The effect of infrapatellar fat pad resection on outcomes post-total knee arthroplasty: a systematic review

Introduction: The infrapatellar fat pad (IPFP) is resected in approximately 88 % of total knee arthroplasty (TKA) surgeries. The aim of this review is to investigate the impact of the IPFP resection on clinical outcomes post-TKA. Materials and methods: A systematic search of five major databases for all relevant articles published until May, 2015 was conducted. Studies comparing the effect of IPFP resection and preservation on outcomes post-TKA were included. Each study was then assessed individually for level of evidence and risk of bias. Studies were then grouped into post-operative outcomes and given a level of evidence ranking based on the collective strength of evidence. Results: The systematic review identified ten studies suitable for inclusion, with a total of 10,163 patients. Within these ten studies, six post-operative outcomes were identified; knee pain, vascularisation of the patella, range of motion (ROM), patella tendon length/patella infera, wound complications and patient satisfaction. Moderate evidence increased knee pain with IPFP resection post-TKA was found. Conflicting evidence was found for patella vascularisation and patellar tendon length post-TKA. Moderate evidence for no difference in ROM was found. One low quality study was found for wound complications and patient satisfaction. Conclusions: This systematic review is limited by the lack of level one randomised controlled trials (RCTs). There is however moderate level evidence that IPFP resection increases post-operative knee pain. Further level one RCTs are required to produce evidence-based guidelines regarding IPFP resection. Systematic Review Level of Evidence: 3

Intubation using apnoeic oxygenation to prevent desaturation: A systematic review and meta-analysis

Purpose To determine whether or not apnoeic oxygenation reduces the incidence of hypoxaemia during endotracheal intubation. Materials and methods A systematic search of six databases for all relevant studies until November 2016 was performed. All study designs using apnoeic oxygenation during intubation were eligible for inclusion. All studies were assessed for level of evidence and risk of bias. A meta-analysis was performed on all data using Revman 5.3. Results Seventeen studies including 2422 patients were retrieved. Overall there was a significant reduction in the incidence of desaturation (RR = 0.65; p \u3c 0.00001), critical desaturation (RR = 0.61, p = 0.002) and safe apnoea time (WMD = 1.73 min, p \u3c 0.00001). There was no significant difference in mortality (RR = 0.77, p = 0.08). Conclusions In patients whom are being intubated for any indication other than respiratory failure, apnoeic oxygenation at any flow rate 15 L or greater is likely to reduce their incidence of desaturation (\u3c 90%) and critical desaturation (\u3c 80%). However, further high quality RCTs are required given the high degree of heterogeneity in many of the outcomes and subgroup analyses

Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis

Background: Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting. Aim: To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval. Methods: We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta-analysis of the pooled data. Results: Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004). Conclusion: Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first-pass success rate in this setting

Apnoeic oxygenation during intubation in the intensive care unit: A systematic review and meta-analysis

Hypoxaemia increases the risk of cardiac arrest and mortality during intubation. The reduced physiological reserve and reduced efficacy of pre-oxygenation in intensive care patients makes their intubation particularly dangerous. Apnoeic oxygenation is a promising means of preventing hypoxaemia in this setting. We sought to ascertain whether apnoeic oxygenation reduces the incidence of hypoxaemia when used during endotracheal intubation in the intensive care unit (ICU). A systematic review of five databases for all relevant studies published up to November 2016 was performed. Eligible studies investigated apnoeic oxygenation during intubation in the ICU, irrespective of design. All studies were assessed for risk of bias and level of evidence. A meta-analysis was performed on all data using Revman 5.3. Six studies including 518 patients were retrieved. The study found level 1 evidence of a significant reduction in the incidence of critical desaturation (RR = 0.69, CI = 0.48-1.00, p = 0.05) and a significant increase in the lowest SpO2 value by 2.83% (CI = 2.28-3.38, p \u3c 0.00001). There was a significant reduction in ICU stay (WMD = -2.89, 95%CI = -3.25 to -2.51, p \u3c 0.00001). There was no significant difference between groups regarding mortality (RR = 0.77, 95%CI = 0.59-1.03, p = 0.08), first pass intubation success (RR = 1.17, 95%CI = 0.67 to 2.03, p = 0.58), arrhythmia during intubation (RR = 0.58, 95%CI = 0.08 to 4.29, p = 0.60), cardiac arrest during intubation (RR = 0.33, 95%CI = 0.01 to 7.84, p = 0.49) and duration of ventilation (WMD = -1.97, 95%CI = -5.89 to 1.95, p = 0.32). Apnoeic oxygenation reduces patient hypoxaemia during intubation performed in the ICU. This meta-analysis found evidence that apnoeic oxygenation may significantly reduce the incidence of critical desaturation and significantly raises the minimum recorded SpO2 in this setting. We recommend apnoeic oxygenation be incorporated into ICU intubation protocol

Tramadol as an adjunct to intra-articular local anaesthetic infiltration in knee arthroscopy: a systematic review and meta-analysis

Background: Arthroscopic knee surgery is a common technique used in Australia. Post-operative pain is common and can lead to delayed discharge and impair early mobilization. Use of local anaesthesia can reduce pain while avoiding systemic side effects. This systematic review and meta-analysis aimed to establish the use of tramadol as an adjunct to intra-articular local anaesthetic infiltration in knee arthroscopy in the current literature. Methods: Two independent reviewers performed a systematic search of four databases, where 24 articles were identified with six studies (four high-quality and two low-quality randomized controlled trials), with a total of 334 patients were included for analysis. RevMan 5.3 software (The Nordic Cochrane Centre, Copenhagen, Denmark) was used to perform the data analysis. The studies included focused on outcomes such as pain scores, breakthrough analgesia, total analgesia, time to discharge and adverse events related to the use of tramadol as an adjunctive therapy. Results: This study found that using tramadol as an adjunct to intra-articular local anaesthetic infiltration in arthroscopic knee surgery reduced post-operative pain and increased time to breakthrough analgesia without an increase in side effects. Conclusion: This meta-analysis suggests that tramadol is an efficacious adjunct for use in intra-articular local anaesthetic infiltration following arthroscopic knee surgery

Intra-articular Alpha-2 Agonists as an Adjunct to Local Anesthetic in Knee Arthroscopy: A Systematic Review and Meta-Analysis

The infiltration of local anesthetic has been shown to reduce postoperative pain in knee arthroscopy. Several studies have shown that the addition of agents such as magnesium and nonsteroidal antiinflammatory drugs (NSAIDs) result in an increased time to first analgesia and overall reduction in pain. The aim of this systematic review and meta-analysis was to determine whether the addition of an α-2 agonist (A2A) to intra-articular local anesthetic, results in a reduction in postoperative pain. Four major databases were systematically searched for relevant randomized controlled trials (RCTs) up to July 2017. RCTs containing a control group receiving a local anesthetic and an intervention group receiving the same with the addition of an A2A were included in the review. The included studies were assessed for level of evidence and risk of bias. The data were then analyzed both qualitatively and where appropriate by meta-analysis. We reviewed 12 RCTs including 603 patients. We found that the addition of an A2A resulted in a significant reduction in postoperative pain up to 24 hours. The addition of the A2A increased time to first analgesia request by 258.85 minutes ( p \u3c 0.00001). Total 24-hour analgesia consumption was analyzed qualitatively with all included studies showing a significant reduction in total analgesia requirement. Interestingly, none of the studies found an increase in side effects associated with the A2A. This study provides strong evidence for the use of A2As as a means to reduce postoperative pain post arthroscopic knee surgery, without a corresponding increase in side effects