Efficacy of high flow nasal oxygenation against hypoxemia in sedated patients receiving gastrointestinal endoscopic procedures: A systematic review and meta-analysis

Clinical evaluation of laryngeal mask airways in video-assisted thoracic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Endotracheal intubation is often associated with postoperative complications such as sore throat discomfort and hoarseness, reducing patient satisfaction and prolonging hospital stays. Laryngeal mask airway (LMA) plays a critical role in reducing airway complications related to endotracheal intubation. This meta-analysis was performed to determine the efficacy and safety of LMA in video-assisted thoracic surgery (VATS).

METHODS

The PubMed, Embase, Cochrane Library, Medline and Web of Science databases were searched for eligible studies from inception until October 5, 2023. Cochrane's tool (RoB 2) was used to evaluate the possibility biases of RCTs. We performed sensitivity analysis and subgroup analysis to assess the robustness of the results.

RESULTS

Seven articles were included in this meta-analysis. Compared with endotracheal intubation, there was no significant difference in the postoperative hospital stay (SMD = -0.47, 95% CI = -0.98-0.03, P = 0.06), intraoperative minimum SpO2 (SMD = 0.00, 95% CI = -0.49-0.49, P = 1.00), hypoxemia (RR = 1.00, 95% CI = 0.26-3.89, P = 1.00), intraoperative highest PetCO2 (SMD = 0.51, 95% CI = -0.12-1.15, P = 0.11), surgical field satisfaction (RR = 1.01, 95% CI = 0.98-1.03, P = 0.61), anesthesia time (SMD = -0.10, 95% CI = -0.30-0.10, P = 0.31), operation time (SMD = 0.06, 95% CI = -0.13-0.24, P = 0.55) and blood loss (SMD =- 0.13, 95% CI = -0.33-0.07, P = 0.21) in LMA group. However, LMA was associated with a lower incidence of throat discomfort (RR = 0.28, 95% CI = 0.17-0.48, P < 0.00001) and postoperative hoarseness (RR = 0.36, 95% CI = 0.16-0.81, P = 0.01), endotracheal intubation was found in connection with a longer postoperative awake time (SMD = -2.19, 95% CI = -3.49 - -0.89, P = 0.001).

CONCLUSION

Compared with endotracheal intubation, LMA can effectively reduce the incidence of throat discomfort and hoarseness post-VATS, and can accelerate the recovery from anesthesia. LMA appears to be an alternative to endotracheal intubation for some specific thoracic surgical procedures, and the efficacy and safety of LMA in VATS need to be further explored in the future.

Comparison of high-flow nasal cannula and conventional nasal cannula during deep sedation for endoscopic submucosal dissection: a randomized controlled trial

PURPOSE

Adequate oxygenation and airway management during deep sedation can be challenging. We investigated the effect of high-flow nasal cannula (group HF) and conventional nasal cannula (group CO) during sedation for endoscopic submucosal dissection (ESD).

METHODS

Patients undergoing ESD with deep sedation were enrolled. The primary outcome was difference in lowest oxygen saturation (SpO2) between the groups. Incidence of hypoxia (SpO2 < 90%), patients with SpO2 < 95%, hypercapnia, and airway interventions; operator satisfaction; and adverse events were recorded.

RESULTS

Thirty-two patients in each group completed the study. The mean of minimum SpO2 values was significantly higher in group HF than in group CO (96.8% ± 4.2% vs. 93.3% ± 5.3%, p = 0.005). The incidence of hypoxia was comparable between the groups (4 [12.5%] vs. 6 [18.8%], p = 0.491); however, patients with SpO2 < 95% were significantly less in group HF (5 [15.6%] vs. 18 [56.3%], p = 0.003). Incidence of hypercapnia was higher in group HF than in group CO (14 [46.7%] vs. 5 [16.7%], p = 0.013). Airway rescue interventions were significantly less common in group HF. Satisfaction of operators and post-procedural complications were comparable between the two groups. In multivariable analysis, group CO and higher body mass index were risk factors for airway managements (odds ratio [95% confidence interval]: 6.204 [1.784-21.575], p = 0.004; 1.337 [1.043-1.715], p = 0.022, respectively).

