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Virtual reality (VR), a technology that provides a stimulated sensory experience, has recently been implemented in various fields of medicine. Several studies have investigated the efficacy of VR on preoperative anxiety. The purpose of this meta-analysis was to validate whether VR could relieve preoperative anxiety in patients undergoing surgery. Electronic databases were searched to identify all randomized controlled trials (RCTs) investigating the effect of VR on preoperative anxiety. The primary outcome was defined as the preoperative anxiety scores. We estimated the effect size using the standard mean difference (SMD) with a 95% confidence interval (CI) using a random effect model. Ultimately, 10 RCTs, with a total of 813 patients, were included in the final analysis. Preoperative anxiety was significantly lower in the VR group than in the control group (SMD −0.64, 95% CI −1.08 to −0.20, p = 0.004). In a subgroup analysis, the preoperative anxiety scores were lower in the VR group than in the control group in pediatric patients (SMD −0.71, 95% CI −1.14 to −0.27, p = 0.002), whereas a significant difference was not observed between the two groups in adult patients (p = 0.226). The results of this meta-analysis indicated that VR could decrease preoperative anxiety, especially in pediatric patients.

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The purpose of this study was to compare the incidence of airway complications between extubation under deep anesthesia (deep extubation) and extubation when fully awake (awake extubation) in pediatric patients after general anesthesia. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement standards. The review protocol was registered with the International Prospective Register of Systematic Reviews (registration number: CRD 42018090172). Electronic databases were searched, without discrimination of publication year and language, to identify all randomized controlled trials investigating airway complications following deep or awake extubation after general anesthesia. The Cochrane tool was used to assess the risk of bias of trials. Randomized trials investigating airway complications of deep extubation compared with awake extubation after general anesthesia with an endotracheal tube and laryngeal mask airway (LMA) were sought. Overall airway complications, airway obstruction, cough, desaturation, laryngospasm and breath holding were analyzed using random-effect modelling. The odds ratio was used for these incidence variables. Seventeen randomized trials were identified, and a total of 1881 pediatric patients were enrolled. The analyses indicated deep extubation reduces the risk of overall airway complications (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.33–0.96, p = 0.04), cough (OR 0.30, 95% CI 0.12–0.72, p = 0.007) and desaturation (OR 0.49, 95% CI 0.25–0.95, p = 0.04) in children after general anesthesia. However, deep extubation increased the risk of airway obstruction compared with awake extubation (OR 3.38 CI 1.69–6.73, p = 0.0005). No difference was observed in the incidence of laryngospasm and breath-holding between the two groups regardless of airway device. The result of this analysis indicates that deep extubation may decrease the risk of overall airway complications including cough and desaturation but may increase airway obstruction compared with awake extubation in pediatric patients after general anesthesia. Therefore, deep extubation may be recommended in pediatric patients to minimize overall airway complications except airway obstruction and the clinicians may choose the method of extubation according to the risk of airway complications of pediatric patients.

NCT02856087.

Tracheostomy performed within 14 days after the initiation of MV was associated with reduced duration of MV and length of ICU and hospital stay. Although there was no effect on mortality rate, children may benefit from early tracheostomy without severe complications.

Background and purpose — New oral anticoagulants have been developed to prevent venous thromboembolism (VTE) after knee or hip arthroplasty. Although there have been several network meta-analyses (NMA) to compare different regimens, an NMA including 2 different enoxaparin doses and edoxaban has not been performed.Methods — Standard NMA for fondaparinux, dabigatran, rivaroxaban, apixaban, edoxaban, and enoxaparin was performed. Outcome variables included a composite of total VTE and major/clinically relevant bleeding. The rank probabilities of each treatment outcome were summarized by the surface under the cumulative ranking curve.Results — Fondaparinux, rivaroxaban, and apixaban were associated with a reduced risk of VTE compared with enoxaparin, while dabigatran was not. None of these 3 drugs increased bleeding compared with enoxaparin 30 mg twice daily. However, fondaparinux and rivaroxaban increased bleeding compared with enoxaparin 40 mg once daily, while apixaban did not. Apixaban was even associated with decreased major/clinically relevant bleeding compared with enoxaparin 30 mg twice daily or 40 mg once daily. When edoxaban was included in the NMA, edoxaban decreased VTE and did not increase bleeding compared with enoxaparin.Interpretation — A higher efficacy of fondaparinux and rivaroxaban compared with enoxaparin was associated with increased bleeding tendency, while apixaban was superior to enoxaparin regarding both efficacy and safety. A clustered ranking plot showed that apixaban might be the most preferred regarding efficacy and safety. However, our results were driven by indirect statistical inference and were limited by the heterogeneity of the bleeding outcome definitions, drug initiation and continuation, and different surgery types.

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