194 research outputs found
Clinical and economic burden of procedural sedation-related adverse events and their outcomes: analysis from five countries
Background: Studies have reported on the incidence of sedation-related adverse events (AEs), but little is known about their impact on health care costs and resource use.
Methods: Health care providers and payers in five countries were recruited for an online survey by independent administrators to ensure that investigators and respondents were blinded to each other. Surveys were conducted in the local language and began with a screener to ensure that respondents had relevant expertise and experience. Responses were analyzed using Excel and R, with the Dixon\u27s Q statistic used to identify and remove outliers. Global and country-specific average treatment patterns were calculated via bootstrapping; costs were mean values. The sum product of costs and intervention probability gave a cost per AE.
Results: Responses were received from 101 providers and 26 payers, the majority having \u3e 5 years of experience. At a minimum, the respondents performed a total of 3,430 procedural sedations per month. All AEs detailed occurred in clinical practice in the last year and were reported to cause procedural delays and cancellations in some patients. Standard procedural sedation costs ranged from euro74 (Germany) to 43 (68). Other frequent AEs, including mild hypotension, bradycardia, tachycardia, mild oxygen desaturation, hypertension, and brief apnea, were estimated to increase health care spending on procedural sedation by $2.2 billion annually in the US.
Conclusion: All sedation-related AEs can increase health care costs and result in substantial delays or cancellations of subsequent procedures. The prevention of even minor AEs during procedural sedation may be crucial to ensuring its value as a health care service
Treatment of spinal anaesthesia-induced hypotension with cafedrine/theodrenaline versus ephedrine during caesarean section: results from HYPOTENS, a national, multicentre, prospective, noninterventional study
BACKGROUND: In Germany, hypotension induced by spinal anaesthesia is commonly treated with a combination of cafedrine hydrochloride (C, 200âmg) and theodrenaline hydrochloride (T, 10âmg) in 2âml. We compared the effectiveness of C/T with ephedrine. OBJECTIVES: The primary objectives were to assess the speed of onset and the ability to restore blood pressure without an increase in heart rate. Secondary objectives were to evaluate maternal/foetal outcomes and the number of required additional boluses or other additional measures. DESIGN: HYPOTENS was a national, multicentre, prospective, open-label, two-armed, noninterventional study comparing C/T with ephedrine in two prospectively defined cohorts. This study relates to the cohort of patients receiving spinal anaesthesia for caesarean section. SETTING: German hospitals using either C/T or ephedrine in their routine clinical practice. PATIENTS: Women aged at least 18 years receiving spinal anaesthesia for caesarean section. INTERVENTIONS: Bolus administration of C/T or ephedrine at the discretion of the attending anaesthesiologist. MAIN OUTCOME MEASURES: Endpoints within 15âmin after initial administration of C/T or ephedrine were area under the curve between the observed SBP and the minimum target SBP; and incidence of newly occurring heart rate of at least 100âbeatsâmin(â1). RESULTS: Although effective blood pressure stabilisation was achieved with both treatments, this effect was faster and more pronounced with C/T (Pâ<â0.0001). The incidence of tachycardia and changes in heart rate were higher with ephedrine (Pâ<â0.01). Fewer additional boluses (Pâ<â0.01) were required with C/T. Although favourable neonatal outcomes were reported in both groups, base deficit and lactate values were greater with ephedrine (Pâ<â0.01). Physician satisfaction was higher with C/T. CONCLUSIONS: After C/T, tachycardia was not a problem, providing an advantage over ephedrine. Fewer additional boluses were required with C/T, suggesting greater effectiveness. An increased base deficit with ephedrine suggests reduced oxygen supply or increased demands in foetal circulation. TRIALS REGISTRATION: Clinicaltrials.gov: NCT02893241, German Clinical Trials Register: DRKS00010740
Intravenous buspirone for the prevention of postoperative nausea and vomiting