CONCLUSIONS

Compared to conventional nasal cannula, high-flow nasal cannula maintained higher minimum SpO2 value during deep sedation with propofol-remifentanil for ESD.

TRIAL REGISTRATION

Clinical Trial Registry of the Republic of Korea (KCT0006618, https://cris.nih.go.kr ; registered September 29, 2021; principal investigator: Ji Won Choi).

Impact of a simple non-invasive nasal mask device on intraprocedural hypoxemia in overweight individuals undergoing upper gastrointestinal endoscopy with sedation provided by a non-anesthesiologist provider

BACKGROUND/AIMS

Hypoxemia is a common side effect of propofol sedation during endoscopy. Applying mild positive airway pressure (PAP) using a nasal mask may offer a simple way to reduce such events and optimize the conditions for diagnostic and therapeutic upper gastrointestinal endoscopies.

METHODS

We compared overweight patients (body mass index >25 kg/m2) with a nasal PAP mask or standard nasal cannula undergoing upper gastrointestinal endoscopies by non-anesthesiologists who provided propofol sedation. Outcome parameters included the frequency and severity of hypoxemic episodes.

RESULTS

We analyzed 102 procedures in 51 patients with nasal PAP masks and 51 controls. Episodes of hypoxemia (oxygen saturation [SpO2] <90% at any time during sedation) occurred in 25 (49.0%) controls compared to 8 (15.7%) patients with nasal PAP masks (p<0.001). Severe hypoxemia (SpO2 <80%) occurred in three individuals (5.9%) in both groups. The mean delta between baseline SpO2 and the lowest SpO2 recorded was significantly decreased among patients with nasal PAP mask compared to controls (3.7 and 8.2 percentage points difference, respectively). There were significantly fewer airway interventions performed in the nasal PAP mask group (15.7% vs. 41.2%, p=0.008).

CONCLUSION

Using a nasal PAP mask may be a simple means of increasing patient safety and ease of examination.

High-Flow Nasal Cannula Therapy as an Adjuvant Therapy for Respiratory Support during Endoscopic Techniques: A Narrative Review

High-flow nasal cannula (HFNC) is a respiratory support technique that delivers a controlled concentration of oxygen with high flow, heat, and humidity via the nasal pathway. As it has many physiological effects, its use has increased for a variety of clinical indications; however, there is limited guidance on using HFNC as a respiratory support tool during endoscopic procedures. We conducted a narrative review to evaluate the effect of HFNC as an adjuvant tool during fiberoptic bronchoscopy (FOB), upper gastrointestinal tract endoscopy, and surgical procedures in adults. A search of the PubMed and Cochrane databases were performed. Approximately 384 publications were retrieved, and 99 were selected (93 original works and 6 case reports with a literature review). In patients who underwent FOB, HFNC appears to be superior to conventional oxygen therapy (COT) in preventing hypoxaemia. In contrast, for gastrointestinal endoscopy, the current evidence is insufficient to recommend HFNC over COT in a cost-effective manner. Finally, in surgical procedures such as laryngeal microsurgery or thoracic surgery, HFNC has been shown to be a safe and effective alternative to orotracheal intubation. As the results are heterogeneous, we advocate for the need for more quality studies to understand the effectiveness of HFNC during endoscopic procedures.

Comparison of high-flow nasal cannula and conventional nasal cannula during sedation for endoscopic submucosal dissection: a retrospective study

Background

The high-flow nasal cannula (HFNC) is a relatively recent method that provides high-flow, heated, humidified gas delivery.

Objectives

We compared HFNC (group HF) and conventional nasal cannula (NC) (group CO) during deep sedation with propofol and remifentanil for endoscopic submucosal dissection (ESD).

Design

Single-center, retrospective observational cohort study.

Methods

In this study, a total of 159 cases were analyzed (group CO, 71 and group HF, 88). We collected the data from electronic medical records from September 2020 to June 2021. The lowest oxygen saturation (SpO2), incidence of hypoxia (SpO2 < 90%), rescue interventions, and adverse events between the two groups were investigated.

