Objective: The objective of this review is to determine the effectiveness of non-opioid pharmacological adjuncts for decreasing perioperative morphine equivalents and acute postoperative pain scores in adult surgical patients. Introduction: Opioids are commonly administered during anesthesia to dull the senses, relieve pain and induce sleep. However, there are significant adverse effects associated with intraoperative opioid use. Anesthesia providers can impact the current opioid epidemic by administering non-opioid-centric anesthetic medications. A large-scale evidence-based review is needed to inform a standardized non-opioid pain treatment strategy in the perioperative period. Inclusion criteria: This review will consider studies of adults 19 years or older who are undergoing surgical procedures and receiving non-opioid oral or intravenous perioperative analgesic medications administered by the anesthesia team. Studies that include patients who receive non-opioid medication as a local infiltrate by the surgical team will be excluded, as will studies with patients who receive regional or neuraxial opioid-sparing techniques. Only systematic reviews and meta-analyses published in English after 2007 will be considered. Methods: MEDLINE, CINAHL and Embase will be searched, as well as two trial registers and two sources of unpublished reviews. Titles and abstracts will be screened to identify potentially relevant papers. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. Meta-analyses will be performed if possible, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented. Systematic review registration number: PROSPERO CRD42019135852
ObjectiveWe compared the efficacy of tibial intraosseous (TIO) administration of epinephrine in a pediatric normovolemic versus hypovolemic cardiac arrest model to determine the incidence of return of spontaneous circulation (ROSC) and plasma epinephrine concentrations over time.MethodsThis experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model.ResultsAll subjects in the TIO normovolemia cardiac arrest group experienced ROSC after TIO administration of epinephrine. In contrast, subjects experiencing hypovolemia and cardiac arrest were significantly less likely to experience ROSC when epinephrine was administered TIO versus intravenous (TIO hypovolemia: 14% [1/7] vs IV hypovolemia: 71% [5/7]; P = 0.031). The TIO hypovolemia group exhibited significantly lower plasma epinephrine concentrations versus IV hypovolemia at 60, 90, 120, and 150 seconds (P < 0.05). Although the maximum concentration of plasma epinephrine was similar, the TIO hypovolemia group exhibited significantly slower time to maximum concentration times versus TIO normovolemia subjects (P = 0.004).ConclusionsTibial intraosseous administration of epinephrine reliably facilitated ROSC among normovolemic cardiac arrest pediatric patients, which is consistent with published reports. However, TIO administration of epinephrine was ineffective in restoring ROSC among subjects experiencing hypovolemia and cardiac arrest. Tibial intraosseous–administered epinephrine during hypovolemia and cardiac arrest may have resulted in a potential sequestration of epinephrine in the tibia. Central or peripheral intravascular access attempts should not be abandoned after successful TIO placement in the resuscitation of patients experiencing concurrent hypovolemia and cardiac arrest.
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