Cochrane Evidence Aid: resources for earthquakes
The Cochrane Reviews in this Evidence Aid Special Collection are freely available; please click on the links below to access the reviews.
A selection of Cochrane Reviews and their conclusions for healthcare topics that have been identified as important in the aftermath of a major earthquake. These are signposts to systematic reviews that might be helpful to decision-makers.
Topics covered: diarrhoea prevention and treatment; wound management; fracture management; physical trauma (excluding fractures); anaesthesia; renal; tuberculosis
Translations: a Japanese translation is maintained by Kyoto University School of Public Health. All countries in Latin America and the Caribbean can access The Cochrane Library in English, Spanish or Portuguese via the Virtual Health Library BIREME interface.
The World Health Organization (WHO) has published guidelines for drug donations following disasters (in English and Russian) and details an interagency emergency health kit (in English, French, and Spanish).
Diarrhoea prevention and treatment
See Cochrane Evidence Aid: resources for flooding and poor water sanitation
WOUND MANAGEMENT
There is no evidence that using tap water to cleanse acute wounds in adults increases infection, and there is some evidence that it reduces infection. However, there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.
Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use. The objective of this review was to assess the effects of water compared with other solutions for wound cleansing. [Resumen en español]
Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention
Evidence for the effectiveness of negative pressure wound therapy (NPWT) for complete healing of acute wounds remains unclear, as does the effect of NPWT on time to complete healing. Rates of graft loss may lower when NPWT is used, but hospital-based products are as effective in this area as commercial applications. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established.
Indications for the use of NPWT are broadening, with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. This review assessed the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention.
Aloe vera for treating acute and chronic wounds
There is currently an absence of high-quality clinical trial evidence to support the use of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds.
Aloe vera is a cactus-like perennial succulent belonging to the Liliaceae family, commonly grown in tropical climates. Animal studies have suggested that Aloe vera may help accelerate the wound healing process. There is currently insufficient clinical trial evidence available regarding the effects of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds. This is primarily due to the lack of high-quality trials with adequate methodology.
FRACTURE MANAGEMENT
Interventions for treating wrist fractures in children
Limited evidence supports the use of removable splintage for buckle fractures and challenges the traditional use of above-elbow casts after reduction of displaced fractures. Although percutaneous wire fixation prevents redisplacement, the effects on longer term outcomes including function are not established.
This review aimed to evaluate removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle) fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children. [Resumen en español]
Bone grafts and bone substitutes for treating distal radial fractures in adults
Bone scaffolding may improve anatomical outcome compared with plaster cast alone but there is insufficient evidence to conclude on functional outcome and safety; or for other comparisons.
Surgical treatment of fractures of the distal radius can involve the implantation of bone scaffolding materials (bone grafts and substitutes) into bony defects that frequently arise after fracture reduction. This review assesses the evidence from randomised controlled trials evaluating the implanting of bone scaffolding materials for treating distal radial fractures in adults. [Resumen en español]
Pre-operative traction for hip fractures in adults
From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Given the continued lack of evidence for the use of pre-operative traction, the onus should now be on clinicians who persist in using pre-operative traction to either stop using it or to use it only in the context of a well-designed randomised controlled trial.
Following a hip fracture, traction may be applied to the injured limb before surgery. This review evaluates the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.
Percutaneous pinning for treating distal radial fractures in adults
There is some evidence to support the use of percutaneous pinning, its precise role and methods are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.
A key method of surgical fixation for distal radial fractures is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture. This review evaluates the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults. [Resumen en español]
Interventions for treating proximal humeral fractures in adults
Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long-term outcomes. There is insufficient evidence to establish what is the best method of surgical treatment or when to start mobilisation after either surgical fixation or hemiarthroplasty.
Shoulder fractures are common in older people. The management (including surgery) of fractures of the proximal humerus fractures varies widely. This review assessed the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.