Results

There were significant differences between the two groups in lowest SpO2 and incidence of hypoxia [group CO versus group HF; 90.3 ± 9.7% versus 95.7 ± 9.0%, 25 (35.2%) versus 10 (11.4%); p < 0.001, p < 0.001; respectively]. Among the rescue interventions, the number of jaw thrust, patient stimulation, O2 flow increase, and nasal airway insertion were significantly higher in the CO group than in the HF group. However, postprocedural chest X-ray showed higher rates of abnormal findings (atelectasis, aspiration, and pneumoperitoneum) in group HF than in group CO [group CO: 8 (11.3%) versus group HF: 26 (29.5%), p = 0.005]. In multivariable analysis, besides group CO, difficult type of lesion was the risk factor for hypoxia.

Conclusions

Compared to the conventional NC, HFNC provided adequate oxygenation and a stable procedure without significant adverse events during sedation for ESD. However, caution is needed to avoid complications associated with deep sedation and difficult type of lesions.

Association of prognostic nutritional index with long-term mortality in patients receiving percutaneous coronary intervention for acute coronary syndrome: a meta-analysis

The predictive value of the prognostic nutritional index (PNI) for the long-term prognosis of patients with acute coronary syndrome (ACS) remains uncertain. Medline, Embase, Cochrane Library, and Google Scholar were searched from inception until January 2023 to study the relationship between all-cause mortality risk and PNI in patients receiving percutaneous coronary intervention for ACS (i.e., primary outcome). Thirteen observational studies were included in this meta-analysis. Analysis of seven studies using PNI as a categorical variable showed a pooled hazard ratio (HR) of all-cause mortality of 2.97 (95% CI 1.65 to 5.34, p = 0.0003, I2 = 89%, n = 11,245) for patients with a low PNI. The meta-analysis also showed a higher risk of major adverse cardiovascular events (MACEs) in patients with a low PNI (HR 2.04; 95% CI 1.59 to 2.61; p < 0.00001; I2 = 21%; n = 8534). Moreover, advanced age, diabetes mellitus, and high Global Registry of Acute Coronary Events risk scores were associated with a high risk of all-cause mortality, whereas a high body mass index was associated with a low risk of all-cause mortality. The results showed an association between a low PNI and an increased risk of long-term mortality in patients undergoing coronary interventions for ACS. Further randomized controlled trials are necessary to confirm these findings.

Examination of stabilization of sedation by Nasal High Flow in patients with endoscopic retrograde cholangiopancreatography during sedation using Dexmedetomidine

INTRODUCTION

Dexmedetomidine is used for the sedation method in the case of endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of relieving patient anxiety. It has been reported that CO2 accumulated during sedation causes an arousal reaction, so how to normalize CO2 during sedation can be improved by administration of the minimum necessary sedative.Nasal High Flow oxygen therapy (NHF) uses a mild positive pressure load that improves carbon dioxide washout and reduces rebreathing to improve respiratory function and therefore is widely used to prevent hypoxemia and hypercapnia. In this study, we will investigate whether the upper airway patency would be maintained and the hypercapnia and hypoxemia during sedation would be prevented, by applying NHF as a respiratory management method to patients undergoing ERCP under sedation.

METHODS/DESIGN

In a randomized comparative study of 2 groups, the NHF device use group and the nasal cannula use group, for adult patients who visited the Nagasaki University Hospital and underwent ERCP examination under sedation. For sedation, Dexmedetomidine will be used in combination with and Midazolam and evaluation by anesthesiologist. In addition, as an analgesic, pethidine hydrochloride was administered intravenously. The total dose of the analgesic pethidine hydrochloride used in combination is used as the primary endpoint. As a secondary evaluation item, the percutaneous CO2 concentration is evaluated with a TCO2 monitor to examine whether it is effective in preventing hypercapnia. Furthermore, we will evaluate the incidence of hypoxemia with a percutaneous oxygen saturation value of 90% or less, and examine whether the use of equipment is effective in preventing the occurrence of hypercapnia and hypoxemia.

DISCUSSION

The purpose of this study was to obtain evidence for the utility of NHF as a potential therapeutic device for patients undergoing an ERCP under sedation, assessed by determining if the incidence rates of hypercapnia and hypoxemia decreased in the NHF device group, compared to the control group that did not use of this device.

Efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy: a meta-analysis of randomized controlled studies

Background

This meta-analysis aimed at investigating the efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy (ESWL).

Methods

Randomized controlled trials comparing the efficacy of acupuncture with conventional treatments were retrieved from major electronic databases (e.g., MEDLINE, EMBASE, and Cochrane Library) until August 28, 2022. The primary outcome was the response rate (i.e., rate of pain relief), while secondary outcomes included stone-free rate, satisfaction rate, duration of ESWL, peri-/post-procedural pain score, and risk of adverse events.

Results

Thirteen eligible studies involving 1,220 participants published between 1993 and 2022 were analyzed. Pooled results indicated that acupuncture had a better response rate compared to conventional treatments (RR = 1.17, 95% CI: 1.06-1.3, p = 0.003, seven trials, n = 832). Despite no difference in ESWL duration (MD = 0.02 min, 95% CI: -1.53 to 1.57, p = 0.98, three trials, n = 141), stone-free rate (RR = 1.11, 95% CI: 1-1.25, p = 0.06, six trials, n = 498), and satisfaction rate (RR = 1.51, 95% CI: 0.92-2.47, p = 0.1, three trials, n = 334) between the two groups, the acupuncture group had a lower risk of adverse events (RR = 0.51, 95% CI: 0.33-0.79, p = 0.003, five trials, n = 327), peri- (MD = -1.91 points, 94% CI: -3.53 to -0.28, p = 0.02, four trials, n = 258 patient) and post-procedural (MD = -1.07, 95% CI: -1.77 to -0.36, p = 0.003, four trials, n = 335) pain score.

Conclusion

The results of this meta-analysis showed that the use of acupuncture in patients receiving ESWL was associated with a higher pain relief rate and a lower risk of adverse events, suggesting feasibility of its use in this clinical setting.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022356327.

High-flow Nasal Cannula versus Conventional Ventilation in Laryngeal Surgery: A Systematic Review and Meta-analysis

High-flow nasal cannula (HFNC) is an emerging option for maintaining oxygenation in patients undergoing laryngeal surgery, as an alternative to traditional tracheal ventilation and jet ventilation (JV). However, the data on its safety and efficacy is sparse. This study aims to aggregate the current data and compares the use of HFNC with tracheal intubation and jet ventilation in adult patients undergoing laryngeal surgery. We searched PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), Embase (Excerpta Medica Database), Google Scholar, Cochrane Library, and Web of Science. Both observational studies and prospective comparative studies were included. Risk of bias was appraised with the Cochrane Collaboration Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) or RoB2 tools and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for case series. Data were extracted and tabulated as a systematic review. Summary statistics were performed. Meta-analyses and trial sequential analyses of the comparative studies were performed. Forty-three studies (14 HFNC, 22 JV, and seven comparative studies) with 8064 patients were included. In the meta-analysis of comparative studies, the duration of surgery was significantly reduced in the THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) group, but the number of desaturations, need for rescue intervention, and peak end-tidal CO₂ were significantly increased compared to the conventional ventilation group. The evidence was of moderate certainty and there was no evidence of publication bias. In conclusion, HFNC may be as effective as tracheal intubation in oxygenation during laryngeal surgery in selected adult patients and reduces the duration of surgery but conventional ventilation with tracheal intubation may be safer. The safety of JV was comparable to HFNC.

Clinical efficacy of acupuncture for pain relief from renal colic: A meta-analysis and trial sequence analysis

Background

This meta-analysis aimed at investigating the efficacy of acupuncture for relieving renal colic and reducing the risk of analgesic-related complications.

Methods

Randomized controlled trials (RCTs) comparing the efficacy of acupuncture (acupuncture group) with conventional interventions (control group) were screened from MEDLINE, EMBASE, Cochrane library databases, China Knowledge Network (CNKI), and Airiti Library till July 15, 2022. The primary outcome was the rate of effective pain relief (response rate), while secondary outcomes included the time of onset of pain relief, visual analog scale (VAS) at 30-60 min and risk of side effects.

