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Kampman JM, Plasmans KYQ, Hermanides J, Hollmann MW, Repping S, Sperna Weiland NH. Influence of nitrous oxide added to general anaesthesia on postoperative mortality and morbidity: a systematic review and meta-analysis. Br J Anaesth 2024:S0007-0912(24)00073-4. [PMID: 38471989 DOI: 10.1016/j.bja.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Nitrous oxide (N2O) is a common adjuvant to general anaesthesia. It is also a potent greenhouse gas and causes ozone depletion. We sought to quantify the influence of N2O as an adjuvant to general anaesthesia on postoperative patient outcomes. METHODS We searched Medline, EMBASE, and Cochrane Central for works published from inception to July 6, 2023. RCTs comparing general anaesthesia with or without N2O were included. Risk ratios (RRs) and standardised mean differences (SMDs) were calculated, along with 95% confidence intervals (CIs), using a random-effects model. Outcomes were derived from the Standardised Endpoints for Perioperative Medicine (StEP) outcome set. Primary outcomes were mortality and organ-related morbidity, and secondary outcomes were anaesthetic and surgical morbidity. RESULTS Of 3305 records, 179 full-text articles were assessed, and 71 RCTs, totalling 22 147 patients, were included in the meta-analysis. Addition of N2O to general anaesthesia did not influence postoperative mortality or most morbidity outcomes. N2O increased the incidence of atelectasis (RR 1.62, 95% CI 1.24 to 2.12) and postoperative nausea and vomiting (RR 1.27, 95% CI 1.15 to 1.40), and decreased intraoperative opioid consumption (SMD -0.19, 95% CI -0.35 to -0.04) and time to extubation (MD -2.17 min, 95% CI -3.32 to -1.03 min). CONCLUSIONS N2O did not influence postoperative mortality or most morbidity outcomes. Considering the environmental effects of N2O, these findings confirm that current policy recommendations to limit its use do not affect patient safety. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023443287.
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Affiliation(s)
- Jasper M Kampman
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Kim Y Q Plasmans
- Department of Anaesthesiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjoerd Repping
- Healthcare Evaluation and Appropriate Use, National Healthcare Institute, Diemen, The Netherlands; Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolaas H Sperna Weiland
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, The Netherlands
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Liu W, Zhang G, Sun B, Wang S, Lu Y, Xie H. Activation of NLR family, domain of pyrin containing 3 inflammasome by nitrous oxide through thioredoxin-interacting protein to induce nerve cell injury. Bioengineered 2021; 12:4768-4779. [PMID: 34348577 PMCID: PMC8806838 DOI: 10.1080/21655979.2021.1954741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nitrous Oxide (N2O) has been shown to be neurotoxic, but its specific mechanism is still unclear. The purpose of this work is to probe into the impact of N2O on nerve cell injury through regulating thioredoxin-interacting protein (TXNIP)/the NOD-like receptor domain of pyrin containing 3 (NLRP3) pathway. The results indicated that, N2O exposure elevated TXNIP/NLRP3 expression in vivo and in vitro, led to declined learning and memory capabilities in mice, reduced apoptosis rate in hippocampal neuron and Nissl bodies, elevated inflammatory factors TNF-α, IL-1β and IL-6 levels, as well as cleaved caspase-3 and Bax expressions, and reduced Bcl-2 expression. Overexpressing TXNIP or NLRP3 further aggravated these injuries, but knocking down TXNIP or NLRP3 improved them. CO-IP indicated that TXNIP and NLRP3 can be combined, with interaction relationship. All in all, the results manifested that N2O is available to promote nerve cell inflammation and apoptosis through activating the TXNIP/NLRP3 pathway that can be used as a potential target for N2O-induced nerve damage in the future.
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Affiliation(s)
- WenJuan Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China.,Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - GuangMing Zhang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - Bo Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
| | - ShuYan Wang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - YinZhong Lu
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
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3
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Maver U, Xhanari K, Žižek M, Gradišnik L, Repnik K, Potočnik U, Finšgar M. Carboxymethyl cellulose/diclofenac bioactive coatings on AISI 316LVM for controlled drug delivery, and improved osteogenic potential. Carbohydr Polym 2020; 230:115612. [DOI: 10.1016/j.carbpol.2019.115612] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/11/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
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Sun W, Liao JP, Hu Y, Zhang W, Ma J, Wang GF. Pulmonary embolism and deep vein thrombosis caused by nitrous oxide abuse: A case report. World J Clin Cases 2019; 7:4057-4062. [PMID: 31832409 PMCID: PMC6906557 DOI: 10.12998/wjcc.v7.i23.4057] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/04/2019] [Accepted: 11/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nitrous oxide (N2O) has gained increasing popularity as a recreational drug, causing hallucinations, excitation, and psychological dependence. However, side effects have been reported in recent years. Our case report proposes a correlation among N2O, pulmonary embolism (PE), and deep vein thrombosis (DVT) and emphasizes the role of homocysteine (Hcy) in thrombotic events.
CASE SUMMARY A 29-year-old man with long-term N2O abuse sought evaluation after acute chest pain. A diagnostic workup revealed PE, DVT, and hyperhomocysteinemia. The patient was successfully treated with thrombolytic and anticoagulant therapy. Moreover, his Hcy level decreased and returned to normal after Hcy-lowering therapy.
CONCLUSION Chronic N2O abuse might increase the risk of PE and DVT, although there have been few studies previously.
