JBI database of systematic reviews and implementation reports
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JBI Database System Rev Implement Rep · Jan 2015
ReviewEffectiveness of ondansetron as an adjunct to lidocaine intravenous regional anesthesia on tourniquet pain and postoperative pain in patients undergoing elective hand surgery: a systematic review protocol.
The objective of this quantitative systematic review is to determine the effects of ondansetron as an adjunct to lidocaine on the tourniquet pain and postoperative pain of American Society of Anesthesiologists (ASA) class 1 or 2 adult patients undergoing elective hand surgery with intravenous regional anesthesia. ⋯ Both injury and deformity of the upper extremity can result in dysfunction to nerves, tendons and bones which can lead to disability and pain. Hand injuries and deformities encompass an area of upper extremity surgery, wherein isolation and accessibility to peripheral nerves allows for a wide range of anesthesia techniques. Common hand surgeries include carpal tunnel or trigger finger release, Dupuytren's contracture fasciectomy, tendon repair, and ganglion cyst removal. According to the extent of injury or deformity, a general anesthetic, regional anesthetic, monitored anesthetic care (MAC) or local anesthetic may be used for these hand surgeries. Depending on the injury or deformity, local anesthesia may not provide sufficient anesthesia, but a general anesthesia may not be completely warranted either. Typical elective hand surgeries performed under regional anesthesia and MAC may be the ideal anesthetic plan that balances adequate sedation and analgesia. Intravenous regional anesthesia (IVRA), commonly known as a bier block, is a safe and effective anesthetic and is typically utilized in uncomplicated hand or forearm surgeries lasting less than an hour. Intravenous regional anesthesia was first developed by August Bier in 1908 for anesthesia of the hand and forearm. It is a regional anesthetic technique that is easy to perform, with success rates up to 98%. Intravenous regional anesthesia is a simple, reliable and cost-effective anesthesia technique for short ambulatory hand surgery. The IVRA technique is ideal for American Society of Anesthesiologists (ASA) class 1 or 2 patients, which according to ASA classification, are individuals who are healthy with well controlled to no comorbidities.The IVRA technique consists of inserting an intravenous catheter into a peripheral vein of the affected extremity. A double pneumatic tourniquet is applied to the same arm. The extremity is lifted and exsanguinated from distal to proximal with an Esmarch bandage. The proximal cuff of the tourniquet is then inflated to the appropriate pressure; standard 250mmHg for an upper extremity followed by the distal cuff. Insufflation times are limited to a maximum of one and a half to two hours, whereas the total insufflation time should never be less than 20 minutes. The Esmarch bandage is removed, and the local anesthetic is injected via the intravenous catheter to promote anesthesia in the operative area. In addition to the advantages of IVRA, there are disadvantages as well. These disadvantages include, but are not limited to, local anesthetic (LA) toxicity, delayed onset of action, poor muscle relaxation, tourniquet pain, and minimal postoperative analgesia. A method for improving analgesia and IVRA is to add medications to the IVRA solution. The ideal IVRA should include rapid onset of sensory and motor block, reduced LA dose, reduced intraoperative and tourniquet pain, prolonged postoperative analgesia, and minimal side effects.Adjuncts to LA can help offset some of the disadvantages mentioned above. In a systematic review of adjuncts for intravenous regional anesthesia conducted by Choyce and Peng, 29 studies were systematically reviewed to include various adjuncts to LA in IVRA. Adjuncts studied in this review included opioids, tramadol, non-steroidal anti-inflammatory drugs (NSAIDs), clonidine, muscle relaxants, sodium bicarbonate and potassium. The results of this systematic review suggest that NSAIDs have the most potential to offer as adjuncts to IVRA, while opioid adjuncts to IVRA proved to be disappointing as a form of postoperative analgesia. The search for the optimal IVRA adjunct that improves analgesia but has limited side effects is ongoing. More recent studies on adjuncts to IVRA have included medications such as neostigmine, dexmetomidine, nitroglycerin, and ondansetron.Ondansetron is a specific 5-hydroxytryptamine-3 (5-HT3 or serotonin) antagonist, commonly used as an antiemetic drug for prevention or treatment of postoperative nausea and vomiting. Used in the recommended dose range, there are minimal reported side effects, with constipation, dizziness and headache being the most common. 