Eine faktorielle Studie von 6 Interventionen zur Vermeidung von �belkeit und Erbrechen nach Narkosen

Comparison of the antiemetic efficacy of a combination of midazolam with ramosetron and midazolam with palonosetron for postoperative nausea and vomiting prophylaxis in laparoscopic cholecystectomy

BACKGROUND

A multimodal therapeutic strategy for preventing postoperative nausea and vomiting (PONV) benefits moderate- and high-risk surgical patients. We compared the efficacy of a combination of midazolam and ramosetron and a combination of midazolam and palonosetron for PONV prophylaxis in patients scheduled for laparoscopic cholecystectomy.

METHODS

We enrolled 68 patients aged 20 to 65 years undergoing laparoscopic cholecystectomy. Patients were randomly allocated to the midazolam 0.05 mg/kg with ramosetron 0.3 mg (MR) or midazolam 0.05 mg/kg with palonosetron 0.075 mg (MP) groups. The incidence of PONV, severity of nausea, use of rescue antiemetics, and pain severity were evaluated at 2, 24, and 48 hours after surgery.

RESULTS

The incidence (38.2% vs 5.9%) and severity of postoperative nausea were significantly lower in the MP group at 2 hours after surgery (P < .05). There were no significant differences in the incidence of vomiting, use of rescue antiemetics, or pain severity between the 2 groups.

CONCLUSION

The combination of midazolam with palonosetron significantly decreased the incidence and severity of postoperative nausea compared with midazolam combined with ramosetron, especially in the early postoperative phase (0-2 hours) in patients undergoing laparoscopic cholecystectomy.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Effect of Dexmedetomidine Compared to Remifentanil During Bariatric Surgery on Postoperative Nausea and Vomiting: a Retrospective Study

PURPOSE

Postoperative nausea and vomiting (PONV) occurs frequently after bariatric surgery and is a major cause of adverse outcomes. This retrospective study investigated whether opioid-restricted total intravenous anesthesia using dexmedetomidine as a substitute for remifentanil can reduce PONV in bariatric surgery.

MATERIALS AND METHODS

The electronic medical records of adult patients who underwent laparoscopic bariatric surgery between January and December 2019 were reviewed. The patients were divided into two groups according to the agents used for anesthesia: Group D, propofol and dexmedetomidine; Group R, propofol and remifentanil.

RESULTS

A total of 134 patients were included in the analyses. The frequency of postoperative nausea was significantly lower in Group D than that in Group R until 2 h after discharge from the postanesthesia care unit (PACU) (P = 0.005 in the PACU, P = 0.010 at 2 h after PACU discharge) but failed to significantly reduce the overall high incidence rates of 60.5% and 65.5%, respectively (P = 0.592). Postoperative pain score was significantly lower in Group D until 6 h after PACU discharge. The rates of rescue antiemetic and analgesic agent administration in the PACU were significantly lower in Group D than those in Group R.

CONCLUSION

Opioid-restricted total intravenous anesthesia using dexmedetomidine reduces postoperative nausea, pain score, antiemetic, and analgesic requirements in the immediate postoperative period after bariatric surgery.

Ondansetron versus ondansetron with dexamethasone to prevent intrathecal-morphine pruritus for caesarean patients: randomised double-blind trial

The objective of this randomised, double blinded clinical trial was to evaluate the efficacy of prophylactic administration of 4 mg ondansetron as monotherapy versus combination therapy of 4 mg ondansetron plus 8 mg dexamethasone for the prevention of intrathecal morphine-associated pruritus in caesarean section within 24 h. A total of 194 patients were included, 96 patients in the monotherapy group and 98 in the combination group. One hour after the operation, 11.5% of patients in ondansetron group had failure of prophylaxis for pruritus compared to 13.5% of patients in the combination group (p = .66). This decreased throughout the follow-up to reach 0.0% and 1.0% at 24 h in the ondansetron vs. the combination groups respectively. There was no superiority of combining ondansetron with dexamethasone over the use of ondansetron as prophylactic antipruritic in parturients receiving intrathecal morphine for caesarean section.IMPACT STATEMENTWhat is already known on this subject? The incidence of pruritus has been reported to be between 36% and 60% in patients undergoing caesarean section with intrathecal morphine. Ondansetron has been identified as possible antipruritic agent while the antipruritic effect of dexamethasone is inconclusive.What do the results of this study add? The study demonstrated that there was no superiority of combining ondansetron with dexamethasone over the use of ondansetron as prophylactic antipruritic in parturients receiving intrathecal morphine for caesarean section. Moreover, it seems that there is no effect of combining ondansetron with dexamethasone over ondansetron alone on antiemetic consequences.What are the implications of these findings for clinical practice and/or further research? Ondansetron could be an effective antipruritic if used solely for patients undergoing caesarean section.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects.