Rationale: Buspirone, a partial 5HT1A agonist and D2 and D3 antagonist, has shown promising antiemetic efficacy when given parenterally in animal models, but its efficacy for the prevention of postoperative nausea and vomiting (PONV) is unknown. Objective: To study the efficacy and dose-responsiveness of intravenous buspirone for the prevention of PONV. Methods: A randomised, double-blind, placebo-controlled study was performed in adults at moderate to high PONV risk undergoing surgery with a general anaesthetic. Patients were randomised to receive an intravenous dose of buspirone (0.3, 1.0, 2.0, 3.0mg) or placebo at the end of surgery. The primary endpoint was the cumulative 24-h PONV incidence (i.e. any nausea and/or vomiting). Vomiting included retching. Nausea was defined as a score of â„4 on an 11-point verbal rating scale running from zero (no nausea) to ten (the worst nausea imaginable). Results: A total of 257 patients received the study drug and fulfilled the criteria for inclusion in the primary efficacy and safety analyses. With placebo, the mean 24-h PONV incidence was 49.0% (90% confidence interval [CI] 37.5-60.5%). With buspirone, that incidence ranged from a mean of 40.8% (29.3-52.4%) in the 1mg arm to 58.0% (46.5-69.5%) in the 0.3mg arm (Pâ>â0.05 for all comparisons). There was no difference between placebo and buspirone at any dose for any other efficacy endpoint, nor in the number or severity of adverse events or any other safety measures. Conclusion: We were unable to show that intravenous single-dose buspirone, at the tested dose-range, was effective at preventing PONV in surgical adult patients. The present study emphasises the difficulty in extrapolating from animal models of emesis to clinical efficacy in PON
Systematic review on the recurrence of postoperative nausea and vomiting after a first episode in the recovery room â implications for the treatment of PONV and related clinical trials
BACKGROUND: Despite the presence of a plethora of publications on the prevention of postoperative nausea and vomiting (PONV) only little is known how to treat established symptoms. Besides the high effort of performing these efficacy trials (much more patients must give their consent than are actually included in a study) and ethical concerns, little is known about the rate of re-occurring PONV/vomiting after placebo. As a consequence investigators will have difficulties defining a clinically relevant effect for the new treatment which is crucial for any planning. A quantitative systematic review was performed in order to provide more reliable estimates of the incidence of re-occurring PONV/vomiting after placebo and to help investigators defining a clinically relevant treatment effect. METHODS: A systematic search of the literature was performed using an extended search strategy of a previous review. Data on the recurrence of PONV (any nausea or emetic symptom) and vomiting (retching or vomiting) was extracted from published reports treating PONV with placebo and unpublished results from two observational trials where no treatment was given. A nonlinear random effects model was used to calculate estimates of the recurrence of symptoms and their 95%-confidence intervals (95%-CI). RESULTS: A total of 29 trials (including the unpublished data) were eligible for the calculations. Depending on the length of observation after administering placebo or no treatment the recurrence rate of PONV was between 65% (95%-CI: 53%...75%) and 84% (95%-CI: 73%...91%) and that of vomiting was between 65% (95%-CI: 44%...81%) and 78% (95%-CI: 59%...90%). CONCLUSION: Almost all trials showed a considerable and consistently high rate of recurrence of emetic symptoms after placebo highlighting the need for a consequent antiemetic treatment. Future (placebo) controlled efficacy trials may use the presented empirical estimates for defining clinically relevant effects and for statistical power considerations
Ivermectin for preventing and treating COVIDâ19
Background
Ivermectin, an antiparasitic agent used to treat parasitic infestations, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARSâCoVâ2) replication in the early stages of infection. Currently, evidence on efficacy and safety of ivermectin for prevention of SARSâCoVâ2 infection and COVIDâ19 treatment is conflicting.
Objectives
To assess the efficacy and safety of ivermectin compared to no treatment, standard of care, placebo, or any other proven intervention for people with COVIDâ19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARSâCoVâ2 (postexposure prophylaxis).
Search methods
We searched the Cochrane COVIDâ19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), medRxiv, and Research Square, identifying completed and ongoing studies without language restrictions to 26 May 2021.
