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Kang T, Tao J, Wang X, Liu Y, Jin D. Epidural ropivacaine versus bupivacaine for cesarean sections: a system review and meta-analysis. J Matern Fetal Neonatal Med 2024; 37:2313356. [PMID: 38342577 DOI: 10.1080/14767058.2024.2313356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/28/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION It is still no consensus on the use of ropivacaine or bupivacaine in epidural anesthesia for cesarean section (CS), because their anesthetic potency and relative complications remains controversial. This system review and meta-analysis aimed to compare the efficacy of epidural ropivacaine and bupivacaine for elective CSs and investigate relative complications for parturients and neonates. METHODS We searched PubMed, MEDLINE, Embase, Cochrane Library, Science-Direct, and Google Scholar to June 30, 2023 for randomized controlled trials (RCTs), which compared epidural ropivacaine with bupivacaine for elective CSs. The success rate of epidural anesthesia (EA) was primary outcome. The secondary outcomes included onset times of sensory block, maternal side effects, neonatal Apgar scores and umbilical artery pH. RESULTS We analyzed 8 RCTs with 532 parturients. 0.75% ropivacaine is associated with a shorter onset time of sensory block than 0.5% bupivacaine (SMD = -0.43, 95% CI: -0.70 to -0.17; p = .001). 0.5% ropivacaine resulted in a reduced nausea than 0.5% bupivacaine (RR = 0.49, 95% CI: 0.28 to 0.83; p = .008). In addition, there were no significant difference between ropivacaine and bupivacaine groups in terms of success rate of epidural anesthesia, maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH. CONCLUSIONS The findings suggest that there were no significant difference between epidural ropivacaine and bupivacaine for elective CSs in terms of the success rate (85.9% vs. 83.5), maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH. But compared with 0.5% bupivacaine, epidural 0.75% ropivacaine was mildly effective for reducing onset time of sensory block and 0.5% ropivacaine reduced the incidence of maternal nausea.
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Affiliation(s)
- Tao Kang
- Department of Neurosurgery, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
| | - Jiwei Tao
- Department of Neurosurgery, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
| | - Xuetao Wang
- Department of Neurosurgery, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
| | - Yu Liu
- Department of Neurosurgery, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
| | - Dan Jin
- Department of Neurosurgery, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
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Au E, Zhao K, Belley-Côté E, Song Y, Al-Hazzani W, Sadeghirad B, Wang E, Young J, Kashani H, Kavosh M, Inami T, Beaver C, Kloppenburg S, Mazer D, Jacobsohn E, Um K, Spence J. The effect of perioperative benzodiazepine administration on postoperative nausea and vomiting: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2024; 132:469-482. [PMID: 38177006 DOI: 10.1016/j.bja.2023.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Despite recent systematic reviews suggesting their benefit for postoperative nausea, vomiting, or both (PONV) prevention, benzodiazepines have not been incorporated into guidelines for PONV prophylaxis because of concerns about possible adverse effects. We conducted an updated meta-analysis to inform future practice guidelines. METHODS We included randomised controlled trials (RCTs) of all languages comparing benzodiazepines with non-benzodiazepine comparators in adults undergoing inpatient surgery. Our outcomes were postoperative nausea, vomiting, or both. We assessed risk of bias for RCTs using the Cochrane Risk of Bias tool. We pooled data using a random-effects model and assessed the quality of evidence for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS We screened 31 413 abstracts and 950 full texts. We included 119 RCTs; 104 were included in quantitative synthesis. Based on moderate certainty evidence, we found that perioperative benzodiazepine administration reduced the incidence of PONV (52 studies, n=5086, relative risk [RR]: 0.77, 95% confidence interval [CI] 0.66-0.89; number needed to treat [NNT] 16; moderate certainty), postoperative nausea (55 studies, n=5916, RR: 0.72, 95% CI 0.62-0.83; NNT 21; moderate certainty), and postoperative vomiting (52 studies, n=5909, RR: 0.74, 95% CI 0.60-0.91; NNT 55; moderate certainty). CONCLUSIONS Moderate quality evidence shows that perioperative benzodiazepine administration decreases the incidence of PONV. The results of this systematic review and meta-analysis will inform future clinical practice guidelines. SYSTEMATIC REVIEW PROTOCOL The protocol for this systematic review was pre-registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42022361088) and published in BMJ Open (PMID 31831540).