OBJECTIVES

• To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded.

DATA COLLECTION AND ANALYSIS

A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo.

MAIN RESULTS

We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

Risk-adapted strategy or universal multimodal approach for PONV prophylaxis?

The issue of postoperative nausea and vomiting (PONV) remains important in surgical practice, contributing to patient distress, slower recovery, and increased use of healthcare resources. Many surgical patients report it to be a worse problem than pain. Numerous findings of research indicate that PONV significantly affects patients' well-being and is among the important determinants of patient satisfaction with perioperative care. Numerous investigations have confirmed the efficacy of combining pharmacological interventions indicating that PONV is a clinical complication that is in principle avoidable. Nonetheless, PONV continues to be bothersome for too many patients. Thus, perhaps the biggest challenge across the field is to achieve a uniformly high standard of PONV management using the currently available resources. Although a risk-adapted approach has been advocated in the past, the current trend incorporated in clinical guidelines support a more liberal approach of multimodal antiemetic prevention. The current article emphasizes pros and cons of the various approaches to PONV prophylaxis and depicts most promising strategies to achieve a "PONV-free hospital."

An Electronic Medical Record-Derived Individualized Performance Metric to Measure Risk-Adjusted Adherence with Perioperative Prophylactic Bundles for Health Care Disparity Research and Implementation Science

BACKGROUND

Health care disparity persists despite vigorous countermeasures. Clinician performance is paramount for equitable care processes and outcomes. However, precise and valid individual performance measures remain elusive.

OBJECTIVES

We sought to develop a generalizable, rigorous, risk-adjusted metric for individual clinician performance (MIP) derived directly from the electronic medical record (EMR) to provide visual, personalized feedback.

METHODS

We conceptualized MIP as risk responsiveness, i.e., administering an increasing number of interventions contingent on patient risk. We embedded MIP in a hierarchical statistical model, reflecting contemporary nested health care delivery. We tested MIP by investigating the adherence with prophylactic bundles to reduce the risk of postoperative nausea and vomiting (PONV), retrieving PONV risk factors and prophylactic antiemetic interventions from the EMR. We explored the impact of social determinants of health on MIP.

RESULTS

We extracted data from the EMR on 25,980 elective anesthesia cases performed at Penn State Milton S. Hershey Medical Center between June 3, 2018 and March 31, 2019. Limiting the data by anesthesia Current Procedural Terminology code and to complete cases with PONV risk and antiemetic interventions, we evaluated the performance of 83 anesthesia clinicians on 2,211 anesthesia cases. Our metric demonstrated considerable variance between clinicians in the adherence to risk-adjusted utilization of antiemetic interventions. Risk seemed to drive utilization only in few clinicians. We demonstrated the impact of social determinants of health on MIP, illustrating its utility for health science and disparity research.

CONCLUSION

The strength of our novel measure of individual clinician performance is its generalizability, as well as its intuitive graphical representation of risk-adjusted individual performance. However, accuracy, precision and validity, stability over time, sensitivity to system perturbations, and acceptance among clinicians remain to be evaluated.

Dexamethasone Reduces Postoperative Nausea in Pediatric Upper Endoscopy With Deep Sedation: A Randomized Controlled Trial

OBJECTIVES

We aimed to evaluate the effect of a single dose of preoperative dexamethasone on postoperative nausea and vomiting (PONV), a frequent complication and a major cause of delayed recovery in pediatric upper gastrointestinal endoscopy (UGIE) under sedation.