Selection criteria
We included randomized controlled trials (RCTs) comparing ivermectin to no treatment, standard of care, placebo, or another proven intervention for treatment of people with confirmed COVIDâ19 diagnosis, irrespective of disease severity, treated in inpatient or outpatient settings, and for prevention of SARSâCoVâ2 infection.
Coâinterventions had to be the same in both study arms.
We excluded studies comparing ivermectin to other pharmacological interventions with unproven efficacy.
Data collection and analysis
We assessed RCTs for bias, using the Cochrane risk of bias 2 tool. The primary analysis excluded studies with high risk of bias. We used GRADE to rate the certainty of evidence for the following outcomes 1. to treat inpatients with moderateâtoâsevere COVIDâ19: mortality, clinical worsening or improvement, adverse events, quality of life, duration of hospitalization, and viral clearance; 2. to treat outpatients with mild COVIDâ19: mortality, clinical worsening or improvement, admission to hospital, adverse events, quality of life, and viral clearance; (3) to prevent SARSâCoVâ2 infection: SARSâCoVâ2 infection, development of COVIDâ19 symptoms, adverse events, mortality, admission to hospital, and quality of life.
Main results
We found 14 studies with 1678 participants investigating ivermectin compared to no treatment, placebo, or standard of care. No study compared ivermectin to an intervention with proven efficacy. There were nine studies treating participants with moderate COVIDâ19 in inpatient settings and four treating mild COVIDâ19 cases in outpatient settings. One study investigated ivermectin for prevention of SARSâCoVâ2 infection. Eight studies had an openâlabel design, six were doubleâblind and placeboâcontrolled. Of the 41 study results contributed by included studies, about one third were at overall high risk of bias.
Ivermectin doses and treatment duration varied among included studies.
We identified 31 ongoing and 18 studies awaiting classification until publication of results or clarification of inconsistencies.
Ivermectin compared to placebo or standard of care for inpatient COVIDâ19 treatment
We are uncertain whether ivermectin compared to placebo or standard of care reduces or increases mortality (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 2 studies, 185 participants; very lowâcertainty evidence) and clinical worsening up to day 28 assessed as need for invasive mechanical ventilation (IMV) (RR 0.55, 95% CI 0.11 to 2.59; 2 studies, 185 participants; very lowâcertainty evidence) or need for supplemental oxygen (0 participants required supplemental oxygen; 1 study, 45 participants; very lowâcertainty evidence), adverse events within 28 days (RR 1.21, 95% CI 0.50 to 2.97; 1 study, 152 participants; very lowâcertainty evidence), and viral clearance at day seven (RR 1.82, 95% CI 0.51 to 6.48; 2 studies, 159 participants; very lowâcertainty evidence). Ivermectin may have little or no effect compared to placebo or standard of care on clinical improvement up to 28 days (RR 1.03, 95% CI 0.78 to 1.35; 1 study; 73 participants; lowâcertainty evidence) and duration of hospitalization (mean difference (MD) â0.10 days, 95% CI â2.43 to 2.23; 1 study; 45 participants; lowâcertainty evidence). No study reported quality of life up to 28 days.
Ivermectin compared to placebo or standard of care for outpatient COVIDâ19 treatment
We are uncertain whether ivermectin compared to placebo or standard of care reduces or increases mortality up to 28 days (RR 0.33, 95% CI 0.01 to 8.05; 2 studies, 422 participants; very lowâcertainty evidence) and clinical worsening up to 14 days assessed as need for IMV (RR 2.97, 95% CI 0.12 to 72.47; 1 study, 398 participants; very lowâcertainty evidence) or nonâIMV or high flow oxygen requirement (0 participants required nonâIMV or high flow; 1 study, 398 participants; very lowâcertainty evidence). We are uncertain whether ivermectin compared to placebo reduces or increases viral clearance at seven days (RR 3.00, 95% CI 0.13 to 67.06; 1 study, 24 participants; lowâcertainty evidence). Ivermectin may have little or no effect compared to placebo or standard of care on the number of participants with symptoms resolved up to 14 days (RR 1.04, 95% CI 0.89 to 1.21; 1 study, 398 participants; lowâcertainty evidence) and adverse events within 28 days (RR 0.95, 95% CI 0.86 to 1.05; 2 studies, 422 participants; lowâcertainty evidence). None of the studies reporting duration of symptoms were eligible for primary analysis. No study reported hospital admission or quality of life up to 14 days.
