Background: Emergence coughing can harm the patient following completion of surgery, but it is unclear which medication is most effective at reducing this event. We conducted a systematic review and network meta-analysis of RCTs to determine the medications' relative efficacies on decreasing moderate to severe emergence coughing after general anaesthesia. Medications studied were lidocaine (i.v., intracuff, topical, or tracheal application), dexmedetomidine, remifentanil, and fentanyl. Methods: We searched eight different medical literature databases, conference abstracts, and article references. After screening, included citations were evaluated for bias and had their data extracted. Pooled odds ratios and 95% confidence intervals for each treatment comparison were calculated. A surface under the cumulative ranking curve analysis (SUCRA) determined the relative rank of each intervention to decrease moderate to severe emergence coughing. Subgroup analyses included severe coughing only, extubation times, type of maintenance anaesthetic, and dosages. Results: The network meta-analysis included 70 studies and 5286 patients. All study medications had favourable odds in reducing moderate and severe peri-extubation coughing compared with either no medication or placebo. No single medication was favoured over another. Dexmedetomidine had the highest SUCRA rank, followed in order by remifentanil, fentanyl, and lidocaine via intracuff, tracheal/topical, and i.v. routes. Remifentanil was ranked highest for decreasing severe coughing only. Intracuff lidocaine had higher odds of prolonging extubation times compared with placebo, dexmedetomidine, fentanyl, and remifentanil. Conclusion: All study medications were better than placebo or no medication in reducing moderate to severe emergence cough, with dexmedetomidine ranked the most effective. Systematic review registration: PROSPERO registration number: CRD42018102870. Editor's key pointsThe authors examined the literature to establish the effectiveness of various drugs in reducing coughing around the time of tracheal extubation.Dexmedetomidine, remifentanil, fentanyl, and lidocaine all reduced the incidence of moderate to severe emergence coughing. Dexmedetomidine appeared to be the most effective medication for decreasing the frequency of moderate to severe emergence cough.

BackgroundEmergence coughing and bucking, secondary to endotracheal tube stimulation of the tracheal mucosa, frequently occurs after the general anesthetic recedes. Besides general unpleasantness, coughing has important physiological sequelae that may be detrimental to the postoperative patient. Multiple pharmacological strategies have been published, but prior systematic reviews on this topic have neither been comprehensive enough in their literature or medication search, nor provided us the answer regarding what the best pharmacological method is to prevent or minimize peri-extubation coughing. Our systematic review and network meta-analysis’ primary objective is to determine the relative efficacies of different pharmacological methods on decreasing coughing (none to mild compared to moderate to severe, as defined by the modified Minogue scale) during emergence after a general anesthetic with endotracheal intubation in adult elective surgeries. Medications of interest are lidocaine or lignocaine (intravenous (IV), intracuff alkalinized, intracuff non-alkalinized, topical, endotracheal application), dexmedetomidine IV, remifentanil IV, and fentanyl IV. These medications were selected based on a preliminary review of the literature.MethodsUsing a predefined search strategy, we will search MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, and the Cochrane Methodology Register, with no date or language restrictions. Gray literature search will encompass conference abstracts, Web of Science, and references from publications selected for full-text review. Two reviewers will independently screen the retrieved literature using predetermined inclusion criteria, process publications selected for full-text review, extract data from publications chosen for study inclusion, and evaluate for bias using the Cochrane risk of bias assessment. Risk ratios and 95% confidence intervals will be calculated for each study, and a surface under the cumulative ranking curve will determine the relative rank of each intervention in its ability to prevent coughing on emergence.DiscussionThe proposed systematic review and network meta-analysis will not only provide a more thorough review of common medications used to decrease emergence coughing, but also inform clinicians which of these pharmacological strategies is the best approach.Systematic review registrationPROSPERO CRD42018102870

Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.

Objective To evaluate practices among first-trimester surgical abortion facilities and providers in Canada in 2012 and examine the characteristics of the surgical abortion work force.Design Self-administered paper or electronic survey adapted from a survey previously fielded in the United States. Setting Canada.Participants Facility administrators and physicians. Main outcomes measuresDescriptive statistics on reported first-trimester surgical abortion practice and provider demographic characteristics. ResultsEighty-three percent of identified facilities (78 of 94) and 178 physicians responded. Of the respondents, 99% of facilities and 96% of physicians provided first-trimester surgical abortions. Responding facilities provided 68,154 first-trimester surgical abortions in 2012. This represented 96% of their reported total (combined medical and surgical) first-trimester abortions. More than half (55%) of responding facilities were community based, while 45% were hospital affiliated. Most physician providers were female (68%) and were family doctors (59%). Preoperatively, 96% of physicians routinely used ultrasound and 89% gave perioperative antibiotics. Almost half (48%) used manual vacuum aspiration, but less than 35% did so beyond 9 weeks after the last menstrual period. At most facilities, most procedures were performed under combined local anesthesia and intravenous sedation (73%); only 7% indicated deep sedation or general anesthesia were used exclusively. Postoperatively, 81% of physicians performed immediate tissue examination and 96% offered postabortion contraception on the same day as the abortion. Other assessed outcomes included medication regimens and cervical preparation, with a high degree of consistency among facilities and physicians. ConclusionFirst-trimester surgical abortion providers are mostly family physicians and most are female. Practices across Canada were mostly uniform and followed evidence-based guidelines. Uptake of the most recent Canadian practice guidelines may help further standardize patient care and improve routine perioperative antibiotic use and immediate tissue examination. Editor's key points} This survey of Canadian facilities offering first-trimester surgical abortions and physicians providing this service in 2012 is the most comprehensive account to date of the 2012 work force and their clinical practice in Canada.} Family physicians represented more than half of survey respondents, and more than 70% of first-trimester surgical abortions were provided in community-based clinics.} These data indicate first-trimester abortion services across Canada were performed in alignment with practice guidelines in important aspects such as ultrasound use, cervical preparation, use of anesthesia, and postoperative care.} These data will be helpful in interpreting abortion practice techniques and work force changes that might have occurred since mifepristone became available in Canada.