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Affiliation(s)
- Wen Sun
- Guang-Fa Wang Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing 100034, China
| | - Ji-Ping Liao
- Guang-Fa Wang Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing 100034, China
| | - Yan Hu
- Guang-Fa Wang Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing 100034, China
| | - Wei Zhang
- Guang-Fa Wang Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing 100034, China
| | - Jing Ma
- Guang-Fa Wang Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing 100034, China
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Oussalah A, Julien M, Levy J, Hajjar O, Franczak C, Stephan C, Laugel E, Wandzel M, Filhine-Tresarrieu P, Green R, Guéant JL. Global Burden Related to Nitrous Oxide Exposure in Medical and Recreational Settings: A Systematic Review and Individual Patient Data Meta-Analysis. J Clin Med 2019; 8:jcm8040551. [PMID: 31018613 PMCID: PMC6518054 DOI: 10.3390/jcm8040551] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 11/16/2022] Open
Abstract
The risk of adverse effects of nitrous oxide (N2O) exposure is insufficiently recognized despite its widespread use. These effects are mainly reported through case reports. We conducted an individual patient data meta-analysis to assess the prevalence of clinical, laboratory, and magnetic resonance findings in association with N2O exposure in medical and recreational settings. We calculated the pooled estimates for the studied outcomes and assessed the potential bias related to population stratification using principal component analysis. Eighty-five publications met the inclusion criteria and reported on 100 patients with a median age of 27 years and 57% of recreational users. The most frequent outcomes were subacute combined degeneration (28%), myelopathy (26%), and generalized demyelinating polyneuropathy (23%). A T2 signal hyperintensity in the spinal cord was reported in 68% (57.2–78.8%) of patients. The most frequent clinical manifestations included paresthesia (80%; 72.0–88.0%), unsteady gait (58%; 48.2–67.8%), and weakness (43%; 33.1–52.9%). At least one hematological abnormality was retrieved in 71.7% (59.9–83.4%) of patients. Most patients had vitamin B12 deficiency: vitamin B12 <150 pmol/L (70.7%; 60.7–80.8%), homocysteine >15 µmol/L (90.3%; 79.3–100%), and methylmalonic acid >0.4 µmol/L (93.8%; 80.4–100%). Consistently, 85% of patients exhibited a possibly or probably deficient vitamin B12 status according to the cB12 scoring system. N2O can produce severe outcomes, with neurological or hematological disorders in almost all published cases. More than half of them are reported in the setting of recreational use. The N2O-related burden is dominated by vitamin B12 deficiency. This highlights the need to evaluate whether correcting B12 deficiency would prevent N2O-related toxicity, particularly in countries with a high prevalence of B12 deficiency.
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Affiliation(s)
- Abderrahim Oussalah
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, F-54000 Nancy, France.
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
- Reference Centre for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, F-54000 Nancy, France.
| | - Mélissa Julien
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Julien Levy
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Olivia Hajjar
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Claire Franczak
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Charlotte Stephan
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Elodie Laugel
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Marion Wandzel
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Pierre Filhine-Tresarrieu
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA 95817, USA.
| | - Jean-Louis Guéant
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, F-54000 Nancy, France.
- Department of Molecular Medicine and Personalized Therapeutics, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, F-54000 Nancy, France.
- Reference Centre for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, F-54000 Nancy, France.
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Petersen C, Wetterslev J, Meyhoff CS. Perioperative hyperoxia and post-operative cardiac complications in adults undergoing non-cardiac surgery: Systematic review protocol. Acta Anaesthesiol Scand 2018; 62:1014-1019. [PMID: 29664117 DOI: 10.1111/aas.13123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/06/2018] [Accepted: 03/14/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Oxygen therapy is used liberally for all patients undergoing anaesthesia. Recent studies have raised concerns that it may not be without complications when arterial oxygen concentrations reach supranormal concentrations (hyperoxia). Studies of oxygen therapy have raised concerns that the risk of myocardial injury and infarction is elevated in patients with hyperoxia due to vasoconstriction and formation of reactive oxygen species. Due to lack of symptoms or silent ischaemia, post-operative myocardial injury may be missed clinically. In some studies, perioperative hyperoxia has been linked to increased long-term mortality, but cardiac complications are sparsely evaluated. The aim of this review is to summarize current evidence to assess the risk and benefits of perioperative hyperoxia on post-operative cardiac complications. METHODS This systematic review will include meta-analyses and Trial Sequential Analyses. We will include randomized clinical trials with patients undergoing non-cardiac surgery if the allocation separates patients into a target of either higher (above 0.60) or lower (below 0.40) inspired oxygen fraction. To minimize the risk of systematic error, we will assess the risk of bias of the included trials using the Cochrane Risk of Bias Tool. The overall quality of evidence for each outcome will be assessed with the Grading of Recommendation, Assessment, Development and Evaluation (GRADE). DISCUSSION This systematic review will provide data on a severe, albeit rare, potential risk of oxygen therapy. We will do a trial sequential analysis to assess the robustness of results as well as help estimate the required patient size for future clinical trials.