Ivermectin compared to no treatment for prevention of SARSâCoVâ2 infection
We found one study. Mortality up to 28 days was the only outcome eligible for primary analysis. We are uncertain whether ivermectin reduces or increases mortality compared to no treatment (0 participants died; 1 study, 304 participants; very lowâcertainty evidence). The study reported results for development of COVIDâ19 symptoms and adverse events up to 14 days that were included in a secondary analysis due to high risk of bias. No study reported SARSâCoVâ2 infection, hospital admission, and quality of life up to 14 days.
Authors' conclusions
Based on the current very lowâ to lowâcertainty evidence, we are uncertain about the efficacy and safety of ivermectin used to treat or prevent COVIDâ19. The completed studies are small and few are considered high quality. Several studies are underway that may produce clearer answers in review updates. Overall, the reliable evidence available does not support the use ivermectin for treatment or prevention of COVIDâ19 outside of wellâdesigned randomized trials
Nirmatrelvir combined with ritonavir for preventing and treating COVIDâ19
Background
Oral nirmatrelvir/ritonavir (PaxlovidÂź) aims to avoid severe COVIDâ19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. Due to its novelty, there are currently few published study results. It remains to be evaluated for which indications and patient populations the drug is suitable.
Objectives
To assess the efficacy and safety of nirmatrelvir/ritonavir (PaxlovidÂź) plus standard of care compared to standard of care with or without placebo, or any other intervention for treating COVIDâ19 and for preventing SARSâCoVâ2 infection.
To explore equity aspects in subgroup analyses.
To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers inâbetween publication of review updates.
Search methods
We searched the Cochrane COVIDâ19 Study Register, Scopus, and WHO COVIDâ19 Global literature on coronavirus disease database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 11 July 2022.
This is a LSR. We conduct monthly update searches that are being made publicly available on the open science framework (OSF) platform.
Selection criteria
Studies were eligible if they were randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus standard of care with standard of care with or without placebo, or any other intervention for treatment of people with confirmed COVIDâ19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARSâCoVâ2 infection.
We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval.
Data collection and analysis
We followed standard Cochrane methodology and used the Cochrane risk of bias 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVIDâ19; 2. to treat inpatients with moderateâtoâsevere COVIDâ19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARSâCoVâ2 infection in postâexposure prophylaxis (PEP); and 4. preâexposure prophylaxis (PrEP) scenarios: SARSâCoVâ2 infection, development of COVIDâ19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events.
We explored inequity by subgroup analysis for elderly people, sociallyâdisadvantaged people with comorbidities, populations from LICs and LMICs, and people from different ethnic and racial backgrounds.
Main results
As of 11 July 2022, we included one RCT with 2246 participants in outpatient settings with mild symptomatic COVIDâ19 comparing nirmatrelvir/ritonavir plus standard of care with standard of care plus placebo. Trial participants were unvaccinated, without previous confirmed SARSâCoVâ2 infection, had a symptom onset of no more than five days before randomization, and were at high risk for progression to severe disease. Prohibited prior or concomitant therapies included medications highly dependent on CYP3A4 for clearance and CYP3A4 inducers.
We identified eight ongoing studies.
Nirmatrelvir/ritonavir for treating COVIDâ19 in outpatient settings with asymptomatic or mild disease
For the specific population of unvaccinated, highârisk patients nirmatrelvir/ritonavir plus standard of care compared to standard of care plus placebo may reduce allâcause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; estimated absolute effect: 11 deaths per 1000 people receiving placebo compared to 0 deaths per 1000 people receiving nirmatrelvir/ritonavir; lowâcertainty evidence, and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; estimated absolute effect: 61 admissions or deaths per 1000 people receiving placebo compared to eight admissions or deaths per 1000 people receiving nirmatrelvir/ritonavir; lowâcertainty evidence).