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Affiliation(s)
- Emily Au
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Karen Zhao
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Côté
- Department of Medicine (Cardiology and Critical Care), Perioperative Research Division, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Yuri Song
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Waleed Al-Hazzani
- Departments of Critical Care, Medicine (Gastroenterology), Health Research Methods, Evaluation, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Eugene Wang
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Hessam Kashani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Medicine, Coney Island Hospital, New York, NY, USA
| | - Toru Inami
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | | | | | - David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Jacobsohn
- Department of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, MB, Canada
| | - Kevin Um
- Department of Medicine (Cardiology), McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, Perioperative Research Division, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
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Fonseca NM, Guimarães GMN, Pontes JPJ, Azi LMTDA, de Ávila Oliveira R. Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:198-216. [PMID: 34954261 PMCID: PMC10068557 DOI: 10.1016/j.bjane.2021.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Spinal infusions of either fentanyl or sufentanil have been reported in international reports, articles, and scientific events worldwide. This study aimed to determine whether intrathecal fentanyl or sufentanil offers safety in mortality and perioperative adverse events. METHODS MEDLINE (via PubMed), EMBASE, CENTRAL (Cochrane library databases), gray literature, hand-searching, and clinicaltrials.gov were systematically searched. Randomized controlled trials with no language, data, or status restrictions were included, comparing the effectiveness and safety of adding spinal lipophilic opioid to local anesthetics (LAs). Data were pooled using the random-effects models or fixed-effect models based on heterogeneity. RESULTS The initial search retrieved 4469 records; 3241 records were eligible, and 3152 articles were excluded after reading titles and abstracts, with a high agreement rate (98.6%). After reading the full texts, 76 articles remained. Spinal fentanyl and sufentanil significantly reduced postoperative pain and opioid consumption, increased analgesia and pruritus. Fentanyl, but not sufentanil, significantly reduced both postoperative nausea and vomiting, and postoperative shivering; compared to LAs alone. The analyzed studies did not report any case of in-hospital mortality related to spinal lipophilic opioids. The rate of respiratory depression was 0.7% and 0.8% when spinal fentanyl or sufentanil was added and when it was not, respectively. Episodes of respiratory depression were rare, uneventful, occurred intraoperatively, and were easily manageable. CONCLUSION There is moderate to high quality certainty that there is evidence regarding the safety and effectiveness of adding lipophilic opioids to LAs in spinal anesthesia.
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Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brazil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, CET, Uberlândia, MG, Brazil; Sociedade Brasileira de Anestesiologia, Brazil; Comitê para o Estudo do Equipamento Respiratório e Anestesia de ABNT, Brazil; Revista Brasileira de Anestesiologia, Brazil.
| | | | - João Paulo Jordão Pontes
- Complexo Hospitalar Santa Genoveva de Uberlândia, Departamento de Anestesiologia, Uberlândia, MG, Brazil
| | - Liana Maria Torres de Araújo Azi
- Universidade Federal da Bahia (UFBA), Faculdade de Medicina, Departamento de Anestesiologia e Cirurgia, Salvador, BA, Brazil; Complexo Hospitalar Universitário Professor Edgard Santos, Salvador, BA, Brazil
| | - Ricardo de Ávila Oliveira
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Cirurgia Vascular, Uberlândia, MG, Brazil; Universidade Federal de Uberlândia (UFU), Departamento de Cirurgia, Uberlândia, MG, Brazil