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Affiliation(s)
- C Petersen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - J Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - C S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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Garcia-Alamino JM, Bankhead C, Heneghan C, Pidduck N, Perera R. Impact of heterogeneity and effect size on the estimation of the optimal information size: analysis of recently published meta-analyses. BMJ Open 2017; 7:e015888. [PMID: 29122784 PMCID: PMC5695413 DOI: 10.1136/bmjopen-2017-015888] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To estimate the proportion of systematic reviews that meet the optimal information size (OIS) and assess the impact heterogeneity and effect size have on the OIS estimate by type of outcome (eg, mortality, semiobjective or subjective). METHODS We carried out searches of Medline and Cochrane to retrieve meta-analyses published in systematic reviews from 2010 to 2012. We estimated the OIS using Trial Sequential Analysis software (TSA V.0.9) and based on several heterogeneity and effect size scenarios, stratifying by type of outcome (mortality/semiobjective/subjective) and by Cochrane/non-Cochrane reviews. RESULTS We included 137 meta-analyses out of 218 (63%) potential systematic reviews (one meta-analysis from each systematic review). Of these reviews, 83 (61%) were Cochrane and 54 (39%) non-Cochrane. The Cochrane reviews included a mean of 6.5 (SD 6.1) studies and the non-Cochrane included a mean of 13.2 (SD 10.2) studies. The mean number of patients was 2619.1 (SD 6245.8 or median 586.0) for the Cochrane and 19 888.5 (SD 32 925.7 or median 6566.5) patients for the non-Cochrane reviews. The percentage of systematic reviews that achieved the OIS for all-cause mortality outcome were 0% Cochrane and 25% for non-Cochrane reviews; for semiobjective outcome 17% for Cochrane and 46% for non-Cochrane reviews and for subjective outcome 45% for Cochrane and 72% for non-Cochrane reviews. CONCLUSIONS The number of systematic reviews that meet an optimal information size is low and varies depending on the type of outcome and the type of publication. Less than half of primary outcomes synthesised in systematic reviews achieve the OIS, and therefore the conclusions are subject to substantial uncertainty.
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Affiliation(s)
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Pidduck
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hounsome J, Nicholson A, Greenhalgh J, Cook TM, Smith AF, Lewis SR. Nitrous oxide-based versus nitrous oxide-free general anaesthesia and accidental awareness during general anaesthesia in surgical patients. Cochrane Database Syst Rev 2016; 2016:CD011052. [PMID: 27508523 PMCID: PMC9284342 DOI: 10.1002/14651858.cd011052.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Accidental awareness during general anaesthesia (AAGA) is when a patient unintentionally becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. Incidence estimates for AAGA vary, with the most common estimate being one to two cases per 1000 general anaesthetics. Evidence linking nitrous oxide use and an increased risk of AAGA has come from observational studies data but the literature is contradictory, with some studies finding a protective effect of nitrous oxide. OBJECTIVES To assess the effect of general anaesthesia including nitrous oxide on the risk of AAGA in patients aged five years and over. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registers ((www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/network/en/) and Current Controlled Trials (www.isrctn.com/)) for eligible studies on December 9 2015. In addition, we conducted forward and backward citation searching using key identified papers. SELECTION CRITERIA We considered all randomized controlled trials (RCTs), including quasi-randomized studies and cluster-randomized studies, of participants aged five years or older receiving general anaesthesia for any type of surgery.We included trials in which participants receiving general anaesthesia that included nitrous oxide for maintenance at a concentration of at least 30% were compared with participants receiving no nitrous oxide during general anaesthesia. The intervention group must have received nitrous oxide in conjunction with an additional anaesthetic. We excluded studies where the depth of anaesthesia differed between the study arms. For inclusion in the review, studies needed to state in their methods that they planned to assess AAGA. We defined this as when a patient becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane to identify studies. We extracted data and conducted 'Risk of bias' assessment using the Covidence database. MAIN RESULTS We included 15 studies. The total number of participants included in the analyses was 3520. Most studies were small with fewer than 120 participants, although two larger studies with 2012 and 671 participants were included. There was considerable variation in many of the study characteristics, including the anaesthetics used. The concentrations of nitrous oxide varied between 50% and 70%, and half of the studies used clinical signs and haemodynamic changes to monitor depth of anaesthesia.As it was not possible to blind the anaesthetist to the anaesthetic used, we rated all studies at high risk of performance bias and we therefore downgraded the quality of evidence by one level for risk of bias using the GRADE approach. Other types of bias were generally low, or were rated unclear due to missing information.No studies were designed to measure AAGA as the primary outcome, and were therefore statistically underpowered to answer this review question. Despite the inclusion of 3520 participants, only three awareness events were reported by two studies. In one study the event was due to technical failure. Due to the rarity of the events, we did not consider it appropriate to pool the data, and we therefore downgraded the quality of evidence by a further level for imprecision using GRADE. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions from this review. The included studies were mainly small (fewer than 120 participants) and there were limited estimates of effect, with only two studies reporting any events. We cannot therefore determine whether the use of nitrous oxide in general anaesthesia increases, decreases or has no effect on the risk of accidental awareness.