Interventions for isolated diaphyseal fractures of the ulna in adults
Overall, there is insufficient evidence to determine which method of treatment (randomised trials assessed four treatment options) is the most appropriate for the treatment of isolated fractures of the ulnar shaft in adults. However, there is weak evidence (all trials were methodologically flawed and potentially biased) that in people with minimally displaced isolated fracture of the ulna, cast immobilisation of the elbow may offer no short-term advantage in respect of pain relief or fracture union, and may be associated with longer delay in return to work, when compared with the use of a cast or brace that immobilises only the forearm. This summary does not imply that practitioners should use cast immobilisation of the elbow.
Isolated fractures of the shaft of the ulna are often sustained when the forearm is raised to shield against a blow. This review assesses the effects of various forms of treatment for isolated fractures of the ulnar shaft in adults.
External fixation versus conservative treatment for distal radial fractures in adults
There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.
Fracture of the distal radius ('broken wrist') can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation. This review evaluates the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults. [Resumen en español]
Conservative versus operative treatment for hip fractures in adults
Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common.
Until operative treatment involving the use of various implants was introduced in the 1950s, hip fractures were managed using conservative methods based on traction and bed rest. This review compares conservative with operative treatment for fractures of the proximal femur (hip) in adults. [Resumen en español]
Conservative interventions for treating distal radial fractures in adults
There remains insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults. Therefore, at present, practitioners applying conservative management should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Patient preferences and circumstances, and the risk of complications should also be considered.
Fracture of the distal radius is a common clinical problem particularly in elderly white women with osteoporosis. This review aims to determine the most appropriate conservative treatment for fractures of the distal radius in adults [Resumen en español]
Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures
Antibiotic prophylaxis for closed fracture surgery is an effective intervention. Single dose intravenous prophylaxis is effective if the agent used provides tissue levels exceeding the minimum inhibitory concentration over a 12-hour period. If the antibiotic chosen has a short half-life which may not allow minimum inhibitory concentrations to be exceeded throughout the period from incision to wound closure, the use of multiple dose regimens using a 12-hour dosage schedule is a satisfactory alternative.
Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. The administration of antibiotics may reduce the frequency of infections. The aim of this review is to determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections.
Intramedullary nailing for tibial shaft fractures in adults
There are a variety of intramedullary nails and associated techniques available and widely used, but it is not clear which is the best method since there is insufficient evidence to draw definitive conclusions.
Fractures of the tibial shaft (breaks in the bone situated in the long middle section of the tibia or shin bone) are mostly caused by high-energy trauma. These fractures are major injuries and can result in severe permanent disability. Other serious complications include infection and compartment syndrome, where a dangerous build-up of pressure from internal bleeding restricts or cuts off the blood supply to the surrounding tissues. Intramedullary nailing is commonly used for treating these types of fractures. This review assesses the effects (benefits and harms) of different methods and types of intramedullary nailing for treating tibial shaft fractures in adults.
Surgical versus non-surgical interventions for treating humeral shaft fractures in adults
There is no evidence available from randomised controlled trials to ascertain whether surgical intervention of humeral shaft fractures gives a better or worse outcome than no surgery.
Fractures of the shaft of the humerus account for 1% to 3% of all fractures in adults. The management of these fractures, including surgical and non-surgical interventions, varies widely. This review assesses and compare the effects of surgical versus non-surgical intervention for non-pathological fractures of the humeral shaft in adults.
Ultrasound and shockwave therapy for acute fractures in adults
This review highlights the limitations of the available evidence on therapeutic ultrasound for acute fractures in adults. Currently, the best assessment of the clinical effectiveness of low intensity ultrasound (LIPUS) for complete or stress fractures in adults does not support the routine use of this intervention in clinical practice.
The morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a patient's recovery after a fracture. This review assesses the effects of LIPUS, high-intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults. The studies included in the review generally assessed upper limb fractures (the tibia being the most investigated bone).
