Interactive Distraction Techniques Versus Midazolam in Anxiolysis In Pediatric Patients: A Systematic Review and Meta-Analysis

Background: Many pediatric patients experience high levels of anxiety prior to undergoing surgery. Midazolam is currently one of the most commonly used sedative drugs in the pediatric preoperative environment. A number of studies have evaluated the use of non-pharmacological methods of relaxing pediatric patients prior to surgery, known as ‘Interactive Distraction’. These techniques involve using various methods of distracting the child from the preoperative anesthetic procedures. Some examples of these methods involve giving the patient an iPad with which they can play video games. There have yet to be any systematic reviews comparing the usage of Midazolam alone against utilizing interactive distraction alone techniques to mitigate pediatric anxiolysis in the preoperative setting. We hypothesize that interactive distraction could be noninferior in reducing anxiety levels in these patients. Purpose: This systematic review and meta analysis compared the preoperative anxiolytic effects of Midazolam to interactive distraction techniques on a pediatric population. Methods: The systematic review and meta analysis followed the 2020 PRISMA guidelines. Six online databases were surveyed (Pubmed, Embase, Scopus, Cochrane, Web of Science). The analysis included randomized controlled trials (RCTs) in which pediatric patients received .3 mg/kg Midazolam alone or interactive distraction. Patient anxiety levels were measured using the modified Yale Perioperative Anxiety Scale (myPAS). MyPAS scores were evaluated at two distinct time marks, the first being arrival to the surgical ward whilst the other time mark measured was during induction of anesthesia. Two RCTs fit the inclusion criteria for the review, yielding 217 distinct evaluations. The average patient age was 6.79 ± 2.13. Results: The results portray clinically significant results as there was a low, but apparent difference in mean effect size with a difference of Cohen’s d = 0.21, in favor of utilizing the Midazolam. However, there was no statistical significance (p = 0.57) between utilizing Midazolam alone versus utilizing the interactive distraction techniques. Discussion: Utilization of .3 mg/kg Midazolam had clinically superior anxiolysis compared to the interactive distractions. A main limitation of our study is the relatively small sample size of 217 patients. Conducting additional RCTs with larger sample sizes would be beneficial in reinforcing our findings

Wide Awake Local Anesthesia No Tourniquet (WALANT) Is More Effective at Decreasing Pain Compared to Distal Nerve Block With a Tourniquet During Carpal Tunnel Release Surgery: A Systematic Review and Pooled Analysis

Background: Carpal tunnel release (CTR) is one of the most common upper extremity procedures, reaching 400,000 - 600,000 procedures yearly in the United States. With such a common procedure, it is pertinent that every step is as comfortable for the patient as possible. Many patients report discomfort due to the usage of a tourniquet during the anesthesia process. However, a growing number of physicians are beginning to use the wide awake local anesthesia no tourniquet (WALANT) approach. WALANT utilizes a distal nerve block (commonly Ropivacaine), Lidocaine, Epinephrine, but no tourniquet. The more commonly used approach utilizes the same distal nerve block, in combination with a tourniquet. To date, there have been no systematic reviews or meta-analyses evaluating whether the WALANT approach yields lower pain than a distal nerve block with a tourniquet during CTR. Purpose: We conducted a systematic review and pooled analysis comparing the WALANT technique to using a tourniquet with a distal nerve block on the pain experienced by patients during carpal tunnel release. Methods: This systematic review and pooled analysis followed the 2020 PRISMA guidelines. Five online databases (Cochrane, Embase, Scopus, Web of Science, Pubmed) were screened for studies that included intraoperative Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) scores of patients having CTR with either the WALANT approach or a tourniquet with a distal nerve block. After the screening process, 2 randomized controlled trials (RCTs) were included in the final analysis, yielding a total of 90 distinct patient evaluations. Results: The results portray a strong clinical significance (Cohen’s d = 1.03, 95% CI 0.59-1.47) on pain reduction, in favor of utilizing the WALANT technique. Conclusion: Our systematic review and pooled analysis serves as a preliminary study in the exploration of the WALANT technique, specifically for CTR. The results illustrate that WALANT is a promising method in reducing patient pain during this procedure, portrayed by the large effect size between using a tourniquet with a distal block, and WALANT. Future RCTs are needed to control for the drug and dose of nerve block used, and to increase the sample size