Biomedical subjects
Publications and source records attributed to Jeffrey M Richman.
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Explore the source record for details and available documents.
STUDY OBJECTIVE: To perform a meta-analysis of available randomized controlled trials to determine if neuraxial anesthesia would decrease blood loss, compared with general anesthesia. DESIGN: Retrospective analysis. SETTING: University medical center. MEASUREMENTS: The National Library of Medicine's PubMed database was searched from the period of 1966 to December 10, 2003 for all abstracts containing words related to neuraxial anesthesia and general anesthesia. The search was limited to randomized controlled trials and the English language and yielded 667 articles. MAIN RESULTS: A total of 66 articles met inclusion criteria and were used for the analysis. Overall, the use of spinal anesthesia resulted in significantly less estimated blood loss (EBL) (P < 0.0001), compared with epidural anesthesia (EA), which, in turn, resulted in significantly less EBL compared with general anesthesia (GA) or combined GA-EA (P < 0.0001). No significant difference between GA and GA-EA was noted when analysis was limited to studies directly comparing GA-EA and GA. CONCLUSIONS: Use of spinal anesthesia or EA is associated with a significant decrease in EBL when compared with that for GA or combined GA-EA.
STUDY OBJECTIVE: To examine, with a large database, the effect of postoperative epidural analgesia (vs systemic analgesia) on mortality after colectomy is unclear. DESIGN: Retrospective cohort (database) design. SETTING: Medicare beneficiaries undergoing elective colectomy. PATIENTS: We examined a cohort of 12817 patients obtained from a 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 who underwent elective partial excision of the large intestine. INTERVENTIONS: Patients were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). MEASUREMENTS: The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. MAIN RESULTS: Multivariate regression analysis revealed that there was no difference between the groups with regard to overall major morbidity; however, the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.35; 95% confidence interval, 0.21-0.59; P < 0.0001) and 30 days (odds ratio, 0.54; 95% confidence interval, 0.42-0.70; P < 0.0001) after surgery. CONCLUSIONS: The presence of postoperative epidural analgesia may decrease the odds of death after elective colectomy; however, the mechanism of such a benefit is not clear from our analysis.
OBJECTIVES: To perform a meta-analysis of available randomized trials investigating the analgesic efficacy of periprostatic block with local anesthetic. METHODS: The National Library of Medicine's PubMed database was searched for the time period 1966 to August 16, 2005 for all relevant articles. Inclusion criteria included subjects undergoing prostate biopsy, trials that were randomized with one arm of the randomization using local anesthetic for periprostatic block before prostate biopsy, and where the assessment of biopsy pain was measured and available in a form compatible for statistical analysis in our meta-analysis. RESULTS: Our search resulted in 107 abstracts, of which a total of 16 articles met all inclusion criteria. There were 660 subjects who received local anesthetics for a periprostatic block and 616 subjects who did not. The weighted mean difference between the groups indicates that subjects receiving local anesthetic periprostatic block would have a statistically lower pain score compared with those who did not (weighted mean difference in visual analogue pain of -1.66 [95% confidence interval -2.03 to -1.29]). CONCLUSIONS: Our meta-analysis suggests that periprostatic block with local anesthetic for prostate biopsy might result in significantly lower levels of pain during the biopsy procedure. Because periprostatic block with local anesthetic is relatively easy to administer and does not seem to be associated with increased morbidity, clinicians performing prostate biopsies should consider using this technique on a routine basis.