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Affiliation(s)
- Juliet Hounsome
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Amanda Nicholson
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
- Q Medical Technologies LimitedUnit 1A Summerlands Trading EstateEndmoorKendalUKLA8 0FB
| | - Janette Greenhalgh
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Tim M Cook
- Royal United HospitalDepartment of AnaesthesiaCombe ParkBathUKBA1 3NG
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | - Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 1RP
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Finšgar M, Uzunalić AP, Stergar J, Gradišnik L, Maver U. Novel chitosan/diclofenac coatings on medical grade stainless steel for hip replacement applications. Sci Rep 2016; 6:26653. [PMID: 27215333 PMCID: PMC4877581 DOI: 10.1038/srep26653] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 05/04/2016] [Indexed: 12/12/2022] Open
Abstract
Corrosion resistance, biocompatibility, improved osteointegration, as well the prevention of inflammation and pain are the most desired characteristics of hip replacement implants. In this study we introduce a novel multi-layered coating on AISI 316LVM stainless steel that shows promise with regard to all mentioned characteristics. The coating is prepared from alternating layers of the biocompatible polysaccharide chitosan and the non-steroid anti-inflammatory drug (NSAID), diclofenac. Electrochemical methods were employed to characterize the corrosion behavior of coated and uncoated samples in physiological solution. It is shown that these coatings improve corrosion resistance. It was also found that these coatings release the incorporated drug in controlled, multi-mechanism manner. Adding additional layers on top of the as-prepared samples, has potential for further tailoring of the release profile and increasing the drug dose. Biocompatibility was proven on human-derived osteoblasts in several experiments. Only viable cells were found on the sample surface after incubation of the samples with the same cell line. This novel coating could prove important for prolongation of the application potential of steel-based hip replacements, which are these days often replaced by more expensive ceramic or other metal alloys.
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Affiliation(s)
- Matjaž Finšgar
- University of Maribor, Faculty of Chemistry and Chemical Engineering, Smetanova ulica 17, SI-2000 Maribor, Slovenia
| | - Amra Perva Uzunalić
- University of Maribor, Faculty of Chemistry and Chemical Engineering, Smetanova ulica 17, SI-2000 Maribor, Slovenia
| | - Janja Stergar
- University of Maribor, Faculty of Medicine, Institute of Biomedical Sciences, Taborska ulica 8, SI-2000 Maribor, Slovenia
| | - Lidija Gradišnik
- University of Maribor, Faculty of Medicine, Institute of Biomedical Sciences, Taborska ulica 8, SI-2000 Maribor, Slovenia
| | - Uroš Maver
- University of Maribor, Faculty of Medicine, Institute of Biomedical Sciences, Taborska ulica 8, SI-2000 Maribor, Slovenia
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10
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Göstemeyer G, Schwendicke F. Inhibition of hybrid layer degradation by cavity pretreatment: Meta- and trial sequential analysis. J Dent 2016; 49:14-21. [PMID: 27107550 DOI: 10.1016/j.jdent.2016.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Inhibition of hybrid layer degradation, for example via inhibition of matrix-metallo-proteinases (MMP) could reduce risk of retention loss and failure of adhesively placed restorations. This systematic review investigated such inhibitory pretreatment qualitatively and via meta- and trial-sequential-analysis. DATA SOURCES We included randomized clinical trials comparing degradation inhibitory cavity pretreatment versus no, placebo or alternative treatments prior adhesive placement of resin-based restorations. Trials reporting retention loss or failure (graded bravo-delta in USPHS or similar criteria) were included. Trial selection, data extraction, and risk of bias assessment were conducted independently by two reviewers. Fixed- or random-effects intention-to-treat, per-protocol, and scenario meta-analyses were performed, and trial-sequential-analysis used to control for risk of random errors. Electronic databases (PubMed, Embase, Cochrane CENTRAL) were systematically screened, and hand searches and cross-referencing performed. STUDY SELECTION The ten included trials involved 208 patients (695 cavities) and used chlorhexidine (seven trials), ethanol-wet-bonding (two trials), and quaternary ammonium compounds for degradation inhibition. All but one trial had high risk of bias. Follow-up ranged from 6 to 36 months. Risk of retention loss was not significantly decreased after pretreatment (per-protocol OR [95% CI] 1.37 [0.68/2.77], intention-to-treat: 1.25 [0.76/2.04]). This was found for risk of restoration failure as well (per-protocol: 0.86 [0.56/1.34], intention-to-treat: 1.22 [0.83/1.80]). Scenario analyses found great uncertainty introduced by attrition. According to trial sequential analysis, no firm evidence was reached. CONCLUSIONS There is insufficient evidence to recommend or refute degradation inhibitory cavity pretreatment prior adhesively placing resin-based restorations. This may change if teeth are followed-up for longer. CLINICAL SIGNIFICANCE Dentists can perform cavity pretreatments for inhibition of hybrid layer degradation, but a beneficial effect is not supported by sufficient evidence. The impact of further effects (e.g. disinfection, pulp-irritation) remains unclear.
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Affiliation(s)
- Gerd Göstemeyer
- Department of Operative and Preventive Dentistry, Charité - Universitätsmedizin Berlin, Germany, Aßmannshauser Str. 4-6, 14199 Berlin, Germany.