Surgical versus conservative interventions for treating ankle fractures in adults
There is insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults.
Ankle fractures usually affect young men and older women and the question of whether surgery or conservative treatment should be used for ankle fractures remains controversial. This review assessed the effects of surgical versus conservative interventions for treating ankle fractures in adults.
Surgical versus conservative interventions for displaced intra-articular calcaneal fractures
There is insufficient high quality evidence to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal (heel bone) fracture.
Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures, and are mostly caused by a fall from a height, and common in younger adults. Treatment can be surgical or non-surgical. However, there is clinical uncertainty over optimal management. This review assessed the effects of surgical compared with conservative treatment of displaced intra-articular calcaneal fractures in adults.
Surgical interventions for treating distal humeral fractures in adults
There is insufficient evidence to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures.
Distal humeral fractures in adults are relatively uncommon injuries that require surgical intervention in most cases. There is a lack of consensus regarding the best management of distal humeral fractures in adults, including the role of conservative treatment, appropriate surgical approach, fixation strategies, the role of total elbow arthroplasty and handling of nerves such as the ulnar nerve. This review assessed the effects (benefits and harms) of surgical interventions for distal humeral fractures in adults.
Early mobilisation for elbow fractures in adults
There is a lack of evidence to inform on the timing of mobilisation, and specifically on the use of early mobilisation, after non-surgical or surgical treatment for adults with elbow fractures.
Falling on the outstretched arm can result in an elbow fracture. Loss of elbow function is a common problem with these fractures and can have major implications for functional capabilities. This review assessed the effects (benefits and harms) of early mobilisation versus delayed mobilisation of the elbow after elbow fractures in adults.
Condylocephalic nails versus extramedullary implants for extracapsular hip fractures
The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate. Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, reoperation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw.
Two types of implants used for the surgical fixation of extracapsular hip fractures are condylocephalic nails (intramedullary nails that are inserted up through the femoral canal from above the knee and across the fracture) and extramedullary implants. This review assessed condylocephalic nails (e.g. Ender and Harris nails) compared to extramedullary implants (e.g. fixed nail plates and sliding hip screws) for the treatment of extracapsular (trochanteric and subtrochanteric) hip fracture in adults.
Perioperative fluid volume optimization following proximal femoral fracture (hip fracture)
For patients with Proximal Femoral Fracture (PFF), invasive methods of fluid optimization during surgery may shorten hospital stay, but their effects on other important, patient-centred, longer-term outcomes are uncertain. Adverse effects on fatality cannot be excluded. Other fluid optimization techniques have not been evaluated.
Proximal Femoral Fracture (PFF) or 'hip fracture' is a frequent injury, and adverse outcomes are common. Several factors suggest the importance of developing techniques to optimize intravascular fluid volume. These may include protocols that enhance the efficacy of clinicians' assessments, invasive techniques such as oesophageal Doppler or central venous pressure monitoring, or advanced non-invasive techniques such as plethysmographic pulse volume determination. This review aimed to determine the optimal method of fluid volume optimization for adult patients undergoing surgical repair of PFF. Comparisons of fluid types, of blood transfusion strategies or of pharmacological interventions are not considered in this review.
Intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There is not enough evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.
Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. This review compared compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults.
Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults
Sliding Hip Screws (SHS) appear to be preferable for fixation of hip fractures in adults, given the markedly increased fixation failure rate of fixed nail plates.
Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. This review compared different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults.
Internal fixation implants for intracapsular hip fractures in adults
There were no major differences in patient survival or complications related to the operation, using different implants for internal fixation of intracapsular hip fractures, from the available evidence within randomised trials.
Numerous different implants with screws, pins and side plates have been used for the internal fixation of intracapsular (close to the hip joint) hip fractures. Implants are used to stabilise the bone during healing thereby reducing the chance of the bones slipping out of line. They consist of either screws or pins and may have an additional side plate attached, which is fixed to the bone. This review aimed to determine which implant is superior for the internal fixation of intracapsular proximal femoral fractures.