BACKGROUND: The effect of lumbar puncture needle bevel direction on the incidence of postdural puncture headache (PDPH) is somewhat controversial. We performed a meta-analysis of available trials to determine if bevel direction during lumbar puncture would influence the incidence of PDPH. REVIEW SUMMARY: Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to November 29, 2004) and abstracts from several national meetings (American Society of Anesthesiology, International Anesthesia Research Society, American Society of Regional Anesthesia, Society of Obstetric Anesthesia and Perinatology) for terms related to needle and bevel direction. Inclusion criteria were assessment of the incidence of PDPH after lumbar puncture with a cutting needle (eg, Quincke, Tuohy), comparison of a "parallel" (bevel oriented in a longitudinal or cephalad to caudad direction) to "perpendicular" (bevel oriented in a transverse direction) orientation during needle insertion, randomized trials, and trials primarily in adult populations. Data on study characteristics and incidence of PDPH were abstracted from qualified studies and subsequently analyzed. The search resulted in 52 abstracts from which the original articles were obtained and data abstracted, with ultimately a total of 5 articles meeting all inclusion criteria. Insertion of a non-pencil-point/cutting needle with the bevel oriented in a parallel/longitudinal fashion resulted in a significantly lower incidence of PDPH compared with that oriented in a perpendicular/transverse fashion (unadjusted rates of 10.9% versus 25.8%; odds ratio = 0.29 [95% CI = 0.17-0.50]). CONCLUSIONS: Our meta-analysis indicates that with use of a cutting needle, insertion in a parallel/longitudinal fashion may significantly reduce the incidence of PDPH, although the reasons for this decrease are unclear.
Although most randomized clinical trials conclude that the addition of continuous peripheral nerve blockade (CPNB) decreases postoperative pain and opioid-related side effects when compared with opioids, studies have included relatively small numbers of patients and the majority failed to show statistical significance during all time periods for reduced pain or side effects. We identified studies primarily by searching Ovid Medline (1966-May 21, 2004) for terms related to postoperative analgesia with CPNB and opioids. Each article from the final search was reviewed and data were extracted from tables, text, or extrapolated from figures as needed. Nineteen articles, enrolling 603 patients, met all inclusion criteria. Inclusion criteria were a clearly defined anesthetic technique (combined general/regional anesthesia, general anesthesia alone, peripheral nerve block), randomized trial, adult patient population (> or =18 yr old), CPNB (or analgesia) used postoperatively (intrapleural catheters were deemed not to be classified as a peripheral nerve catheter), and opioids administered for postoperative analgesia in groups not receiving peripheral nerve block. Perineural analgesia provided better postoperative analgesia compared with opioids (P < 0.001). This effect was seen for all time periods measured for both mean visual analog scale and maximum visual analog scale at 24 h (P < 0.001), 48 h (P < 0.001), and 72 h (mean visual analog scale only) (P < 0.001) postoperatively. Perineural catheters provided superior analgesia to opioids for all catheter locations and time periods (P < 0.05). Nausea/vomiting, sedation, and pruritus all occurred more commonly with opioid analgesia (P < 0.001). A reduction in opioid use was noted with perineural analgesia (P < 0.001). CPNB analgesia, regardless of catheter location, provided superior postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia.
Epidural analgesia provides superior analgesia compared with other postoperative analgesic techniques. Additionally, perioperative epidural analgesia confers physiologic benefits, which may potentially decrease perioperative complications and improve postoperative outcome. However, there are many variables (eg, choice of analgesics, catheter-incision congruency, and duration of analgesia) that may influence the efficacy of epidural analgesia. In addition, the use of epidural analgesia should be evaluated on an individual basis because there are risks associated with this technique.
The authors performed a meta-analysis and found that epidural analgesia overall provided superior postoperative analgesia compared with intravenous patient-controlled analgesia. For all types of surgery and pain assessments, all forms of epidural analgesia (both continuous epidural infusion and patient-controlled epidural analgesia) provided significantly superior postoperative analgesia compared with intravenous patient-controlled analgesia, with the exception of hydrophilic opioid-only epidural regimens. Continuous epidural infusion provided statistically significantly superior analgesia versus patient-controlled epidural analgesia for overall pain, pain at rest, and pain with activity; however, patients receiving continuous epidural infusion had a significantly higher incidence of nausea-vomiting and motor block but lower incidence of pruritus. In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared to intravenous patient-controlled analgesia.