| | - Falk Schwendicke
- Department of Operative and Preventive Dentistry, Charité - Universitätsmedizin Berlin, Germany, Aßmannshauser Str. 4-6, 14199 Berlin, Germany
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11
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Wong SSC, Irwin MG. Peri-operative cardiac protection for non-cardiac surgery. Anaesthesia 2016; 71 Suppl 1:29-39. [PMID: 26620144 DOI: 10.1111/anae.13305] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 10/22/2022]
Abstract
Cardiovascular complications are an important cause of morbidity and mortality after non-cardiac surgery. Pre-operative identification of high-risk individuals and appropriate peri-operative management can reduce cardiovascular risk. It is important to continue chronic beta-blocker and statin therapy. Statins are relatively safe and peri-operative initiation may be beneficial in high-risk patients and those scheduled for vascular surgery. The pre-operative introduction of beta-blockers reduces myocardial injury but increases rates of stroke and mortality, possibly due to hypotension. They should only be considered in high-risk patients and the dose should be titrated to heart rate. Alpha-2 agonists may also contribute to hypotension. Aspirin continuation can increase the risk of major bleeding and offset the benefit of reduced myocardial risk. Contrary to the initial ENIGMA study, nitrous oxide does not seem to increase the risk of myocardial injury. Volatile anaesthetic agents and opioids have been shown to be cardioprotective in animal laboratory studies but these effects have, so far, not been conclusively reproduced clinically.
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Affiliation(s)
- S S C Wong
- Department of Anaesthesia, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - M G Irwin
- Department of Anaesthesia, The University of Hong Kong, Hong Kong Special Administrative Region, China
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Schwendicke F, Brouwer F, Schwendicke A, Paris S. Different materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis. Clin Oral Investig 2016; 20:1121-32. [PMID: 27037567 DOI: 10.1007/s00784-016-1802-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 03/16/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVES We systematically assessed randomized controlled trials comparing direct pulp capping materials. METHODS Trials comparing materials for direct capping and evaluating clinically and/or radiographically determined success after minimum 3 months were included. Two reviewers independently screened electronic databases (Medline, Central, Embase) and performed hand searches. Risk of bias was assessed and meta-analyses were performed, separated for dentition. Trial sequential analysis was used to assess risk of random errors. Strength of evidence was graded using the GRADE approach. RESULTS From a total of 453 identified studies, 11 (all with high risk of bias) investigating 1094 teeth (922 patients) were included. Six studies were on primary teeth (all with carious exposures) and five on permanent teeth (carious and artificial exposures). Mean follow-up was 14 months (range 3-24). Most studies used calcium hydroxide as control, comparing it to mineral trioxide aggregate (MTA) (three studies), bonding without prior etching/conditioning (two), or bonding with prior etching/conditioning, enamel matrix proteins, resin-modified glass ionomer cement, calcium sulfate, zinc oxide eugenol, corticosteroids, antibiotics, or formocresol (each in only one study). One study compared MTA and calcium-enriched cement. In permanent teeth, risk of failure was significantly decreased if MTA instead of calcium hydroxide was used (risk ratio (RR) [95 % confidence intervals (CI)] 0.59 [0.39/0.90]); no difference was found for primary teeth. Other comparisons did not find significant differences or were supported by only one study. No firm evidence was reached according to trial sequential analysis. CONCLUSION There is insufficient data to recommend or refute the use of a specific material. More long-term practice-based studies with real-life exposures are required. CLINICAL RELEVANCE To reduce risk of failure, dentists might consider using MTA instead of calcium hydroxide (CH) for direct capping. Current evidence is insufficient for definitive recommendations.
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Affiliation(s)
- Falk Schwendicke
- Department of Operative and Preventive Dentistry, Charité-Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197, Berlin, Germany.
| | - Fredrik Brouwer
- Department of Operative and Preventive Dentistry, Charité-Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197, Berlin, Germany
| | - Anja Schwendicke
- Department of Operative and Preventive Dentistry, Charité-Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197, Berlin, Germany
| | - Sebastian Paris
- Department of Operative and Preventive Dentistry, Charité-Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197, Berlin, Germany
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Impact of nitrous oxide on the haemodynamic consequences of venous carbon dioxide embolism: An experimental study. Eur J Anaesthesiol 2015; 33:356-60. [PMID: 26627915 DOI: 10.1097/eja.0000000000000384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) is still considered an important component of general anaesthesia. However, should gas embolisation occur as result of carbon dioxide (CO2) pneumoperitoneum, N2O may compromise safety, as the consequences of a gas embolus consisting of a combination of CO2 and N2O may be more severe than CO2 alone. OBJECTIVE This experimental study was designed to compare the cardiopulmonary consequences of gas embolisation with a N2O/CO2 mixture, or CO2 alone. DESIGN Experimental study. SETTING Research Institute Against Digestive Cancer laboratory, Strasbourg, France. ANIMALS Seven Large-White pigs receiving standardised inhalation anaesthesia. INTERVENTIONS Each animal, acting as its own control, was studied in two successive experimental conditions - intravenous gas injections of 2 ml kg of 100% CO2 and 2 ml kg of a gas mixture consisting of 10% N2O and 90% CO2. MAIN OUTCOMES MEASURES Haemodynamic and ventilatory consequences of embolisation with the gases. RESULTS We found that the haemodynamic (heart rate, mean arterial blood pressure, central venous pressure, mean pulmonary artery pressure, pulmonary artery occlusion pressure and transoesophageal echocardiography parameters) and ventilatory (arterial oxygen saturation, end-tidal CO2 concentration and mixed venous oxygen saturation) consequences of embolisation with either 100% CO2 or 10% N2O with 90% CO2 were similar. CONCLUSION The findings of this study may alleviate concerns that the use of N2O, as a part of a balanced general anaesthesia technique, may have greater adverse consequences should embolisation of pneumoperitoneal gas containing N2O occur.