METHODS

In this double-blind randomized controlled study, 98 children aged 2 to 14, with American Society of Anesthesiologists status I to II, and undergoing elective UGIE with deep sedation were included and randomly assigned to 2 groups. Preoperatively, after anesthesia induction with sodium thiopental and maintenance with sevoflurane, patients in the intervention (n = 49) and control (n = 49) groups, respectively received 0.1 mg/kg i.v. dexamethasone and 2 cm i.v. 0.9% saline. Postoperatively, PONV incidence was measured as the primary outcome.

RESULTS

PONV incidence was significantly less in dexamethasone group (8.2%) compared to the control group (26.5%) (difference = 18.3%, 95% confidence interval: 3.4%-33%, P = 0.016). For secondary outcomes, between-group differences were not statistically significant: incidence of bronchospasm or laryngospasm (both 4.1%, P = 1); emergence delirium assessed with Pediatric Anesthesia Emergence Delirium scale (5.9 ± 3.4 vs 5.7 ± 3.2, P = 0.751); Modified Aldrete score at 0 minutes (9.4 ± 0.8 vs 9.3 ± 0.9, P = 0.909) and at 5 minutes (9.5 ± 0.7 vs 9.4 ± 0.9, P = 0.527); and recovery time (21.1 ± 6.6 vs 23.4 ± 8.6 minutes, P = 0.130).

CONCLUSIONS

A single preoperative dose of i.v. dexamethasone reduces PONV in children undergoing elective UGIE with deep sedation, but has no significant effect on the patient recovery time or the incidence of postoperative bronchospasm or laryngospasm and emergence delirium.

Non-opioid analgesics as adjuvants to opioid for pain management in adult patients in the ICU: A systematic review and meta-analysis

PURPOSE

To identify the impact of non-opioid analgesics as adjuvants to opioid on opioid consumption and its side effects, as well as the analgesic effectiveness in adult patients in the ICU.

METHODS

Only randomized clinical trials using non-opioid analgesics for analgesia in the ICU were included. Pooled analyses with 95% CI were determined.

RESULTS

Twelve studies (mainly surgical and Guillain-Barre syndrome patients) were included. Non-opioid analgesics as adjuvants to opioid were associated with a significant reduction in the consumption of opioids when compared with opioid use alone at Day 1 (MD -15.40; 95% CI -22.41 to -8.39; P < .001) and Day 2 (MD -22.93; 95% CI -27.70 to -18.16; P < .001). Non-opioid analgesics as adjuvants to opioid were associated with a significantly lower incidence of nausea and vomiting when compared with opioid use alone (RR 0.46; 95% CI 0.30 to 0.68; P < .001). Non-opioid analgesics as adjuvants to opioid significantly decreased the pain score at Day 1 (MD -0.68; 95% CI -1.28 to -0.08; P = .03) and Day 2 (MD -1.36; 95% CI -2.47 to -0.24; P = .02).

CONCLUSIONS

Non-opioid analgesics as adjuvants to opioid reduced the consumption and the side effects of opioids in adult surgical and Guillain-Barre syndrome patients in the ICU.

TRIAL REVIEW REGISTRATION

PROSPERO international prospective register of systematic reviews on January 23, 2017, registration number CRD42017055768.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

The effects of tramadol on postoperative shivering after sevoflurane and remifentanil anesthesia

BACKGROUNDS

Remifentanil has been reported to cause post-anesthetic shivering (PAS). Higher doses of remifentanil reportedly induce more intense PAS. Tramadol, a synthetic opioid that acts at multiple sites, is considered to be an effective treatment for PAS, but the evidence for its therapeutic benefit after remifentanil anesthesia is limited. We investigated the effect of tramadol on the incidence of PAS after remifentanil anesthesia.