Both regional anesthesia and general anesthesia have been proposed to provide optimal ambulatory anesthesia. We searched MEDLINE and other databases for randomized controlled trials comparing regional anesthesia and general anesthesia in ambulatory surgery patients for meta-analysis. Only major conduction blocks were considered to be regional anesthesia. Regional anesthesia was further separated into central neuraxial block and peripheral nerve block. Fifteen (1003 patients) and 7 (359 patients) trials for central neuraxial block and peripheral nerve block were included in the meta-analysis. Both central neuraxial block and peripheral nerve block were associated with increased induction time, reduced pain scores, and decreased need for postanesthesia care unit analgesics. However, central neuraxial block was not associated with decreased postanesthesia care unit bypass or time or reduced nausea despite reduced analgesics, and it was associated with a 35-min increase in total ambulatory surgery unit time. In contrast, peripheral nerve block was associated with decreased postanesthesia care unit need and decreased nausea but, again, not with decreased ambulatory surgery unit time. This meta-analysis indicates potential advantages for regional anesthesia, such as decreased postanesthesia care unit use, nausea, and postoperative pain. Although these factors have been proposed to reduce ambulatory surgery unit stay, neither central neuraxial block nor peripheral nerve block were associated with reduced ambulatory surgery unit time. Other factors, such as unsuitable discharge criteria and limitations of meta-analysis, may explain this discrepancy.
PURPOSE OF REVIEW: Quality of recovery is recognized as a valid and important outcomes measurement in clinical care and research. The increasing interest in evaluating quality of recovery reflects the overall increased interest in patient-focused assessments. Assessment of quality of recovery incorporates measuring many dimensions or domains including physiologic endpoints, adverse events and psychosocial status. Unlike 'traditional' outcomes that focus on major morbidity and mortality, quality of recovery assesses 'nontraditional' outcomes focused around patient-oriented endpoints. By adversely influencing the many domains assessed by quality of recovery, postoperative pain may have a general detrimental effect on quality of recovery. RECENT FINDINGS: Studies utilizing validated instruments to assess quality of recovery have revealed that different levels of postoperative pain may differentially affect quality of recovery. In addition, quality of recovery in the immediate postoperative period may predict long-term quality of life. SUMMARY: Higher levels of postoperative pain typically correlate with a decrease in quality of recovery. Different analgesic techniques and regimens may differentially influence quality of recovery, with preliminary evidence suggesting that some regional analgesic techniques may provide superior quality of recovery, quality of life and patient satisfaction. Further studies are needed to elucidate the effects of different analgesic techniques on quality of recovery.
BACKGROUND AND OBJECTIVES: It has been suggested that intraoperative neuraxial (spinal, epidural) anesthesia may decrease postoperative cognitive dysfunction when compared with general anesthesia, but the issue remains controversial. We systematically reviewed the data from published studies to determine the effect of intraoperative neuraxial anesthesia versus general anesthesia on postoperative cognitive dysfunction and delirium. METHODS: Studies were identified by searching the PubMed database of the National Library of Medicine (1966 to 2003) for terms related to cognitive dysfunction after surgery. Inclusion criteria were a comparison of intraoperative neuraxial anesthesia versus general anesthesia, and the outcome of postoperative cognitive dysfunction. A total of 196 abstracts were identified, and 24 articles were analyzed. Each article was reviewed, and data were extracted from tables or text or extrapolated from figures as needed. RESULTS: Of the 24 trials obtained, 19 were randomized and 4 were observational (nonrandomized) trials (1 trial was a combination of randomized and observational data). The age of patients studied was typically greater than 60 years, and a wide range of neuropsychometric tests were used to evaluate cognitive function. The majority of trials (23/24 of all trials and 18/19 of randomized trials) did not demonstrate a benefit from neuraxial anesthesia in decreasing the incidence of postoperative cognitive dysfunction. CONCLUSIONS: The use of intraoperative neuraxial anesthesia does not appear to decrease the incidence of postoperative cognitive dysfunction when compared with general anesthesia. There are methodologic and study-design issues present in many studies, and further elucidation of the pathophysiology of postoperative cognitive dysfunction may provide a direction for future studies.