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Sun R, Jia WQ, Zhang P, Yang K, Tian JH, Ma B, Liu Y, Jia RH, Luo XF, Kuriyama A. Nitrous oxide-based techniques versus nitrous oxide-free techniques for general anaesthesia. Cochrane Database Syst Rev 2015; 2015:CD008984. [PMID: 26545294 PMCID: PMC9326975 DOI: 10.1002/14651858.cd008984.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. OBJECTIVES To determine if nitrous oxide-based anaesthesia results in similar outcomes to nitrous oxide-free anaesthesia in adults undergoing surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites (http://clinicaltrials.gov/, http://controlled-trials.com/, and http://www.centerwatch.com). SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol-based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the outcome data. We used meta-analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed-effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random-effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta-analyses showed that nitrous oxide-based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta-analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide-based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. AUTHORS' CONCLUSIONS Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre-existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review.
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Affiliation(s)
- Rao Sun
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Wen Qin Jia
- Gansu Provincial HospitalDepartment of AnesthesiaNo. 204, Donggang West RoadLanzhou CityGansuChina730000
| | - Peng Zhang
- Nanyang Central HospitalDepartment of Pediatric SurgeryNanyangHenanChina473000
| | - KeHu Yang
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Jin Hui Tian
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Bin Ma
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Yali Liu
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Run H Jia
- Chinese Medicine Hospital in Gansu ProvinceDepartment of RadiologyLanzhou CityGansuChina730000
| | - Xiao F Luo
- Lanzhou UniversityEpidemiology and Health Statistics Institution of School of Public HealthNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Akira Kuriyama
- Kurashiki Central HospitalDepartment of General Medicine1‐1‐1 MiwaKurashikiOkayamaJapan710‐8602
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van Amsterdam J, Nabben T, van den Brink W. Recreational nitrous oxide use: Prevalence and risks. Regul Toxicol Pharmacol 2015; 73:790-6. [PMID: 26496821 DOI: 10.1016/j.yrtph.2015.10.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/14/2015] [Accepted: 10/19/2015] [Indexed: 02/02/2023]
Abstract
Nitrous oxide (N2O; laughing gas) is clinically used as a safe anesthetic (dentistry, ambulance, childbirth) and appreciated for its anti-anxiety effect. Since five years, recreational use of N2O is rapidly increasing especially in the dance and festival scene. In the UK, N2O is the second most popular recreational drug after cannabis. In most countries, nitrous oxide is a legal drug that is widely available and cheap. Last month prevalence of use among clubbers and ravers ranges between 40 and almost 80 percent. Following one inhalation, mostly from a balloon, a euphoric, pleasant, joyful, empathogenic and sometimes hallucinogenic effect is rapidly induced (within 10 s) and disappears within some minutes. Recreational N2O use is generally moderate with most users taking less than 10 balloons of N2O per episode and about 80% of the users having less than 10 episodes per year. Side effects of N2O include transient dizziness, dissociation, disorientation, loss of balance, impaired memory and cognition, and weakness in the legs. When intoxicated accidents like tripping and falling may occur. Some fatal accidents have been reported due to due to asphyxia (hypoxia). Heavy or sustained use of N2O inactivates vitamin B12, resulting in a functional vitamin B12 deficiency and initially causing numbness in fingers, which may further progress to peripheral neuropathy and megaloblastic anemia. N2O use does not seem to result in dependence. Considering the generally modest use of N2O and its relative safety, it is not necessary to take legal measures. However, (potential) users should be informed about the risk of vitamin B12-deficiency related neurological and hematological effects associated with heavy use.
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Affiliation(s)
- Jan van Amsterdam
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.
| | - Ton Nabben
- Bonger Institute for Criminology, University of Amsterdam, P.O. Box 1030, 1000 BA Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands; Amsterdam Institute for Addiction Research, Academic Medical Center, P.O. Box 75867, 1070 AW Amsterdam, The Netherlands
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Schwendicke F, Göstemeyer G, Gluud C. Cavity lining after excavating caries lesions: meta-analysis and trial sequential analysis of randomized clinical trials. J Dent 2015; 43:1291-7. [PMID: 26265350 DOI: 10.1016/j.jdent.2015.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/03/2015] [Accepted: 07/30/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES After removal of dentine caries lesions, cavity lining has been advocated. Non-clinical data support this approach, but clinical data are sparse and ambiguous. We aimed at evaluating the benefits and harms of cavity lining using meta-analysis and Trial Sequential Analysis. DATA We included randomized clinical trials comparing restorations without versus with cavity lining for treating primary caries lesions. Only trials reporting failure (defined as need to re-retreat) after ≥1 year follow-up were included. Trial selection, data extraction, and risk of bias assessment were conducted independently by two reviewers. We conducted random-effects intention-to-treat and per-protocol meta-analyses, and Trial Sequential Analysis to control for random errors. SOURCES Electronic databases (PubMed, Embase, CENTRAL) were systematically screened, and hand searches and cross-referencing performed. STUDY SELECTION From 128 studies, three randomized trials (89/130 patients or teeth), all treating primary teeth, were included. The trials had high risk of bias. All trials compared no lining versus calcium hydroxide lining after selective caries removal followed by adhesive restoration. Follow-up was 36 to 53 months. Restoring the cavity without lining did not significantly affect the risk of failure (intention-to-treat relative risk (RR) (95% confidence interval) 0.71 (0.49-1.04), per-protocol RR 0.52 (0.24-1.10). According to Trial Sequential Analysis, no firm evidence was reached. The quality of evidence was very low. CONCLUSIONS Strong recommendations for using cavity liners are unsubstantiated, but firm evidence for omitting lining is also unavailable. Our findings apply only to primary teeth and calcium hydroxide liner. CLINICAL SIGNIFICANCE Whilst lining is frequently performed in dental practice, very few randomized clinical trials investigated this issue. The three trials included in this review treated deciduous teeth and did not find lining with calcium hydroxide beneficial. Lining is not supported by sufficient clinical evidence.