PHYSICAL TRAUMA (EXCLUDING FRACTURES)
Colloids versus crystalloids for fluid resuscitation in critically ill patients
There is no evidence from randomised trials that resuscitation with colloids reduces the risk of death, compared with resuscitation with crystalloids, in patients with trauma or burns, or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of randomised trials.
Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. This review assesses the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. [Resumen en español]
Antifibrinolytic drugs for acute traumatic injury
Tranexamic acid safely reduces mortality in bleeding trauma patients without increasing the risk of adverse events. Tranexamic acid should be given as early as possible and within three hours of injury, as treatment later than this is unlikely to be effective.
Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma. This review quantified the effects of antifibrinolytic drugs on mortality, vascular occlusive events, surgical intervention and receipt of blood transfusion after acute traumatic injury. [Listen to podcast]
Steroids for acute spinal cord injury
Methylprednisolone has been shown to enhance sustained neurologic recovery in a phase III randomised trial; findings replicated in a second trial. Therapy must be started within 8 hours of injury using an initial bolus of 30 mg/kg by IV for 15 minutes followed 45 minutes later by a continuous infusion of 5.4 mg/kg/hour for 24 hours. Further improvement in motor function recovery has been shown to occur when the maintenance therapy is extended for 48 hours. This is particularly evident when the initial bolus dose could only be administered 3 to 8 hours after injury.
Steroid treatment in the early hours after acute spinal cord injury (SCI) is aimed at reducing the extent of permanent paralysis during the rest of the patient's life. This review assessed randomised trials of steroids for human acute SCI.
Gangliosides for acute spinal cord injury
The evidence available does not support the use of ganglioside treatment to reduce the death rate in spinal cord injury (SCI) patients. No evidence has yet emerged that ganglioside treatment improves recovery or quality of life in survivors.
SCI results in loss of feeling and movement. Care for people with SCI has improved, leading to an increase in survival rates. Attempts to improve patients' feeling and movement have involved the use of a wide range of treatments. Laboratory studies have suggested that gangliosides may have protective effects on nerves and even help them to re-grow. Clinical trials have taken place using gangliosides (usually GM1 ganglioside) for a number of neurological conditions. The aim of this review is to quantify the evidence for the effectiveness and safety of gangliosides when used to treat acute SCI.
Mannitol for acute traumatic brain injury
Mannitol therapy for raised intracranial pressure (ICP) may have a beneficial effect on mortality when compared with pentobarbital treatment, but it may have a detrimental effect on mortality compared with hypertonic saline. ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators.
Mannitol is sometimes effective in reversing acute brain swelling, but its effectiveness in the ongoing management of severe head injury remains unclear. There is evidence that, in prolonged dosage, mannitol may pass from the blood into the brain, where it might cause increased ICP. This review assesses the effects of different mannitol therapy regimens, of mannitol compared with other ICP-lowering agents, and to quantify the effectiveness of mannitol administration given at other stages following acute traumatic brain injury. [Resumen en español]
Hypothermia for traumatic head injury
There is no evidence that hypothermia is beneficial in the treatment of head injury. Hypothermia should not be used except in the context of a high-quality randomised controlled trial with good allocation concealment.
Hypothermia has been used in the treatment of head injury for many years. This review assesses the effect of mild hypothermia for traumatic head injury on mortality and long-term functional outcome complications. [Resumen en español]
Corticosteroids for acute traumatic brain injury
The increase in mortality with steroids in one trial suggest that steroids should no longer be routinely used in people with traumatic head injury (TBI).
TBI is a leading cause of death and disability. Corticosteroids have been widely used in treating people with TBI. This review quantifies the effectiveness and safety of corticosteroids in the treatment of acute TBI.
