Emmanuel Marret

Introduction: The efficacy of steroid administration before planned tracheal extubation in critical care patients remains controversial with respect to the selection of patients most likely to benefit from this treatment. Methods: We performed an extensive literature search for adult trials testing steroids versus placebo to prevent reintubation or laryngeal dyspnoea. Studies were evaluated on a five-point scale based on randomisation, double-blinding and follow-up. Our analysis included trials having a score three or higher with patients mechanically ventilated for at least 24 hours and treated with steroids before extubation, taking into account the time of their administration (early vs late) and if the population selected was at risk or not. Results: Seven prospective, randomised, double-blinded trials, including 1846 patients, (949 of which received steroids) were selected. Overall, steroids significantly decreased the risk of reintubation (relative risk (RR) = 0.58, 95% confidence interval (CI) = 0.41 to 0.81; number-needed-to-treat (NNT) = 28, 95% CI = 20 to 61) and stridor (RR = 0.48, 95% CI = 0.26 to 0.87; NNT = 11, 95% CI = 8 to 42). The effect of steroids on reintubation and stridor was more pronounced for selected high-risk patients, as determined by a reduced cuff leak volume (RR = 0.38, 95% CI = 0.21 to 0.72; NNT = 9, 95% CI = 7 to 19; and RR = 0.40, 95% CI = 0.25 to 0.63; NNT = 5, 95% CI = 4 to 8, respectively). In contrast, steroid benefit was unclear when trials did not select patients for their risk of reintubation (RR = 0.67, 95% CI = 0.45 to 1.00; NNT = 44, 95% CI ≥ 26 to infinity) or stridor (RR = 0.56, 95% CI = 0.20 to 1.55). Conclusions: The efficacy of steroids to prevent stridor and reintubation was only observed in a high-risk population, as identified by the cuff-leak test and when it was administered at least four hours before extubation. The benefit of steroids remains unclear when patients at high risk are not selected.

Background: Continuous intravenous administration of lidocaine may decrease the duration of ileus and pain after abdominal surgery. Methods: Three databases (Medline, Embase and the Cochrane Controlled Trials Register) were searched to retrieve randomized controlled trials comparing continuous intravenous lidocaine infusion during and after abdominal surgery with placebo. Study design was scored using the Oxford Quality Score based on randomization, double‐blinding and follow‐up. Outcome measures were duration of ileus, length of hospital stay, postoperative pain, and incidence of nausea and vomiting. Results: Eight trials were selected. A total of 161 patients received intravenous lidocaine, with 159 controls. Intravenous lidocaine administration decreased the duration of ileus (weighted mean difference (WMD) − 8·36 h; P < 0·001), length of hospital stay (WMD − 0·84 days; P = 0·002), postoperative pain intensity at 24 h after operation on a 0–100‐mm visual analogue scale (WMD − 5·93 mm; P = 0·002), and the incidence of nausea and vomiting (odds ratio 0·39; P = 0·006). Conclusion: Continuous intravenous administration of lidocaine during and after abdominal surgery improves patient rehabilitation and shortens hospital stay. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly combined with intravenous morphine patient-controlled analgesia to relieve postoperative pain. NSAIDs have a documented 30-50% sparing effect on morphine consumption. However, most of the studies have not demonstrated a decrease in morphine adverse effects. A meta-analysis of randomized controlled trials was performed to evaluate the risk of morphine adverse effects in patients treated with NSAIDs. Twenty-two prospective, randomized, double-blind studies including 2,307 patients were selected. NSAIDs decreased significantly postoperative nausea and vomiting by 30%, nausea alone by 12%, vomiting alone by 32% and sedation by 29%. A regression analysis yielded findings indicating that morphine consumption was positively correlated with the incidence of nausea and vomiting. Pruritus, urinary retention, and respiratory depression were not significantly decreased by NSAIDs.