Results

Thirteen eligible studies involving 1,212 participants published between 1992 and 2021 were analyzed. Compared with the control group, patients receiving acupuncture had a higher overall response rate [risk ratio (RR) = 1.12, 95% CI: 1.05-1.19, p = 0.0002, I ² = 41%, 1,136 patients] (primary outcome) and a faster pain relief [MD = -10.74 min, 95% CI: -12.65 to -8.82, p < 0.00001, I ² = 87%, 839 patients]. Patients receiving acupuncture had a lower pain score [MD = -0.65, 95% CI: -1.09 to -0.21, p = 0.21, I ² = 55%, 327 patients] and risk of side effects (RR = 0.11, 95% CI: 0.04-0.26, p < 0.00001, I ² = 0, 314 patients) compared to those receiving conventional interventions. Results from trial sequence analysis revealed sufficient evidence supporting the beneficial effects of acupuncture on response rate, time to pain relief, and pain score at 30-60 min.

Conclusion

Compared with conventional analgesic-based interventions, acupuncture can more efficiently relieve renal colic with fewer adverse effects. The limited number and quality of included studies warrant more clinical RCTs to support our findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022346714.

Impact of cognitive behavior therapy on osteoarthritis-associated pain, insomnia, depression, fatigue, and physical function in patients with knee/hip osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Background

This meta-analysis aimed at evaluating the efficacy of cognitive behavior therapy (CBT) against osteoarthritis-associated symptoms in patients with knee/hip osteoarthritis.

Methods

Medline, PubMed, Cochrane Library, and EMBASE databases were searched from inception to July 2022 to identify randomized controlled trials (RCTs) comparing the efficacy of CBT with other treatment approaches in adults with confirmed knee/hip osteoarthritis. The pain intensity (primary outcome) and the secondary outcomes including insomnia severity, sleep efficiency, physical function as well as the severity of depression and fatigue were assessed at two time points (i.e., immediately after treatment and during the follow-up period). The effect size is expressed as standardized mean difference (SMD) with SMDs of < 0.2, 0.2-0.5, and 0.5-0.8, and > 0.8 representing negligible, small, medium, and large effect sizes, respectively.

Results

Fifteen RCTs were included for analysis. Immediately after CBT intervention, meta-analysis showed similar treatment effect in pain severity [SMD = -0.46, 95% confidence interval (CI): -0.95 to 0.04, 11 studies, 1557 participants] and other symptoms including depression (SMD = -0.26, 95% CI: -0.58 to 0.06, five studies, 735 participants), fatigue (SMD = -2.44, 95% CI:-6.53 to 1.65, two RCTs, 511 participants), and physical function (SMD = -0.11, 95% CI:-0.25 to 0.02, five RCTs, 720 participants) between CBT and control groups, while there was an improvement in insomnia severity (SMD = -0.65, 95% CI: -1.06 to -0.24, four RCTs, 639 participants, medium treatment effect) and sleep efficiency (SMD = 0.32, 95% CI: 0.04 to 0.59, three RCTs, 352 patients, small treatment effect). During follow-up, CBT improved pain severity (SMD = -0.52, 95% CI: -1.03 to -0.01, eight studies, 1447 participants, medium treatment effect), insomnia (SMD = -0.43, 95% CI: -0.85 to -0.01, three RCTs, 571 participants, small treatment effect), and depression (SMD = -0.39, 95% CI: -0.59 to -0.18, four RCTs, 791 participants, small treatment effect). Nevertheless, sleep efficiency, fatigue, and physical function were not improved in the follow-up period.

Conclusion

Our results may suggest the durability of CBT-associated treatment benefits, supporting its role as a potential promising alternative or complementary intervention for patients with knee/hip osteoarthritis, especially against pain and insomnia. Future large-scale investigations are warranted to verify our findings.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022331165].