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Hung TY, Huang YS, Lin YC. Maternal and neonatal outcomes with the addition of intrathecal midazolam as an adjuvant to spinal anesthesia in cesarean delivery: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2022; 80:110786. [PMID: 35461171 DOI: 10.1016/j.jclinane.2022.110786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To determine the efficacy and safety, in terms of maternal and neonatal outcomes, of adding intrathecal midazolam to spinal anesthesia for cesarean delivery in healthy pregnant women. DESIGN A meta-analysis of randomized controlled trials was conducted. PubMed, Cochrane Library, Embase, and Web of Science were searched manually, and citation screening was completed on May 20, 2021. SETTING Most of the included data were collected in the operating room and postoperative recovery area. PATIENTS A total of 1382 healthy parturients undergoing cesarean delivery with single-shot spinal anesthesia were recruited in 19 eligible randomized controlled trials. INTERVENTIONS Single intrathecal midazolam adjuvant was compared to a control, with the local anesthetic dose in spinal anesthesia identical between the intervention and control groups. MEASUREMENTS The primary outcomes were time to first analgesic use, maternal adverse effects, and neonatal Apgar scores at 1 and 5 min. The secondary outcomes were the onset and duration of the sensory and motor blocks. MAIN RESULTS Adjuvant intrathecal midazolam prolonged the time to the first analgesic (mean difference [MD]: 59.96 min, 95% confidence interval [CI]: [23.12, 96.79]) and decreased perioperative maternal nausea and/or vomiting (odds ratio [OR], 0.28; 95% CI: [0.17, 0.45]). However, more sedation events were observed with midazolam (OR, 3.93; 95% CI: [1.12, 13.78]). There was no significant difference in the neonatal Apgar scores at 1 or 5 min (MD: -0.29, 95% CI: [-0.61, 0.03]; MD: -0.00, 95% CI: [-0.11, 0.1], respectively). Intrathecal midazolam also shortened sensory and motor block onset by less than 1 min and prolonged sensory block duration but had no significant effect on motor block duration. CONCLUSIONS Current evidence indicates that intrathecal midazolam, as an adjuvant to spinal anesthesia, provides modest analgesic and significant antiemetic effects at the cost of more sedation events in cesarean delivery patients. The neonatal Apgar score was not affected by intrathecal midazolam administration. However, more objective, sensitive, and long-term measurements of neonatal safety and maternal neurological effects should be performed in the future.
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Affiliation(s)
- Tsung-Yu Hung
- Department of Anesthesia, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan
| | - Yin-Shan Huang
- Department of Anesthesia, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan
| | - Ying-Chun Lin
- Department of Anesthesia, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Room 501, No. 17, Xu-Zhou Road, Taipei, Taiwan; MacKay Medical College, No. 46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, Taiwan.
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Huang H, Wang S, Lin R, He Z. Sufentanil for Spinal Analgesia during Cesarean Section Delivery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int J Clin Pract 2022; 2022:4741141. [PMID: 36105787 PMCID: PMC9453095 DOI: 10.1155/2022/4741141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the effect of sufentanil for spinal analgesia during cesarean section. METHOD Eligible papers were systematically retrieved from PubMed, Embase, Ovid, and ScienceDirect. Two researchers independently extracted primary and secondary endpoints to compute relative risk and mean difference by using the random-effects model or the fixed-effects model, as appropriate. Publication bias was quantified and assessed using funnel plot and Egger's test. RESULT A total of 8 publications with 503 pregnant women were included in this study for meta-analysis. Subarachnoid administration of sufentanil did not significantly reduce the onset time of sensory block and motor block. Nonetheless, subarachnoid administration of sufentanil significantly increased the incidence of postoperative skin pruritus (RR = 5.25, 95%CI: 1.90, 14.49, P < 0.001). CONCLUSION Subarachnoid administration of sufentanil has no significant difference in the combined effect value of shortening the onset time of sensory block and motor block, prolonging the onset time of local anesthesia and the incidence of some adverse reactions (such as postoperative nausea, vomiting, hypotension, and tremors). However, the incidence of skin pruritus was significantly increased, and the difference was statistically significant. Because of this, the drug still needs to be used with caution in combination with the actual situation in clinical use.