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Affiliation(s)
- Falk Schwendicke
- Department of Operative and Preventive Dentistry, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Gerd Göstemeyer
- Department of Operative and Preventive Dentistry, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Wetterslev J, Meyhoff CS, Jørgensen LN, Gluud C, Lindschou J, Rasmussen LS. The effects of high perioperative inspiratory oxygen fraction for adult surgical patients. Cochrane Database Syst Rev 2015; 2015:CD008884. [PMID: 26110757 PMCID: PMC6457590 DOI: 10.1002/14651858.cd008884.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Available evidence on the effects of a high fraction of inspired oxygen (FIO2) of 60% to 90% compared with a routine fraction of inspired oxygen of 30% to 40%, during anaesthesia and surgery, on mortality and surgical site infection has been inconclusive. Previous trials and meta-analyses have led to different conclusions on whether a high fraction of supplemental inspired oxygen during anaesthesia may decrease or increase mortality and surgical site infections in surgical patients. OBJECTIVES To assess the benefits and harms of an FIO2 equal to or greater than 60% compared with a control FIO2 at or below 40% in the perioperative setting in terms of mortality, surgical site infection, respiratory insufficiency, serious adverse events and length of stay during the index admission for adult surgical patients.We looked at various outcomes, conducted subgroup and sensitivity analyses, examined the role of bias and applied trial sequential analysis (TSA) to examine the level of evidence supporting or refuting a high FIO2 during surgery, anaesthesia and recovery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, BIOSIS, International Web of Science, the Latin American and Caribbean Health Science Information Database (LILACS), advanced Google and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) up to February 2014. We checked the references of included trials and reviews for unidentified relevant trials and reran the searches in March 2015. We will consider two studies of interest when we update the review. SELECTION CRITERIA We included randomized clinical trials that compared a high fraction of inspired oxygen with a routine fraction of inspired oxygen during anaesthesia, surgery and recovery in individuals 18 years of age or older. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently. We conducted random-effects and fixed-effect meta-analyses, and for dichotomous outcomes, we calculated risk ratios (RRs). We used published data and data obtained by contacting trial authors.To minimize the risk of systematic error, we assessed the risk of bias of the included trials. To reduce the risk of random errors caused by sparse data and repetitive updating of cumulative meta-analyses, we applied trial sequential analyses. We used Grades of Recommendation, Assessment, Development and Evaluation (GRADE) to assess the quality of the evidence. MAIN RESULTS We included 28 randomized clinical trials (9330 participants); in the 21 trials reporting relevant outcomes for this review, 7597 participants were randomly assigned to a high fraction of inspired oxygen versus a routine fraction of inspired oxygen.In trials with an overall low risk of bias, a high fraction of inspired oxygen compared with a routine fraction of inspired oxygen was not associated with all-cause mortality (random-effects model: RR 1.12, 95% confidence interval (CI) 0.93 to 1.36; GRADE: low quality) within the longest follow-up and within 30 days of follow-up (Peto odds ratio (OR) 0.99, 95% CI 0.61 to 1.60; GRADE: low quality). In a trial sequential analysis, the required information size was not reached and the analysis could not refute a 20% increase in mortality. Similarly, when all trials were included, a high fraction of inspired oxygen was not associated with all-cause mortality to the longest follow-up (RR 1.07, 95% CI 0.87 to 1.33) or within 30 days of follow-up (Peto OR 0.83, 95% CI 0.54 to 1.29), both of very low quality according to GRADE. Neither was a high fraction of inspired oxygen associated with the risk of surgical site infection in trials with low risk of bias (RR 0.86, 95% CI 0.63 to 1.17; GRADE: low quality) or in all trials (RR 0.87, 95% CI 0.71 to 1.07; GRADE: low quality). A high fraction of inspired oxygen was not associated with respiratory insufficiency (RR 1.25, 95% CI 0.79 to 1.99), serious adverse events (RR 0.96, 95% CI 0.65 to 1.43) or length of stay (mean difference -0.06 days, 95% CI -0.44 to 0.32 days).In subgroup analyses of nine trials using preoperative antibiotics, a high fraction of inspired oxygen was associated with a decrease in surgical site infections (RR 0.76, 95% CI 0.60 to 0.97; GRADE: very low quality); a similar effect was noted in the five trials adequately blinded for the outcome assessment (RR 0.79, 95% CI 0.66 to 0.96; GRADE: very low quality). We did not observe an effect of a high fraction of inspired oxygen on surgical site infections in any other subgroup analyses. AUTHORS' CONCLUSIONS As the risk of adverse events, including mortality, may be increased by a fraction of inspired oxygen of 60% or higher, and as robust evidence is lacking for a beneficial effect of a fraction of inspired oxygen of 60% or higher on surgical site infection, our overall results suggest that evidence is insufficient to support the routine use of a high fraction of inspired oxygen during anaesthesia and surgery. Given the risk of attrition and outcome reporting bias, as well as other weaknesses in the available evidence, further randomized clinical trials with low risk of bias in all bias domains, including a large sample size and long-term follow-up, are warranted.