5-HT3 antagonists such as ondansetron possess anti-inflammatory, anesthetic, and analgesic properties which may have a potential role in decreasing pain. 5-HT3 antagonists participate in the pathway of nociception by interfering with peripheral effects of serotonin on nociception. By binding to opioid mu receptors and acting as a potential opioid agonist, the result is a peripheral nociceptive analgesic effect. A study by Deegan shows that there are 5-HT3 receptors on the central spinal terminal, which suggests that ondansetron could have both peripheral and central nociceptive effects. Ambesh et al. found that pain during injection of propofol can be successfully prevented by the administration of 4 mg of ondansetron. In a study performed by Reddy et al., it was shown that 4 mg of ondansetron could significantly reduce pain during the intravenous (IV) injection of rocuronium and propofol.Ondansetron may be useful for its potential anti-in-ammatory effect as an adjunct to medication to reduce acute inflammation. Ondansetron can block sodium channels similar to local anesthetics and produce a local anesthetic effect. It has been shown to be approximately fifteen times more potent than lidocaine. A study by Farouk suggests the addition of ondansetron to lidocaine may improve the quality of IVRA and prolong postoperative analgesia in patients undergoing hand surgery. A study conducted by Honarmand, concluded that the addition of ondansetron to lidocaine for IVRA reduced intraoperative and postoperative analgesic use.Tourniquet pain, which is described as a dull and aching pain sensation, is caused by the nerve compression from the tourniquet. Neuropathic pain produced by nerve compression plays an important role in the etiology of this discomfort. Tourniquet pain is thought to be mediated by impulse propagation via small, unmyelinated, slow-conducting C fibers. The duration of the tourniquet time is directly proportional to the onset of tourniquet pain. In a study by Asik, onset of tourniquet pain ranged from eight to fifteen minutes. Tourniquet pain is a well-known limitation of IVRA and is a factor that can limit the number of times which IVRA can be used for extremity surgery. Lidocaine is one of the most frequently used LAs for IVRA. It has a relatively brief duration of action which may limit the postoperative analgesia. Duration of postoperative analgesia, measured as time to first analgesic requirement ranged from 34 to 45 minutes (median) with LA alone.Outcome measures will include pain assessment for intraoperative tourniquet pain and postoperative pain measured by first analgesic requirement time (the time elapsed after tourniquet release to the first request by the patient for analgesic). Pain will be assessed with a visual analog scale (VAS) (0 = no pain and 10 = worst pain imaginable). A VAS score of more than three would indicate pain threshold has been exceeded.A preliminary search of the Joanna Briggs Database of Systematic Reviews and Implementation Reports, the Cochrane Library, CINAHL, PubMed and PROSPERO has revealed that there are currently no systematic reviews (either published or underway) on the topic of ondansetron as an adjunct to lidocaine intravenous regional anesthesia. Search terms included Zofran, ondansetron, intravenous regional anesthesia, and IVRA. Outcomes of this review will determine if ondansetron, admixed with lidocaine, has an effect on tourniquet pain, and secondly to determine if ondansetron, admixed with lidocaine, has an effect on the duration of postoperative analgesia.
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JBI Database System Rev Implement Rep · Jan 2015
ReviewThe experiences of family members in the year following the diagnosis of a child or adolescent with cancer: a qualitative systematic review.
Research shows that it is stressful for family members when a child or an adolescent within the family unit is diagnosed with cancer and this stress continues over the course of the year after the diagnosis. Qualitative studies have been conducted aimed at exploring parental, siblings' and other family members' experiences when facing health-illness transition-related stress during the first year after the child is diagnosed with cancer. This study integrates the research findings of relevant existing qualitative studies on this topic in order to provide empirical evidence-based suggestions for clinical care. ⋯ Clinical guideline suggestions for health professionals working with families of children or adolescent diagnosed with cancer within the first year following the diagnosis were identified. Health professionals must listen to and accept the emotions of shock, anger and loss by the family members who are facing the potential loss of their healthy child together with the upheaval in their lives and disruptions to their plans for the future. Health professionals should be encouraged to provide clear information to the whole family in relation to the treatment plan and caring strategies for the child. Nurses should provide family members with strategies to help with the normalization of their life and a return to their previous pre-cancer lifestyle. The medical team should exhibit professionalism and skills when treating the cancer in order to enhance the child’s and his/her family members’ trust and sense of safety in the medical care environment. Encouraging the family members of children with cancer to develop positive thinking and to plan for their future life should be a priority of the nursing care plan.