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Affiliation(s)
- Hongming Huang
- Department of Anesthesiology, People's Hospital of Wanning, Hainan 571500, China
| | - Shiwu Wang
- Department of Anesthesiology, Chinese Medicine Hospital of Chengmai County, Chengmai 571900, China
| | - Rujun Lin
- Department of Anesthesiology, People's Hospital of Wanning, Hainan 571500, China
| | - Zhongrun He
- Department of Anesthesiology, Hainan Second People's Hospital, Wuzhishan 572299, China
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The relationship between core temperature and perioperative shivering during caesarean section under intrathecal anesthesia with bupivacaine and ropivacaine: a randomized controlled study. J Anesth 2021; 35:889-895. [PMID: 34476612 PMCID: PMC8595161 DOI: 10.1007/s00540-021-02995-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
Purpose To assess the incidence rate of perioperative shivering for cesarean section and explore the associations between the occurrence of shivering and hypothermia, core temperature change, local anesthetic. Methods This is a prospective, randomized, controlled, double-blinded study of 100 patients consenting for caesarean section under intrathecal anesthesia. Parturients with ASA I or II accepted elective caesarean section with combined spinal-epidural anesthesia (SA). 2–2.5 ml of 0.5% bupivacaine or 0.5% ropivacaine was intrathecally injected in group B and group R, respectively. Results The intraoperative shivering incidence in group B was significantly higher than that in group R (66.7 vs. 20.5%, Pvalue < 0.001), and shivering intensity in group B was significantly greater than group R (score: 1.4 vs. 0.3, Pvalue < 0.001). The core temperature in both groups gradually decreased with the time after SA. Hypothermia (core temperature < 36.0 ℃) 5–30 min after SA was not associated with shivering. However, changes of temperature at 25 and 30 min after SA, and bupivacaine were statistically associated with shivering, with the odds of 10.77 (95% CI: 1.36–85.21, P value = 0.02), 8.88 (95% CI: 1.29–60.97, P value = 0.03), and 7.78 (95% CI: 2.94–20.59, P value < 0.01), respectively. Conclusions In our study, for cesarean section, the occurrence of shivering was associated with the local anesthetics and the change of core temperature after SA, while not the hypothermia.
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Seki H, Shiga T, Mihara T, Hoshijima H, Hosokawa Y, Hyuga S, Fujita T, Koshika K, Okada R, Kurose H, Ideno S, Ouchi T. Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials. J Anesth 2021; 35:911-927. [PMID: 34338864 DOI: 10.1007/s00540-021-02980-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE We aimed to compare the beneficial and harmful effects of opioids used as adjuncts to local anesthetics in patients undergoing cesarean section under spinal anesthesia. METHODS We searched electronic databases and ClinicalTrials.gov from their inception until March, 2021 without language restrictions. The primary outcome was the complete analgesia duration (Time to VAS > 0). Data were synthesized using the Bayesian random-effects model. Evidence confidence was evaluated using the Confidence In Network Meta-Analysis. RESULTS We identified 66 placebo-controlled randomized controlled trials (RCTs) comprising 4400 patients undergoing elective cesarean section. Compared with the placebo, intrathecal opioids (fentanyl, sufentanil, and morphine) significantly prolonged the analgesia duration by 96, 96, and 190 min, respectively (mean difference). Despite morphine ranking first, opioid efficacy was similar; the results were inconsistent with respect to other analgesic outcomes. Except for diamorphine, all opioids were associated with significant increases in the pruritus incidence. Sufentanil and morphine were associated with increases in the respiratory depression incidence. CONCLUSIONS We confirmed that intrathecal opioids benefit postoperative analgesia. Although morphine seems to be the most appropriate agent, some results were inconsistent, and the evidence confidence was often moderate or low, especially for adverse outcomes. Well-designed RCTs with an evidence-based approach are imperative for determining the most appropriate opioid for cesarean sections.
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Affiliation(s)
- Hiroyuki Seki
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan. .,Department of Anesthesiology, Kyorin University School of Medicine, 6-20-2, ShinkawaTokyo, Mitaka, 181-8611, Japan.
| | - Toshiya Shiga
- Department of Anesthesiology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.,Department of Health Data Science, Yokohama City University Graduate School of Data Science, Kanagawa, Japan
| | - Hiroshi Hoshijima
- Division of Dento-Oral Anesthesiology, Tohoku University Graduate School of Dentistry, Miyagi, Japan
| | - Yuki Hosokawa
- Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | - Shunsuke Hyuga
- Department of Anesthesiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tomoe Fujita
- Department of Anesthesiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kyotaro Koshika
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Reina Okada
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Hitomi Kurose
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Ideno
- Department of Anesthesiology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Takashi Ouchi
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
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Chen XR, Gao T, Zhang Y, Peng MQ. Addition of low-dose sufentanil to ropivacaine for reducing shivering and visceral traction pain during cesarean section. J Int Med Res 2021; 49:3000605211017000. [PMID: 34038198 PMCID: PMC8161908 DOI: 10.1177/03000605211017000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the efficacy of low-dose sufentanil for preventing shivering and visceral traction pain during cesarean section under spinal anesthesia. Methods This was a prospective, randomized, controlled study. A total of 112 full-term parturients who underwent elective caesarean delivery were randomly divided into two groups. Group R received 0.75% isobaric ropivacaine intrathecally and group RS received 0.75% isobaric ropivacaine plus 5 µg sufentanil intrathecally. Results There were no significant differences in the maximum sensory block time, motor block time, duration of the surgery, and heart rate, mean arterial pressure, and blood oxygen saturation before and 1, 5, and 10 minutes after spinal anesthesia, and at the end of the surgery between the two groups. Shivering was significantly more common in group R (n = 30) than in group RS (n = 8). The incidence of visceral traction pain in group R (46.43%) was significantly higher than that in group RS (14.29%). There was no significant difference in the newborns’ Apgar scores between the groups. Conclusion Adding low-dose sufentanil to ropivacaine can significantly reduce the incidence of shivering and visceral traction pain after spinal anesthesia.