Effect of high-flow nasal oxygen on hypoxaemia during procedural sedation: a systematic review and meta-analysis

We conducted a systematic review to evaluate the effect of high-flow nasal oxygen and conventional oxygen therapy during procedural sedation amongst adults and children. We searched MEDLINE, EMBASE and CINAHL for randomised controlled trials that reported the effects of high-flow nasal oxygen during procedural sedation. The primary outcome measure was hypoxaemia and the secondary outcomes were minimum oxygen saturation; hypercarbia; requirement for airway manoeuvres; and procedure interruptions. The quality of evidence was assessed using the revised Cochrane risk-of bias tool and grading of recommendations, assessment, development and evaluation (GRADE). Nineteen randomised controlled trials (4121 patients) including three in children were included. Administration of high-flow nasal oxygen reduced hypoxaemia, risk ratio (95%CI) 0.37 (0.24-0.56), p < 0.001; minor airway manoeuvre requirements, risk ratio (95%CI) 0.26 (0.11-0.59), p < 0.001; procedural interruptions, risk ratio (95%CI) 0.17 (0.05-0.53), p = 0.002; and increased minimum oxygen saturation, mean difference (95%CI) 4.1 (2.70-5.50), p < 0.001; as compared with the control group. High-flow nasal oxygen had no impact on hypercarbia, risk ratio (95%CI) 1.24 (0.97-1.58), p = 0.09, I²  = 0%. High-flow nasal oxygen reduced the incidence of hypoxaemia regardless of the procedure involved, degree of fractional inspired oxygen, risk-profile of patients and mode of propofol administration. The evidence was ascertained as moderate for all outcomes except for procedure interruptions. In summary, high-flow nasal oxygen compared with conventional oxygenation techniques reduced the risk of hypoxaemia, increased minimum oxygen saturation and reduced the requirement for airway manoeuvres. High-flow nasal oxygen should be considered in patients at risk of hypoxaemia during procedural sedation.

Association of a low vitamin D status with risk of post-stroke depression: A meta-analysis and systematic review

Background

Although post-stroke depression (PSD) affects one-third of patients following an acute stroke, pooled evidence addressing the correlation between a low vitamin D status and the risk of PSD remains inconclusive.

Methods

Comprehensive database search of Medline, EMBASE, Cochrane library, and Google Scholar was performed from inception to December 2022. The primary outcome was the association of PSD risk with a low vitamin D status, while the secondary outcomes included the relationship between PSD and other risk factors.

Results

Analysis of seven observational studies published between 2014 and 2022 with 1,580 patients showed pooled incidences of vitamin D deficiency (defined as 25[OH] D levels < 50 nmol/L) and PSD of 60.1 and 26.1%, respectively. Patients with PSD had a lower circulating vitamin D concentration compared to those without [mean difference (MD) =-13.94 nmol/L, 95% CI: -21.83 to -6.05, p = 0.0005, I ² = 91%, six studies, 1,414 patients]. Meta-analysis also demonstrated a correlation between a low vitamin D level and an increased PSD risk [odd ratio (OR) = 3.25, 95% CI: 1.57-6.69, p = 0.001, I ² = 78.7%, 1,108 patients], the heterogeneity of which was found to be associated with the incidence of vitamin D deficiency but not female proportion on meta-regression. Besides, female gender (OR = 1.78, 95% CI: 1.3-2.44, p = 0.003, I ² = 31%, five studies, 1,220 patients), hyperlipidemia (OR = 1.55, 95% CI: 1.01-2.36, p = 0.04, I ² = 0%, four studies, 976 patients), and high National Institutes of Health Stroke Scale (NIHSS) scores (MD = 1.45, 95% CI: 0.58-2.32, p = 0.001, I ² = 82%, five studies, 1,220 patients) were potential risk factors for PSD. For the primary outcome, the certainty of evidence was very low. Regarding secondary outcomes, the certainty of evidence was low for BMI, female gender, hypertension, diabetes, and stroke history, and very low for age, level of education, hyperlipidemia, cardiovascular disease, and NIHSS scores.

Conclusion

The results suggested an association of a low circulating vitamin D level with an increased risk of PSD. Besides, female gender, hyperlipidemia, high NIHSS score were related to an increased risk or occurrence of PSD. The current study may imply the necessity of routine circulating vitamin D screening in this population.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022381580.

