucose/administração & dosagem , Assistência Perioperatória/métodos , Náusea e Vômito Pós-Operatórios/prevenção & controle , Antieméticos/efeitos adversos , Glicemia/efeitos dos fármacos , Glicemia/metabolismo , Esquema de Medicação , Feminino , Glucose/efeitos adversos , Humanos , Hiperglicemia/sangue , Hiperglicemia/induzido quimicamente , Incidência , Infusões Intravenosas , Masculino , Assistência Perioperatória/efeitos adversos , Náusea e Vômito Pós-Operatórios/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: Although evidence from observational studies in a variety of clinical settings supports the utility of cerebral oximetry as a predictor of outcomes, prospective clinical trials thus far have reported conflicting results. This systematic review and meta-analysis was designed to evaluate the influence of management associated with intraoperative cerebral oximetry on postoperative outcomes. The primary outcome was postoperative cognitive dysfunction (POCD), with secondary outcomes that included postoperative delirium, length of intensive care unit (ICU) stay, and hospital length of stay (LOS). SOURCE: After searching the PubMed, EMBASE, Cochrane Library, Scopus, and Google Scholar databases, all randomized controlled trials (RCTs) assessing the impact of intraoperative cerebral oximetry-guided management on clinical outcomes following surgery were identified. PRINCIPAL FINDINGS: Fifteen RCTs comprising 2,057 patients (1,018 in the intervention group and 1,039 in control group) were included. Intraoperative management guided by the use of cerebral oximetry was associated with a reduction in the incidence of POCD (risk ratio [RR] 0.54; 95% confidence interval [CI], 0.33 to 0.90; P = 0.02; I2 = 85%) and a significantly shorter length of ICU stay (standardized mean difference [SMD], -0.21 hr; 95% CI, -0.37 to -0.05; P = 0.009; I2 = 48%). In addition, overall hospital LOS (SMD, -0.06 days; 95% CI, -0.18 to 0.06; P = 0.29; I2 = 0%) and incidence of postoperative delirium (RR, 0.69; 95% CI, 0.36 to 1.32; P = 0.27; I2 = 0%) were not impacted by the use of intraoperative cerebral oximetry. CONCLUSIONS: Intraoperative cerebral oximetry appears to be associated with a reduction in POCD, although this result should be interpreted with caution given the significant heterogeneity in the studies examined. Further large (ideally multicentre) RCTs are needed to clarify whether POCD can be favourably impacted by the use of cerebral oximetry-guided management.
Assuntos
Disfunção Cognitiva/prevenção & controle , Oximetria , Complicações Pós-Operatórias/prevenção & controle , Delírio/prevenção & controle , Humanos , Unidades de Terapia Intensiva , Período Intraoperatório , Tempo de Internação , Garantia da Qualidade dos Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Nonopioid adjuvant medications are increasingly included among perioperative Enhanced Recovery After Surgery protocols. Preoperative pregabalin has been shown to improve postoperative pain and limit reliance on opioid analgesia. Our group investigated the ability of preoperative pregabalin to also prevent postoperative nausea and vomiting (PONV). METHODS: Our group performed a meta-analysis of randomized trials that report outcomes on the effect of preoperative pregabalin on PONV endpoints in patients undergoing general anesthesia. RESULTS: Among all included trials (23 trials; n = 1693), preoperative pregabalin was associated with a significant reduction in PONV (risk ratio [RR] = 0.53; 95% confidence interval [CI], 0.39-0.73; P = 0.0001), nausea (RR = 0.62; 95% CI, 0.46-0.83; P = 0.002), and vomiting (RR = 0.68; 95% CI, 0.52-0.88; P = 0.003) at 24 hours. Subgroup analysis designed to account for major PONV confounders, including the exclusion trials with repeat dosing, thiopental induction, nitrous oxide maintenance, and prophylactic antiemetics and including high-risk surgery, resulted in similar antiemetic efficacy. Preoperative pregabalin is also associated with significantly increased rates of postoperative visual disturbance (RR = 3.11; 95% CI, 1.34-7.21; P = 0.008) compared with a control. CONCLUSIONS: Preoperative pregabalin is associated with significant reduction of PONV and should not only be considered as part of a multimodal approach to postoperative analgesia but also for prevention of PONV.