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Affiliation(s)
- Xiao-Rong Chen
- Department of Anesthesia, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Gao
- Department of Anesthesia, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Yin Zhang
- Department of Anesthesia, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Ming-Qing Peng
- Department of Anesthesia, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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Griffiths JD, Gyte GM, Popham PA, Williams K, Paranjothy S, Broughton HK, Brown HC, Thomas J. Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. Cochrane Database Syst Rev 2021; 5:CD007579. [PMID: 34002866 PMCID: PMC8130052 DOI: 10.1002/14651858.cd007579.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Nausea and vomiting are distressing symptoms which are experienced commonly during caesarean section under regional anaesthesia and in the postoperative period. OBJECTIVES: To assess the efficacy of pharmacological and non-pharmacological interventions versus placebo or no intervention given prophylactically to prevent nausea and vomiting in women undergoing regional anaesthesia for caesarean section. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (16 April 2020), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of studies and conference abstracts, and excluded quasi-RCTs and cross-over studies. DATA COLLECTION AND ANALYSIS Review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Our primary outcomes are intraoperative and postoperative nausea and vomiting. Data entry was checked. Two review authors independently assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Eighty-four studies (involving 10,990 women) met our inclusion criteria. Sixty-nine studies, involving 8928 women, contributed data. Most studies involved women undergoing elective caesarean section. Many studies were small with unclear risk of bias and sometimes few events. The overall certainty of the evidence assessed using GRADE was moderate to very low. 5-HT3 antagonists: We found intraoperative nausea may be reduced by 5-HT3 antagonists (average risk ratio (aRR) 0.55, 95% confidence interval (CI) 0.42 to 0.71, 12 studies, 1419 women, low-certainty evidence). There may be a reduction in intraoperative vomiting but the evidence is very uncertain (aRR 0.46, 95% CI 0.29 to 0.73, 11 studies, 1414 women, very low-certainty evidence). There is probably a reduction in postoperative nausea (aRR 0.40, 95% CI 0.30 to 0.54, 10 studies, 1340 women, moderate-certainty evidence), and these drugs may show a reduction in postoperative vomiting (aRR 0.47, 95% CI 0.31 to 0.69, 10 studies, 1450 women, low-certainty evidence). Dopamine antagonists: We found dopamine antagonists may reduce intraoperative nausea but the evidence is very uncertain (aRR 0.38, 95% CI 0.27 to 0.52, 15 studies, 1180 women, very low-certainty evidence). Dopamine antagonists may reduce intraoperative vomiting (aRR 0.41, 95% CI 0.28 to 0.60, 12 studies, 942 women, low-certainty evidence) and postoperative nausea (aRR 0.61, 95% CI 0.48 to 0.79, 7 studies, 601 women, low-certainty evidence). We are uncertain if dopamine antagonists reduce postoperative vomiting (aRR 0.63, 95% CI 0.44 to 0.92, 9 studies, 860 women, very low-certainty evidence). Corticosteroids (steroids): We are uncertain if intraoperative nausea is reduced by corticosteroids (aRR 0.56, 95% CI 0.37 to 0.83, 6 studies, 609 women, very low-certainty evidence) similarly for intraoperative vomiting (aRR 0.52, 95% CI 0.31 to 0.87, 6 studies, 609 women, very low-certainty evidence). Corticosteroids probably reduce postoperative nausea (aRR 0.59, 95% CI 0.49 to 