Efficacy of laryngeal mask airway against postoperative pharyngolaryngeal complications following thyroid surgery: a systematic review and meta-analysis of randomized controlled studies

This meta-analysis aimed at investigating the effectiveness of laryngeal mask airway (LMA) against postoperative pharyngolaryngeal complications after thyroidectomy. MEDLINE, Cochrane Library, google scholar, and EMBASE databases were searched from inception through February, 2021, for randomized controlled trials (RCTs) comparing the incidence of pharyngolaryngeal complications following the use of LMA or endotracheal tube (ETT). Pooled results from seven RCTs involving 600 patients showed an association of LMA with a reduced risk of postoperative sore throat (POST) at 24 h [risk ratio (RR) 0.75, p = 0.006, four trials], but not at 1 h and 48 h after thyroidectomy. POST severity and hoarseness risk were lower in the LMA group than the ETT group at 1 h, 24 h, and 48 h (all p < 0.05). Nevertheless, hoarseness severity was lower in the LMA group only at postsurgical 48 h [standardized mean difference = - 0.35, p = 0.008, three trials]. Moreover, the risk of emergence cough was lower in patients using LMA than those receiving ETT (RR = 0.14, p = 0.002, two trials). The two groups did not differ in the severity of dysphagia at postoperative 1 h, 24 h, and 48 h. This meta-analysis showed that LMA may be associated with fewer pharyngolaryngeal complications compared to ETT without airway impacts. The limited number of included studies warrants further research to support our findings.

High flow nasal oxygen versus conventional oxygen therapy in gastrointestinal endoscopy with conscious sedation: Systematic review and meta-analysis with trial sequential analysis

OBJECTIVES

Although conventional oxygen therapy (COT) is widely used, hypoxemia frequently occurs in gastrointestinal endoscopy with conscious sedation and can lead to life-threatening consequences. High flow nasal oxygen (HFNO) has been applied to improve oxygenation in clinical entities. However, its efficacy to prevent hypoxemia in gastrointestinal endoscopy with conscious sedation has not been evaluated.

METHODS

We searched databases to identify randomized controlled trials that compared the efficacy of HFNO with COT in gastrointestinal endoscopy with conscious sedation. The primary outcome was hypoxemia. Meta-analyses with trial sequential analysis were performed using a random-effects model.

RESULTS

Eight trials with 3212 patients were included. Compared with COT, HFNO significantly reduced the risk of hypoxemia (eight trials; 3212 patients; risk ratio 0.30; 95% confidence interval [CI] 0.13-0.70). Trial sequential analysis showed that the cumulative Z curve did not cross the monitoring or futility boundaries, nor reach the required information size line, indicating that more trials are needed to reach a definitive conclusion. Subgroup analyses indicated the superiority of HFNO over COT with respect to hypoxemia in patients at low risk and high risk. HFNO further improved the lowest oxygen saturation (four trials; 459 patients; mean difference 2.30, 95% CI 0.84-3.77).

CONCLUSIONS

Compared with COT, HFNO can reduce the risk of hypoxemia and improve the lowest oxygen saturation in gastrointestinal endoscopy with conscious sedation. However, the results should be interpreted with caution due to substantial heterogeneity and limited evidence. Further studies are needed to verify the preliminary findings.

High flow nasal cannula for patients undergoing bronchoscopy and gastrointestinal endoscopy: A systematic review and meta-analysis

Background

High flow nasal cannula is gaining increasingly used in patients undergoing endoscopic procedures. We undertook this systematic review and meta-analysis to determine whether high flow nasal cannula (HFNC) could effectively minimize the risk of hypoxemia as compared with conventional oxygen therapy (COT).

Methods

We performed a comprehensive search of Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Web of Science. Studies involving the application of HFNC during endoscopic procedures were identified.

Results

We included 15 randomized controlled trials (7 bronchoscopy, 8 gastrointestinal endoscopy). Patients receiving HFNC during endoscopic procedures had a significantly lower risk of hypoxemia (defined as SpO2 &lt; 90%) versus COT group (risk ratio = 0.32; 95%CI (0.22–0.47), 13 studies, 4,093 patients, moderate-quality evidence, I2 = 48.82%, P &lt; 0.001). The lowest SpO2 was significantly higher in HFNC group (mean difference = 4.41; 95%CI (2.95–5.86), 9 studies, 1,449 patients, moderate-quality evidence, I2 = 81.17%, P &lt; 0.001) than those receiving COT. No significant difference was detected between groups in end-procedure partial pressure of CO2 (standard mean difference  =  −0.18; 95%CI (−0.52–0.15), 5 studies, 238 patients, moderate-quality evidence, I2 = 42.25%, P = 0.29). Patients receiving HFNC were associated a lower need for airway intervention (risk ratio = 0.45; 95%CI (0.24–0.84), 8 studies, 2,872 patients, moderate-quality evidence, I2 = 85.97%, P = 0.01) and less procedure interruption (risk ratio = 0.36; 95%CI (0.26–0.51), 6 studies, 1,562 patients, moderate-quality evidence, I2 = 0.00%, P &lt; 0.001). The overall intubation rate after endoscopy was 0.20% in both group, with no difference detected (risk ratio = 1.00; 95%CI (0.30–3.35), 7 studies, 2,943 patients, low-quality evidence, I2 = 0.00%, P = 1.00).

