Meta-analysis of randomized controlled trials on the efficacy and safety of ondansetron in preventing postanesthesia shivering Min Li, Xiaolan Hu, Yuan.

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Meta-analysis of randomized controlled trials on the efficacy and safety of ondansetron in preventing postanesthesia shivering Min Li, Xiaolan Hu, Yuan Tan, Baoping Yang, Kun Li, Zhenyu Tang International Journal of Surgery Volume 35, Pages 34-43 (November 2016) DOI: 10.1016/j.ijsu.2016.09.009 Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions

Fig. 1 Flow chart of systematic search for RCT. RCT: randomized controlled trials. International Journal of Surgery 2016 35, 34-43DOI: (10.1016/j.ijsu.2016.09.009) Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions

Fig. 2 Forest plot for the incidence of PAS in patients randomized to ondansetron versus placebo. CI = confidence interval, M-H = Mantel-Haenszel, PAS = postanesthesia shivering. International Journal of Surgery 2016 35, 34-43DOI: (10.1016/j.ijsu.2016.09.009) Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions

Fig. 3 Trial sequential analysis of 11 trials comparing ondansetron with placebo for PAS. Trial sequential analysis of 11 trials illustrating that the cumulative Z-curve crossed both the conventional boundary for benefit and the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence and suggesting further trials are not required. A diversity adjusted required information size of 2328 patients was calculated using α = 0.05 (two sided), β = 0.20 (power 80%), an anticipated relative risk reduction of 25%, and an event proportion of 43.8% in the control arm. X-axis: the number of patients randomized; Y-axis: the cumulative Z-Score; Horizontal brown dotted lines: conventional boundaries (upper for benefit, Z-score = 1.96, lower for harm, Z-score = −1.96, two-sided P = 0.05); Sloping red full lines with black circle fill icons: trial sequential monitoring boundaries calculated accordingly; Blue full line with black square fill icons: Z-curve; Vertical red full line: required information size calculated accordingly; Upper square area: area of harm; Lower square area: area of benefit. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) International Journal of Surgery 2016 35, 34-43DOI: (10.1016/j.ijsu.2016.09.009) Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions

Fig. 4 Forest plot for the incidence of PAS in patients randomized to ondansetron versus meperidine. CI = confidence interval, M-H = Mantel-Haenszel, PAS = postanesthesia shivering. International Journal of Surgery 2016 35, 34-43DOI: (10.1016/j.ijsu.2016.09.009) Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions

Fig. 5 Trial sequential analysis of 5 trials comparing ondansetron with meperidine for PAS. Trial sequential analysis of 5 trials illustrating that the sequential monitoring boundary has not been crossed, establishing sufficient and conclusive evidence and suggesting further trials are required. A diversity adjusted required information size of 579 patients was calculated using α = 0.05 (two sided), β = 0.20 (power 80%), an anticipated relative risk reduction of 40%, and an event proportion of 31.2% in the control arm. X-axis: the number of patients randomized; Y-axis: the cumulative Z-Score; Horizontal brown dotted lines: conventional boundaries (upper for benefit, Z-score = 1.96, lower for harm, Z-score = −1.96, two-sided P = 0.05); Sloping red full lines with black circle fill icons: trial sequential monitoring boundaries calculated accordingly; Blue full line with black square fill icons: Z-curve; Vertical red full line: required information size calculated accordingly; Upper square area: area of harm; Lower square area: area of benefit. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) International Journal of Surgery 2016 35, 34-43DOI: (10.1016/j.ijsu.2016.09.009) Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions

Fig. 6 Funnel plot for the incidence of PAS in patients randomized to ondansetron versus placebo. SE = standard error, RR = relative risk, PAS = postanesthesia shivering. International Journal of Surgery 2016 35, 34-43DOI: (10.1016/j.ijsu.2016.09.009) Copyright © 2016 IJS Publishing Group Ltd Terms and Conditions