0.73, 6 studies, 733 women, moderate-certainty evidence), and may reduce postoperative vomiting (aRR 0.68, 95% CI 0.49 to 0.95, 7 studies, 793 women, low-certainty evidence). Antihistamines: Antihistamines may have little to no effect on intraoperative nausea (RR 0.99, 95% CI 0.47 to 2.11, 1 study, 149 women, very low-certainty evidence) or intraoperative vomiting (no events in the one study of 149 women). Antihistamines may reduce postoperative nausea (aRR 0.44, 95% CI 0.30 to 0.64, 4 studies, 514 women, low-certainty evidence), however, we are uncertain whether antihistamines reduce postoperative vomiting (average RR 0.48, 95% CI 0.29 to 0.81, 3 studies, 333 women, very low-certainty evidence). Anticholinergics: Anticholinergics may reduce intraoperative nausea (aRR 0.67, 95% CI 0.51 to 0.87, 4 studies, 453 women, low-certainty evidence) but may have little to no effect on intraoperative vomiting (aRR 0.79, 95% CI 0.40 to 1.54, 4 studies; 453 women, very low-certainty evidence). No studies looked at anticholinergics in postoperative nausea, but they may reduce postoperative vomiting (aRR 0.55, 95% CI 0.41 to 0.74, 1 study, 161 women, low-certainty evidence). Sedatives: We found that sedatives probably reduce intraoperative nausea (aRR 0.65, 95% CI 0.51 to 0.82, 8 studies, 593 women, moderate-certainty evidence) and intraoperative vomiting (aRR 0.35, 95% CI 0.24 to 0.52, 8 studies, 593 women, moderate-certainty evidence). However, we are uncertain whether sedatives reduce postoperative nausea (aRR 0.25, 95% CI 0.09 to 0.71, 2 studies, 145 women, very low-certainty evidence) and they may reduce postoperative vomiting (aRR 0.09, 95% CI 0.03 to 0.28, 2 studies, 145 women, low-certainty evidence). Opioid antagonists: There were no studies assessing intraoperative nausea or vomiting. Opioid antagonists may result in little or no difference to the number of women having postoperative nausea (aRR 0.75, 95% CI 0.39 to 1.45, 1 study, 120 women, low-certainty evidence) or postoperative vomiting (aRR 1.25, 95% CI 0.35 to 4.43, 1 study, 120 women, low-certainty evidence). Acupressure: It is uncertain whether acupressure/acupuncture reduces intraoperative nausea (aRR 0.55, 95% CI 0.41 to 0.74, 9 studies, 1221 women, very low-certainty evidence). Acupressure may reduce intraoperative vomiting (aRR 0.52, 95% CI 0.33 to 0.80, 9 studies, 1221 women, low-certainty evidence) but it is uncertain whether it reduces postoperative nausea (aRR 0.46, 95% CI 0.27 to 0.75, 7 studies, 1069 women, very low-certainty evidence) or postoperative vomiting (aRR 0.52, 95% CI 0.34 to 0.79, 7 studies, 1069 women, very low-certainty evidence). Ginger: It is uncertain whether ginger makes any difference to the number of women having intraoperative nausea (aRR 0.66, 95% CI 0.36 to 1.21, 2 studies, 331 women, very low-certainty evidence), intraoperative vomiting (aRR 0.62, 95% CI 0.38 to 1.00, 2 studies, 331 women, very low-certainty evidence), postoperative nausea (aRR 0.63, 95% CI 0.22 to 1.77, 1 study, 92 women, very low-certainty evidence) and postoperative vomiting (aRR 0.20, 95% CI 0.02 to 1.65, 1 study, 92 women, very low-certainty evidence). Few studies assessed our secondary outcomes including adverse effects or women's views. AUTHORS' CONCLUSIONS This review indicates that 5-HT3 antagonists, dopamine antagonists, corticosteroids, sedatives and acupressure probably or possibly have efficacy in reducing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. However the certainty of evidence varied widely and was generally low. Future research is needed to assess side effects of treatment, women's views and to compare the efficacy of combinations of different medications.