Conclusion

This systematic review and meta-analysis found moderate to low evidence that the application of HFNC was associated with improved oxygenation, decreased need for airway intervention, and reduced procedure interruption in patients undergoing endoscopic procedures. Future larger sample and high-quality studies are warranted to confirm our result and further investigate the effectiveness of HFNC in patients at risk.

Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42022298032.

Impact of Opioid-Free Anesthesia on Analgesia and Recovery Following Bariatric Surgery: a Meta-Analysis of Randomized Controlled Studies

This meta-analysis aimed at exploring the impact of opioid-free anesthesia (OFA) on pain score and opioid consumption in patients undergoing bariatric surgery (BS). Literature search identified eight eligible trials. Forest plot revealed a significantly lower pain score (mean difference (MD) =  - 0.96, p = 0.0002; 318 patients), but not morphine consumption (MD =  - 5.85 mg, p = 0.1; 318 patients) at postoperative 24 h in patients with OFA than in those without. Pooled analysis also showed a lower pain score (p = 0.002), morphine consumption (p = 0.0003) in the postanesthetic care unit, and risk of postoperative nausea/vomiting (p = 0.0003) in the OFA group compared to the controls. In conclusion, this meta-analysis demonstrated that opioid-free anesthesia improved pain outcomes immediately and at 24 h after surgery without a beneficial impact on opioid consumption at postoperative 24 h. KEY POINTS: • Roles of opioid-free anesthesia (OFA) in bariatric surgery (BS) were investigated. • Outcomes included postoperative pain score, opioid use, and nausea/vomiting risk. • OFA was associated with lower 24-h pain score but not opioid consumption. • Lower pain score and opioid consumption were noted in the postanesthetic care unit. • OFA correlated with a lower risk of postoperative nausea/vomiting.

Should We Use High-Flow Nasal Cannula in Patients Receiving Gastrointestinal Endoscopies? Critical Appraisals through Updated Meta-Analyses with Multiple Methodologies and Depiction of Certainty of Evidence

(1) Background: High-flow nasal cannula (HFNC) therapy or conventional oxygen therapy (COT) are typically applied during gastrointestinal (GI) endoscopic sedation. (2) Methods: We conducted a rigorous systematic review enrolling randomized controlled trials (RCTs) from five databases. Risk of bias was assessed using Cochrane’s RoB 2.0 tool; certainty of evidence (CoE) was assessed using GRADE framework. Meta-analysis was conducted using inverse-variance heterogeneity model and presented as relative risk (RR) with 95% confidence interval (CI). Trial sequential analysis was performed, and sensitivity analysis was conducted with Bayesian approach. (3) Results: Eight RCTs were included. Compared to COT, HFNC did not reduce the overall incidence of hypoxemia (RR 0.51; 95% CI 0.24–1.09; CoE: very low) but might reduce the incidence of hypoxemia in patients at moderate to high risk for hypoxemia (RR 0.54; 95% CI 0.31–0.96; and CoE: very low). HFNC might reduce the incidence of severe hypoxemia (RR 0.38; 95% CI 0.20–0.74; and CoE: low). HFNC might not affect the need of minor airway interventions (RR 0.31; 95% CI 0.08–1.22; and CoE: very low) and had no effect on procedure duration (CoE: very low); (4) Conclusions: During GI endoscopic sedation, HFNC might reduce the incidence of hypoxemia in patients at moderate to high risk for hypoxemia and prevent severe hypoxemia.