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Affiliation(s)
- Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian S Meyhoff
- Bispebjerg Hospital, University of CopenhagenDepartment of AnaesthesiologyCopenhagen NVDenmark
| | - Lars N Jørgensen
- Bispebjerg Hospital, University of CopenhagenDepartment of Surgery KBispebjerg Bakke 23CopenhagenDenmark2400 NV
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Lars S Rasmussen
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsDpt. 4231Blegdamsvej 9CopenhagenDenmarkDK‐2100 Ø
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Sathitkarnmanee T, Tribuddharat S, Nonlhaopol D, Thananun M, Somdee W. 1-1-12 one-step wash-in scheme for desflurane low flow anesthesia: performance without nitrous oxide. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:977-81. [PMID: 25733815 PMCID: PMC4338778 DOI: 10.2147/dddt.s78233] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background We reported a 1-1-12 wash-in scheme for desflurane-nitrous oxide (N2O) low flow anesthesia that is simple, rapid, and predictable. There remain some situations where N2O should be avoided, which limits the generalizability of this wash-in scheme. The objective of our study was to determine the performance of this scheme in contexts where N2O is not used. Methods We recruited 106 patients scheduled for elective surgery under general anesthesia. After induction and intubation, wash-in was started with a fresh gas flow of air:O2 1:1 L/min and a vaporizer concentration of desflurane of 12%. Controlled ventilation was then adjusted to maintain PACO2 at 30–35 mmHg. Results The alveolar concentration of desflurane (FAD) rose rapidly from 0% to 6% in 4 minutes in the same pattern as observed in our previous study in which N2O was used. An FAD of 7% was achieved in 6 minutes. An FAD of 1% to 7% occurred at 0.6, 1, 1.5, 2, 3, 4, and 6 minutes. The rise in heart rate during wash-in was statistically significant, although not clinically so. There was a slight but statistically significant decrease in blood pressure, but this had no clinical significance. Conclusion Performance of the 1-1-12 wash-in scheme is independent of the use of N2O. Respective FADs of 1%, 2%, 3%, 4%, 5%, 6%, and 7% can be expected at 0.6, 1, 1.5, 2, 3, 4, and 6 minutes.
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Affiliation(s)
| | - Sirirat Tribuddharat
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Duangthida Nonlhaopol
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Maneerat Thananun
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Wilawan Somdee
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Myles PS, Leslie K, Chan MTV, Forbes A, Peyton PJ, Paech MJ, Beattie WS, Sessler DI, Devereaux PJ, Silbert B, Schricker T, Wallace S. The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet 2014; 384:1446-54. [PMID: 25142708 DOI: 10.1016/s0140-6736(14)60893-x] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nitrous oxide is commonly used in general anaesthesia but concerns exist that it might increase perioperative cardiovascular risk. We aimed to gather evidence to establish whether nitrous oxide affects perioperative cardiovascular risk. METHODS We did an international, randomised, assessor-blinded trial in patients aged at least 45 years with known or suspected coronary artery disease having major non-cardiac surgery. Patients were randomly assigned via automated telephone service, stratified by site, to receive a general anaesthetic with or without nitrous oxide. Attending anaesthetists were aware of patients' group assignments, but patients and assessors were not. The primary outcome measure was a composite of death and cardiovascular complications (non-fatal myocardial infarction, stroke, pulmonary embolism, or cardiac arrest) within 30 days of surgery. Our modified intention-to-treat population included all patients randomly assigned to groups and undergoing induction of general anaesthesia for surgery. This trial is registered at ClinicalTrials.gov, number NCT00430989. FINDINGS Of 10,102 eligible patients, we enrolled 7112 patients between May 30, 2008, and Sept 28, 2013. 3543 were assigned to receive nitrous oxide and 3569 were assigned not to receive nitrous oxide. 3483 patients receiving nitrous oxide and 3509 not receiving nitrous oxide were assessed for the primary outcome. The primary outcome occurred in 283 (8%) patients receiving nitrous oxide and in 296 (8%) patients not receiving nitrous oxide (relative risk 0·96, 95% CI 0·83–1·12; p=0·64). Surgical site infection occurred in 321 (9%) patients assigned to nitrous oxide, and in 311 (9%) patients in the no-nitrous oxide group (p=0·61), and severe nausea and vomiting occurred in 506 patients (15%) assigned to nitrous oxide and 378 patients (11%) not assigned to nitrous oxide (p<0·0001). INTERPRETATION Our findings support the safety profile of nitrous oxide use in major non-cardiac surgery. Nitrous oxide did not increase the risk of death and cardiovascular complications or surgical-site infection, the emetogenic effect of nitrous oxide can be controlled with antiemetic prophylaxis, and a desired effect of reduced volatile agent use was shown. FUNDING Australian National Health and Medical Research Council; Australian and New Zealand College of Anaesthetists; Heart and Stroke Foundation of Quebec, Heart and Stroke Foundation of Ontario, Canada; General Research Fund of the Research Grant Council, Hong Kong Special Administrative Region, China.
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Role of Nitrous Oxide in Ambulatory Anaesthesia. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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