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Affiliation(s)
- James D Griffiths
- Department of Anaesthesia, Royal Women's Hospital, Parkville, Australia
| | - Gillian Ml Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Kacey Williams
- Department of Anaesthesia, Monash Medical Centre, Monash Health, Clayton, Australia
| | - Shantini Paranjothy
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Hannah K Broughton
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Heather C Brown
- Department of Obstetrics and Gynaecology, Royal Sussex County Hospital, Brighton, UK
| | - Jane Thomas
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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10
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Roofthooft E, Joshi GP, Rawal N, Van de Velde M. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 76:665-680. [PMID: 33370462 PMCID: PMC8048441 DOI: 10.1111/anae.15339] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.
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Affiliation(s)
- E Roofthooft
- Department of Anesthesiology, GZA Sint-Augustinus Hospital, Antwerp, Belgium.,Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - N Rawal
- Department of Anesthesiology, Orebro University, Orebro, Sweden
| | - M Van de Velde
- Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium
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11
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Zhang YW, Zhang J, Hu JQ, Wen CL, Dai SY, Yang DF, Li LF, Wu QB. Neuraxial adjuvants for prevention of perioperative shivering during cesarean section: A network meta-analysis following the PRISMA guidelines. World J Clin Cases 2019; 7:2287-2301. [PMID: 31531322 PMCID: PMC6718794 DOI: 10.12998/wjcc.v7.i16.2287] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/25/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Perioperative shivering is clinically common during cesarean sections under neuraxial anesthesia, and several neuraxial adjuvants are reported to have preventive effects on it. However, the results of current studies are controversial and the effects of these neuraxial adjuvants remain unclear.
AIM To evaluate the effects of neuraxial adjuvants on perioperative shivering during cesarean sections, thus providing an optimal choice for clinical application.
METHODS A systematic review and network meta-analysis were conducted following the PRISMA (Preferred Reported Items for Systematic Review and Meta-analysis) guidelines. Analyses were performed using Review Manager 5.3 and Stata 14.0. We searched PubMed, EMBASE, Web of Science, and Cochrane Central databases for eligible clinical trials assessing the effects of neuraxial adjuvants on perioperative shivering and other adverse events during cesarean sections. Perioperative shivering was defined as the primary endpoint, and nausea, vomiting, pruritus, hypotension, and bradycardia were the secondary outcomes.
RESULTS Twenty-six studies using 9 neuraxial adjuvants for obstetric anesthesia during caesarean sections were included. The results showed that, compared with placebo, pethidine, fentanyl, dexmedetomidine, and sufentanil significantly reduced the incidence of perioperative shivering. Among the four neuraxial adjuvants, pethidine was the most effective one for shivering prevention (OR = 0.15, 95%CI: 0.07-0.35, surface under the cumulative ranking curve 83.9), but with a high incidence of nausea (OR = 3.15, 95%CI: 1.04-9.57) and vomiting (OR = 3.71, 95%CI: 1.81-7.58). The efficacy of fentanyl for shivering prevention was slightly inferior to pethidine (OR = 0.20, 95%CI: 0.09-0.43), however, it significantly decreased the incidence of nausea (OR = 0.34, 95%CI: 0.15-0.79) and vomiting (OR = 0.25, 95%CI: 0.11-0.56). In addition, compared with sufentanil, fentanyl showed no impact on haemodynamic stability and the incidence of pruritus.
CONCLUSION Pethidine, fentanyl, dexmedetomidine, and sufentanil appear to be effective for preventing perioperative shivering in puerperae undergoing cesarean sections. Considering the risk-benefit profiles of the included neuraxial adjuvants, fentanyl is probably the optimal choice.
