BACKGROUND: Side effects of opioids used for the treatment of acute pain frequently limit their analgesic quality. Many studies have compared opioid side effects in patient-controlled analgesia (PCA), but it remains unclear whether there are specific side effect profiles that can be exploited when choosing an opioid for a patient. In this review, we wanted to determine the risk ratios (RRs) for the most common side effects when using different opioids for intravenous PCA in equianalgesic doses and rank the substances accordingly. METHODS: A search of MEDLINE, EMBASE, the Cochrane Library (CENTRAL), and Web of Science identified 63 randomized controlled trials comparing opioids under equianalgesic conditions. Inclusion criteria were comparable pain stimulus between groups, equal coanalgesic treatment, and comparable resulting pain scores. Quality of studies was assessed using the Cochrane risk of bias tool with 6 items. Frequentistic network meta-analysis was conducted with morphine as the comparator. This method not only summarizes all estimated effects from direct comparisons of different interventions but also allows for indirect comparisons between interventions that can be linked via the common comparator, in which case the indirect evidence can be used to enhance the precision of the direct comparisons. Primary end points of this study were RRs for nausea and vomiting, pruritus, and events of sedation, as well as mean differences for scores of sedation. Events of respiratory depression were counted. Secondary end point was patient satisfaction (mean difference). The study protocol was registered at PROSPERO (CRD42017062355). RESULTS: Sixteen opioid interventions were compared in the largest network (nausea and vomiting outcome) and 7 opioid interventions in the smallest network (sedation events outcome). Most interventions did not differ from morphine on the primary outcomes (side effects), with some exceptions. Buprenorphine had a significantly higher RR of nausea and vomiting, whereas fentanyl had a lower RR of nausea and vomiting. Nalbuphine, butorphanol, methadone, and pethidine/meperidine had a lower risk of pruritus. Respiratory depression was rare (22 of 2452 patients). Pethidine/meperidine, fentanyl, and oxymorphone caused significantly lower sedation scores. Tramadol caused significantly lower satisfaction scores, whereas oxycodone, alfentanil, remifentanil, fentanyl, and pethidine/meperidine caused significantly higher satisfaction scores. CONCLUSIONS: The opiate chosen for treatment most likely has little effect on the incidence of pruritus and nausea/vomiting, although considerable differences exist in terms of better and worse opioids in the presented rankings. Larger differences between drugs were observed with regard to sedation and patient satisfaction, and choosing the appropriate opioid may help to improve PCA in this regard.

Background: Double-lumen tube (DLT) intubation is necessary for thoracic surgery and other operations with the need for lung separation. However, DLT insertion is complex and might result in airway trauma. A new videolaryngoscopy (GVL) with a thin blade might improve the intubation time and reduce complexity as well as iatrogenic airway complications compared to conventional direct laryngoscopy (DL) for DLT intubation. Methods: A randomised, controlled trial was conducted in 70 patients undergoing elective thoracic surgery using DLT for lung separation. Primary endpoint was time to successful intubation. The secondary endpoints of this study were number of intubation attempts, the assessment of difficulty, any complications during DLT intubation and the incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms. Results: 65 patients were included (DL group [n = 31], GVL group [n = 34]). Median intubation time (25th-75th percentiles) in GVL group was 93 s (63-160) versus 74 (58-94) in DL group [p = 0.044]. GVL resulted in significantly improved visualisation of the larynx (Cormack and Lehane grade of 1 in GVL group was 97% vs. 74% in DL Group [p = 0.008]). Endoscopic examinations revealed significant differences in GVL group compared to DL group showing less red-blooded vocal cord [p = 0.004], vocal cord haematoma [p = 0.022] and vocal cord haemorrhage [p = 0.002]. No significant differences regarding the postoperative subjective symptoms of airway were found. Conclusions: Videolaryngoscopy using the GlideScope®-Titanium shortly prolongs DLT intubation duration compared to direct laryngoscopy but improves the view. Objective intubation trauma but not subjective complaints are reduced.

Background:We investigated the impact of videolaryngoscopy for double-lumen tube (DLT) intubation in thoracic anaesthesia with videolaryngoscopy (GVL) using a thin GlideScope®-Titanium single use blade.Methods:A clinical, prospective, randomised, controlled trial was conducted with a total of 70 patients undergoing elective thoracic surgery and need for a DLT intubation. Finally, 65 patients were analysed (DL group [n = 31] vs. GVL group [n = 34]). Endpoints were time to intubate, subjective symptoms and objective trauma of the oropharynx and supraglottic space. Results:Mean intubation time in GVL group was 178 seconds ± 279 versus 84 seconds ± 62 in DL group [p = 0.044]. Videolaryngoscopy resulted in significantly improved visualisation of the larynx compared with Direct Laryngoscopy (DL). Cormack and Lehane (CL) grade of 1 was more frequent in GVL group (97%) than in DL Group (74%) [p = 0.008]. In analysis of the postoperatively completed questionnaires, no significant differences regarding the subjective symptoms could be determined. Objectifiable endoscopic examinations revealed significant differences in GVL group compared to DL group showing less hypopharyngeal haematoma [p = 0.048], red-blooded vocal cord [p = 0.01], vocal cord haematoma [p = 0.027] and vocal cord haemorrhage [p = 0.03]. Conclusions:Videolaryngoscopy prolongs DLT intubation duration; on the other hand, it allows a better view of the glottis and reduces postoperative trauma. Due to the better view, there is objectively less intubation trauma. The different objective intubation traumata did not seem to affect subjective symptoms of the patients after a DLT intubation.