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JBI Database System Rev Implement Rep · Jan 2015
ReviewCarers' experiences when the person for whom they have been caring enters a residential aged care facility permanently: a systematic review.
Primary research, including qualitative research, as well as experts working in social services and aged care have identified the mixed feelings carers experience when the person they have been caring for is admitted into a residential aged care facility permanently. They have raised the importance of understanding these experiences as a means to implementing policies and programs that enhance carers' well-being. This systematic review was motivated by the need to use evidence to inform effective and feasible interventions to support carers, and the absence of a systematic review synthesizing the qualitative evidence on how carers experience this transition. ⋯ Fourteen studies matched the inclusion criteria and were included in the review. From these 14 studies a total of 71 study findings about how carers experience the transition when the person they have been caring for is TRUNCATED AT 500 WORDS.
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JBI Database System Rev Implement Rep · Jan 2015
The effectiveness of neural mobilizations in the treatment of musculoskeletal conditions: a systematic review protocol.
The objective of this review is to identify the effectiveness of neural mobilization techniques in various neuro-musculoskeletal conditions. Outcomes will be analyzed in terms of subgroups such as low back pain, cervico-brachial pain and carpal tunnel syndrome. ⋯ Musculoskeletal disorders were ranked as the second largest contributor to disability worldwide in a study on the global burden of disease. Low back pain and neck pain contributed to 70% of disability in this comprehensive population-based study. Low back pain and neck pain are multifactorial, with heterogeneous populations. It has been proposed that targeting subgroups of patients may result in better treatment outcomes. Neck pain associated with upper limb pain is prevalent. These patients are more disabled than patients with neck pain alone. Similarly, low back pain with leg pain is a common phenomenon and is acknowledged as a predictor for chronicity.Neuropathic pain is often associated with musculoskeletal complaints including low back pain, whiplash associated disorders (WAD) and acute or chronic radiculopathy, and can be a feature of syndromes such as cervico-brachial pain syndrome. According to the International Association for the Study of Pain, neuropathic pain can be described as "pain caused by a lesion or disease of the somatosensory nervous system." Leg pain associated with back pain can be caused by central sensitization, denervation, nerve sensitization or somatically referred pain. In patients with WAD, neck pain is the most common symptom, but upper limb pain, weakness, paraesthesia and anesthesia are often present. Other conditions in which neural tissue is thought to contribute to the clinical picture are, for instance, lateral epicondalalgia and carpal tunnel syndrome.Management strategies for back pain and neck pain are often multimodal. However, the evidence for effective treatment of nerve related pain is lacking. Neural mobilizations are often used to affect the neural structures in conditions with signs of neural involvement or neural mechano-sensitivity. Neural mobilizations are defined as interventions aimed at affecting the neural structures or surrounding tissue (interface) directly or indirectly through manual techniques or exercise. Neural mobilizations have been studied in various populations such as low back pain, carpal tunnel syndrome, lateral epicondalalgia and cervico-brachial pain. Neural mobilization techniques studied include cervical lateral glides for cervico-brachial pain, nerve gliding exercises for the treatment of carpal tunnel syndrome, cervical lateral glides for lateral epicondalalgia and the slump as a neural mobilization technique in the treatment of low back pain. No specialized equipment is needed in the performance of neural mobilization techniques, which contributes to its popularity.Neural mobilization is said to affect the axoplasmic flow, movement of the nerve and its connective tissue and the circulation of the nerve by alteration of the pressure in the nervous system and dispersion of intraneural oedema. Neural mobilization decreases the excitability of dorsal horn cells. Neural mobilizations can be performed in various ways using passive movement, manual mobilization of the nerve or interface, and exercise. The aim of neural mobilization is to restore the mechanical and neurophysiological function of the nerve.Only one systematic review on the effectiveness of neural mobilizations could be identified in the literature. Since this review, several more studies have been published on this subject. The authors hypothesize that a review of the more recent literature (2008-2014) may confirm positive support for the use of neural mobilizations for neuro-musculoskeletal complaints as previously seen by Ellis and Hing. This review aims to include a meta-analysis and subgrouping of conditions which will be an extension of the previous review by Ellis and Hing. The outcomes of this systematic review may be used to inform clinical practice and the development of best practice guidelines.