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Affiliation(s)
- Yi-Wei Zhang
- State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macau 999078, China
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau 999078, China
| | - Juan Zhang
- Department of Anesthesiology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Jia-Qi Hu
- Department of Anesthesiology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
- Department of Pain, Zhejiang Provincial People's Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Chun-Lei Wen
- Department of Anesthesiology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Shu-Yang Dai
- Department of Anesthesiology, Ruian People's Hospital, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Dan-Feng Yang
- Department of Anesthesiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Li-Fang Li
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau 999078, China
| | - Qi-Biao Wu
- State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macau 999078, China
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau 999078, China
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12
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Liu J, Wang Y, Ma W. Shivering prevention and treatment during cesarean delivery under neuraxial anesthesia: a systematic review. Minerva Anestesiol 2018; 84:1393-1405. [PMID: 29945433 DOI: 10.23736/s0375-9393.18.12478-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Perioperative shivering during cesarean sections (CSs) under neuraxial anesthesia (NA) is clinically common but often under-treated. It may prominently increase oxygen consumption, which can be catastrophic for parturients with ischemic cardiovascular disease. Thus, the prevention and treatment of shivering may be of great significance in parturients. The purpose of this systematic review was to investigate the effectiveness of several drugs on shivering prevention and treatment during CSs under NA. EVIDENCE ACQUISITION A literature search was carried out using PubMed, EMBASE and the Cochrane Library to identify relevant studies. After literature screening and information extraction, a systematic review was performed. EVIDENCE SYNTHESIS Eighteen randomized controlled trials met the inclusion criteria. Intrathecal dexmedetomidine effectively reduced shivering, but effectiveness depended on the dose administered. Intrathecal fentanyl, intrathecal sufentanil, intrathecal meperidine, intravenous ketamine and intravenous tramadol were beneficial for reducing shivering during CSs under NA. MgSO4 administered intrathecally resulted in transient alleviation of shivering, and the effect did not persist. Two trials investigated the antishivering effect of intravenous ondansetron. The medication appeared to be effective in one trial, but ineffective in the other. CONCLUSIONS Appropriate use of dexmedetomidine, fentanyl, sufentanil, ketamine, meperidine, tramadol and MgSO4 may effectively reduce the incidence and severity of shivering during CSs under NA, while trials on the effect of intravenous ondansetron reached inconclusive results.
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Affiliation(s)
- Jie Liu
- Department of Anesthesia, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yong Wang
- Department of Anesthesia, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wuhua Ma
- Department of Anesthesia, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China -
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Feng LS, Hong G, Yan Z, Qiu LY, Liang LA. Intrathecal Sufentanil Does Not Reduce Shivering During Neuraxial Anesthesia: A Meta-Analysis. Med Sci Monit 2016; 22:258-66. [PMID: 26806131 PMCID: PMC4732550 DOI: 10.12659/msm.897293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We performed this meta-analysis to evaluate the efficacy of intrathecal sufentanil in preventing shivering during neuraxial anesthesia. MATERIAL/METHODS We searched the Cochrane Library, PubMed, and Embase for all randomized controlled trials (RCT) on use of intrathecal sufentanil for preventing shivering during neuraxial anesthesia. References of retrieved articles were also screened. The quality of the studies was evaluated by the method recommended by the Cochrane Collaboration. Meta-analysis was conducted using the Cochrane Collaboration's RevMan 5.3 software. The primary outcome was incidence and severity of shivering, and the secondary outcomes were drug-related complications of pruritus, nausea, vomiting, hypotension, and bradycardia. RESULTS Eight original RCTs investigating a total of 1032 patients, of whom 599 received sufentanil and 473 received placebo, met the inclusion criteria. Compared to the placebo group, sufentanil did not reduce incidence of shivering (OR, 0.60; 95% CI, 0.35 to 1.01; P=0.06), but it increased the incidence of pruritus (OR, 12.52; 95% CI, 5.07 to 30.91; P<0.00001). Compared to the placebo group, sufentanil did not increase the incidence of nausea (OR, 0.69; 95% CI, 0.41 to 1.16; P=0.16), hypotension (OR, 0.93; 95% CI, 0.62 to 1.41; P=0.74), or bradycardia (OR, 0.86; 95% CI, 0.41 to 1.82; P=0.70). In addition, sufentanil reduced the incidence of vomiting during neuraxial anesthesia (OR, 0.45; 95% CI, 0.22 to 0.92; P=0.03). CONCLUSIONS Neither epidural nor subarachnoid intrathecal sufentanil reduced shivering during neuraxial anesthesia, but it did increase the incidence of pruritus.
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Affiliation(s)
- Lin Shao Feng
- Department of Anesthesiology, Guizhou Medical University, Guiyang, Guizhou, China (mainland)
| | - Gao Hong
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China (mainland)
| | - Zhao Yan
- Department of Anesthesiology, The First People's Hospital of Guiyang, Guiyang, Guizhou, China (mainland)
| | - Liu Yan Qiu
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China (mainland)
| | - Li An Liang
- Department of Anesthesiology, Guizhou Medical University, Guiyang, Guizhou, China (mainland)
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