Psychological treatment for anxiety in people with traumatic brain injury
There is some evidence for the effectiveness of cognitive behavioural therapy (CBT) for treating acute stress disorder following mild traumatic brain injury (TBI) and of CBT combined with neurorehabilitation for targeting general anxiety symptomatology in people with mild-to-moderate TBI.
Psychological treatments are commonly used in the management of anxiety. Certain types of psychological treatments are well suited to needs of people with TBI. This review assesses the effects of psychological treatments for anxiety in people with TBI. [Resumen en español]
Interventions for treating acute elbow dislocations in adults
Overall, there is a lack of evidence to inform clinical decisions for treating acute simple elbow dislocations in adults. Nonetheless, it should be noted that, while weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment did not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improved long-term function.
Dislocation of the elbow joint is a relatively uncommon injury and this review assessed the effects of various forms of treatment for acute simple elbow dislocations in adults.
Surgical versus non-surgical treatment for acute anterior shoulder dislocation
Limited evidence supports primary surgery for young people engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine which treatment is better for other patient groups.
Acute anterior shoulder dislocation occurs where the top end of the humerus (the upper arm bone) is pushed out of the joint socket in a forward direction, usually as a result of an accident such as a fall and it is the commonest type of shoulder dislocation. Subsequently, the shoulder is less stable and more susceptible to redislocation, especially in active young adults. This review compared surgical versus non-surgical treatment for acute anterior dislocation of the shoulder.
Damage control surgery for abdominal trauma
Evidence that supports the efficacy of damage control surgery (DCS) with respect to traditional laparotomy in patients with major abdominal trauma is limited and its benefit cannot be established. Patients with major trauma are usually unstable and are at risk of complications including bleeding, acidosis, hypothermia, and coagulopathy.
Trauma is one of the leading causes of death in any age group. The 'lethal triad' of acidosis, hypothermia, and coagulopathy has been recognized as a significant cause of death in patients with traumatic injuries. In order to prevent the lethal triad two factors are essential, early control of bleeding and prevention of further heat loss. In patients with major abdominal trauma, DCS avoids extensive procedures on unstable patients, stabilizes potentially fatal problems at initial operation, and applies staged surgery after successful initial resuscitation. This review assessed the effects of DCS compared to traditional immediate definitive surgical treatment for patients with major abdominal trauma.
Helicopter emergency medical services for adults with major trauma
An accurate composite estimate of the benefit of helicopter emergency medical services (HEMS) could not be determined using the evidence identified in this review. The question of which elements of HEMS are most beneficial for patients has not been fully answered, and any HEMS-associated benefit could be the result of some combination of crew expertise, decreased prehospital time, and the fact that HEMS are an integral part of organized trauma systems in many developed countries. HEMS-associated benefits may include physician adjudicated launching criteria based on severity injury and mechanism, centrally coordinated launching algorithms with selected HEMS deployment, trauma volumes at receiving trauma centres, and the ability of the helicopter to transport patients in areas inaccessible by ground vehicles or prohibitively distant from trauma centres. This review stresses the importance of triage criteria since the benefits of HEMS may be greatest for patients with serious but potentially survivable injuries. Ideal dispatch criteria and triage guidelines to ensure the efficient use of helicopters remain elusive.
Although helicopter emergency medical services (HEMS) transport are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured patients derive the greatest benefit. This review assessed whether helicopter emergency medical services transport (HEMS) was associated with improved morbidity and mortality, compared to ground emergency medical services transport (GEMS), for adults with major trauma.
anaesthesia
Anaesthesia for hip fracture surgery in adults
There was insufficient evidence available from trials comparing regional versus general anaesthesia for surgical repair of hip fractures in adults to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.
The majority of people with hip fracture are elderly and are treated surgically, requiring anaesthesia. The most common types of anaesthesia are 'general' and 'spinal'. This review assessed different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults.
Anaesthesia for treating distal radial fracture in adults
There was insufficient evidence to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than intravenous regional anaesthesia (IVRA), and can compromise reduction.