Nirmatrelvir/ritonavir plus standard of care may reduce serious adverse events during the study period compared to standard of care plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; lowâcertainty evidence). Nirmatrelvir/ritonavir plus standard of care probably has little or no effect on treatmentâemergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderateâcertainty evidence), and probably increases treatmentârelated adverse events such as dysgeusia and diarrhoea during the study period compared to standard of care plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderateâcertainty evidence). Nirmatrelvir/ritonavir plus standard of care probably decreases discontinuation of study drug due to adverse events compared to standard of care plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderateâcertainty evidence).
No study results were identified for improvement of clinical status, quality of life, and viral clearance.
Subgroup analyses for equity
Most study participants were younger than 65 years (87.1% of the : modified intention to treat (mITT1) population with 2085 participants), of white ethnicity (71.5%), and were from UMICs or HICs (92.1% of study centres). Data on comorbidities were insufficient.
The outcome âadmission to hospital or deathâ was investigated for equity: age (< 65 years versus â„ 65 years) and ethnicity (Asian versus Black versus White versus others). There was no difference between subgroups of age. The effects favoured treatment with nirmatrelvir/ritonavir for the White ethnic group. Estimated effects in the other ethnic groups included the line of no effect (RR = 1). No subgroups were reported for comorbidity status and World Bank country classification by income level. No subgroups were reported for other outcomes.
Nirmatrelvir/ritonavir for treating COVIDâ19 in inpatient settings with moderate to severe disease
No studies available.
Nirmatrelvir/ritonavir for preventing SARSâCoVâ2 infection (PrEP and PEP)
No studies available.
Authors' conclusions
There is lowâcertainty evidence that nirmatrelvir/ritonavir reduces the risk of allâcause mortality and hospital admission or death based on one trial investigating unvaccinated COVIDâ19 participants without previous infection that were at high risk and with symptom onset of no more than five days. There is lowâ to moderateâcertainty evidence that nirmatrelvir/ritonavir is safe in people without prior or concomitant therapies including medications highly dependent on CYP3A4.
Regarding equity aspects, except for ethnicity, no differences in effect size and direction were identified.
No evidence is available on nirmatrelvir/ritonavir to treat hospitalized people with COVIDâ19 and to prevent a SARSâCoVâ2 infection.
We will continually update our search and make search results available on OSF
Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines.
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1ĐĄ). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1ĐĄ). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B)
Use of local anaesthetics and adjuncts for spinal and epidural anaesthesia and analgesia at German and Austrian University Hospitals: an online survey to assess current standard practice
<p>Abstract</p> <p>Background</p> <p>The present anonymous multicenter online survey was conducted to evaluate the application of regional anaesthesia techniques as well as the used local anaesthetics and adjuncts at German and Austrian university hospitals.</p> <p>Methods</p> <p>39 university hospitals were requested to fill in an online questionnaire, to determine the kind of regional anaesthesia and preferred drugs in urology, obstetrics and gynaecology.</p> <p>Results</p> <p>33 hospitals responded. No regional anaesthesia is conducted in 47% of the minor gynaecological and 44% of the urological operations; plain bupivacaine 0.5% is used in 38% and 47% respectively. In transurethral resections of the prostate and bladder no regional anaesthesia is used in 3% of the responding hospitals, whereas plain bupivacaine 0.5% is used in more than 90%. Regional anaesthesia is only used in selected major gynaecological and urological operations. On the contrary to the smaller operations, the survey revealed a large variety of used drugs and mixtures. Almost 80% prefer plain bupivacaine or ropivacaine 0.5% in spinal anaesthesia in caesarean section. Similarly to the use of drugs in major urological and gynaecological operations a wide range of drugs and adjuncts is used in epidural anaesthesia in caesarean section and spontaneous delivery.</p> <p>Conclusions</p> <p>Our results indicate a certain agreement in short operations in spinal anaesthesia. By contrast, a large variety concerning the anaesthesiological approach in larger operations as well as in epidural analgesia in obstetrics could be revealed, the causes of which are assumed to be primarily rooted in particular departmental structures.</p
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