Carry out a meta-analysis on high-dose versus low-dose opioid use during anesthesia for cardiac surgery in adults.
The article that I chose to review is a meta-analysis on high-dose versus low-dose opioid use during anesthesia for cardiac surgery in adults. According to Rong et al. (2019), high-dose opioid administration has been the mainstay during cardiac anesthesia for decades because of its ability to preserve hemodynamic stability and diminish hormonal and metabolic responses to surgical stress. However, high-dose opioid administration can potentially result in prolonged ventilation for patients postoperatively (Rong et al., 2019). In the more recent years, synthetic opioids such as fentanyl and remifentanil have replaced previously used opioid medications such as morphine during cardiac surgery due to their shorter duration of action and improved side effects (Rong et al., 2019). Furthermore, recent evidence indicates that increased opioid use during cardiac surgery may lead to an increase in post-operative pain medication requirements for patients during the immediate recovery phase as well as long-term (Rong et al., 2019). Therefore, this analysis specifically focuses on comparing in-hospital outcomes of high-dose and low-dose opioid anesthesia for adults undergoing cardiac procedures.
I think that this article demonstrates high quality research. The research was designed as a systematic review and meta-analysis of randomized controlled trials. This type of design categorizes the research as level 1a evidence according to the Oxford Centre for Evidence-Based Medicine (2009). The design of this research is appropriate and beneficial because previously no meta-analysis had been completed comparing high dose and low dose opioid administration specifically during anesthesia for patients undergoing cardiac procedures (Rong et al., 2019). The methods of the research were in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as well as the Meta-Analysis of Observational studies in Epidemiology (MOOSE) guidelines (Rong et al., 2019). Likewise, this analysis used multiple appropriate statistical analysis approaches to ensure accuracy of results. A random effect model was used to compare outcomes of interest within the studies and the standard mean difference was estimated (Rong et al., 2019). Additionally, the I2 and Tau2 tests were used to determine inter-study heterogeneity and a leave-one-out sensitivity analysis was performed if significant heterogeneity was detected (I2 > 75%) (Rong et al., 2019). Importantly, the authors did perform a meta-regression analysis to ensure there was no effect from age, gender, or type of opioid used between the studies. This meta-analysis utilized a large patient sample by including eighteen studies for a total of 1400 patients undergoing cardiac procedures (Rong et al., 2019). Of the eighteen studies, seventeen were randomized controlled trials and one was an observational study (Rong et al., 2019). The article also provides a chart that identifies all eighteen studies included with details on procedure type, medication use, and patient samples. By using a large sample size, the meta-analysis results have increased statistical power.
The results of this meta-analysis found similar safety and efficacy between low-dose and high-dose opioid anesthesia for patients undergoing cardiac surgery. Initially, no difference was found in postoperative ventilation time between the two groups, however, after one study was excluded based on significant heterogeneity, there was a trend to shorter ventilation time in the group using low-dose opioid anesthesia (P=0.05) (Rong et al., 2019). Furthermore, the analysis found no significant differences in secondary outcomes between the groups related to perioperative hypotension, vasopressor requirements, perioperative myocardial infarction, or perioperative strokes (Rong et al., 2019).
This meta-analysis is applicable to clinical practice as it suggests that low-dose opioid anesthesia can be just as effective as high-dose opioid anesthesia for patients undergoing cardiac surgery. By using lower doses of opioid medications, patients may experience fewer of the postoperative complications associated with opioid use such as nausea and vomiting, delayed emergence, delayed bowel function return, and increased length of stay (Rong et al., 2019). By being educated on these findings, providers can adjust their practices to reduce cost and potentially improve recovery times and overall outcomes for patients undergoing cardiac surgical procedures.
References
Rong, L. Q., Kamel, M. K., Rahouma, M., Naik, A., Mehta, K., Abouarab, A. A., … Gaudino, M. (2019). High-dose versus low-dose opioid anesthesia in adult cardiac surgery: A meta-analysis. Journal of Clinical Anesthesia, 57, 57–62. https://doi.org/10.1016/j.jclinane.2019.03.009
University of Oxford. (2020, October 1). Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009.