Fracture of the distal radius (wrist) is a common clinical problem, particularly in women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment. This review asssessed the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults.
There is evidence that multiple injection techniques using nerve stimulation for axillary plexus block produce more effective anaesthesia than either double or single injection techniques. There is insufficient evidence for a significant difference in other outcomes, including safety.
Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. Successful blocking of the nerves produces a numb and limp arm that enables pain-free surgery. This review compared the relative effects of single, double or multiple injections for axillary block of the brachial plexus for distal upper limb surgery.
RENAL
Emergency interventions for hyperkalaemia
Nebulised or inhaled salbutamol, or IV insulin-and-glucose are the first-line therapies for the management of emergency hyperkalaemia that are best supported by the evidence. Their combination may be more effective than either alone, and should be considered when hyperkalaemia is severe. When arrhythmias are present, a wealth of anecdotal and animal data suggests that IV calcium is effective in treating arrhythmia.
Hyperkalaemia occurs in outpatients and in between 1% and 10% of hospitalised patients. When severe, consequences include arrhythmia and death. This review evaluates evidence from randomised trials informing the emergency management of hyperkalaemia. [Resumen en español]
Tidal versus other forms of peritoneal dialysis for acute kidney injury
There is insufficient evidence to determine whether tidal peritoneal dialysis is superior to any other mode of peritoneal dialysis for the treatment of patients with acute kidney injury.
Acute kidney injury is associated with substantial morbidity and mortality. Recent studies have shown that dialysis dose was a major factor associated with patient survival. Unresolved questions persist about which mode of peritoneal dialysis should be used for most patients with acute kidney injury. The one RCT identified by this review evaluated tidal peritoneal dialysis for the treatment of patients with acute kidney injury and was not designed to enable assessment of clinical outcome measures of efficacy.
Interventions for protecting renal function in the perioperative period
There is no reliable evidence to suggest that interventions during surgery can protect the kidneys from damage, including the use of dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors or hydration fluids.
Varying methods have been used to try to protect kidney function in patients undergoing surgery. These include the administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors and hydration fluids. This review assessed randomized controlled trials which employed different methods to protect renal function during the perioperative period.
Tuberculosis
Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults
Xpert used as an initial diagnostic test for TB detection and rifampicin resistance detection in patients suspected of having TB, MDR-TB, or HIV-associated TB is sensitive and specific. Xpert may also be valuable as an add-on test following microscopy for patients who have previously been found to be smear-negative. An Xpert result that is positive for rifampicin resistance should be carefully interpreted and take into consideration the risk of MDR-TB in a given patient and the expected prevalence of MDR-TB in a given setting.
Accurate and rapid detection of tuberculosis (TB) and drug resistance are critical for improving patient care and decreasing the spread of TB. Xpert® MTB/RIF assay (Xpert) is a rapid, automated test that can detect both TB and rifampicin resistance, within two hours after starting the test, with minimal hands-on technical time, but is more expensive than conventional sputum microscopy. This review assessed the diagnostic accuracy of Xpert for pulmonary TB (TB detection), both where Xpert was used as an initial test replacing microscopy, and where Xpert was used as an add-on test following a negative smear microscopy result. It also assessed the diagnostic accuracy of Xpert for rifampicin resistance detection where Xpert was used as the initial test, replacing conventional culture-based drug susceptibility testing. The assessment was made in the adult population suspected of having pulmonary TB or multidrug-resistant TB (MDR-TB), with or without HIV infection. Most studies were performed in high TB burden countries.
Image credit: Will and Deni Mcintyre/Science Photo Library
Date published: 10 March 2010; updated 21 December 2010, 25 October 2011, 9 December 2011, 20 December 2012, 1 February 2013 and14 Februay 2013. Last updated 21 May 2013 to add 2 new reviews.
Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org) for suggestions for additions or changes to this Special Collection or queries about the included Cochrane Reviews; and Evidence Aid (evidenceaid@cochrane.org) for information about this initiative.