METHODS

Sixty-three patients who had undergone upper abdominal surgery under general anesthesia were studied retrospectively. Tramadol was administered at induction of anesthesia. The patients were divided into four groups: HT(+), high dose remifentanil (1-1.5 μg/kg/min) with tramadol; HT(-), high dose remifentanil without tramadol; LT(+), low dose remifentanil (0.15-0.25 μg/kg/min) with tramadol; and LT(-), low dose remifentanil without tramadol. We recorded perioperative changes in nasopharyngeal temperature and episodes of PAS on emergence from anesthesia.

RESULTS

The incidences of PAS in both tramadol treatment groups were significantly lower than the groups that did not receive tramadol. Nasopharyngeal temperature after surgery fell significantly more from baseline in the tramadol treatment groups compared with the non-treatment groups.

CONCLUSION

Tramadol administered at induction of anesthesia appears to suppress PAS following remifentanil anesthesia.

Effects of remifentanil versus nitrous oxide on postoperative nausea, vomiting, and pain in patients receiving thyroidectomy: Propensity score matching analysis

Remifentanil and nitrous oxide (N2O) are 2 commonly used anesthetic agents. Both these agents are known risk factors for postoperative nausea and vomiting (PONV). However, remifentanil and N2O have not been directly compared in a published study. Remifentanil can induce acute tolerance or hyperalgesia, thus affecting postoperative pain. The objective of this retrospective study is to compare the effects of remifentanil and N2O on PONV and pain in patients receiving intravenous patient-controlled analgesia (IV-PCA) after thyroidectomy.We analyzed the electronic medical records of 992 patients receiving fentanyl-based IV-PCA after thyroidectomy at Chung-Ang University Hospital from January 1, 2010 to April 30, 2016. We categorized the patients according to anesthetic agents used: group N2O (n = 745) and group remifentanil (n = 247). The propensity score matching method was used to match patients in the 2 groups based on their covariates. Finally, 128 matched subjects were selected from each group.There were no differences between groups for all covariates after propensity score matching. The numeric rating scale for nausea (0.55 ± 0.88 vs 0.27 ± 0.76, P = 0.01) was higher and complete response (88 [68.8%] vs 106 [82.8%], P = 0.001) was lower in group N2O compared with group remifentanil on postoperative day 0. However, the visual analog scale score for pain (3.47 ± 2.02 vs 3.97 ± 1.48, P = 0.025) was higher in group remifentanil than group N2O on postoperative day 0.In patients receiving IV-PCA after thyroidectomy, postoperative nausea was lower but postoperative pain was higher in group remifentanil.

Phenothiazine vs 5HT3 antagonist prophylactic regimens to prevent Post-Anesthesia Care Unit rescue antiemetic: an observational study

PURPOSE

Our practitioners are asked to consider a patient's postoperative nausea and vomiting (PONV) risk profile when developing their prophylactic antiemetic strategy. There is wide variation in employed strategies, and we have yet to determine the most effective PONV prophylactic regimen. The objective of this study is to compare prophylactic antiemetic regimens containing: phenothiazines to 5HT3 antagonists for effectiveness at reducing the incidence of Post-Anesthesia Care Unit (PACU) rescue antiemetic administration.

METHODS

This is an observational study of 4,392 nonsmoking women who underwent general anesthesia for breast surgery from 1/1/2009 through 6/30/2012. Previous history of PONV or motion sickness (HxPONV/MS) and the use of PACU opioids were recorded. Prophylactic antiemetic therapy was left to the discretion of the anesthesia care team. We compared phenothiazines and 5HT3 antagonists alone and with a glucocorticoid to determine the most effective treatment regimen in our practice for the prevention of the administration of PACU rescue antiemetics.

RESULTS

Patients who received a phenothiazine regimen compared to a 5HT3 antagonist regimen were less likely to have an antiemetic administered in the PACU (p=0.0100) and this significant difference in rates holds in a logistic regression model adjusted for HxPONV/MS and PACU Opioid use (p=0.0103).

CONCLUSIONS

Based on our findings our clinicians are encouraged to administer a combination of a phenothiazine and a glucocorticoid in female, nonsmoking surgical breast patients for the prevention of PACU rescue antiemetic administration.

Does anaesthesia with nitrous oxide affect mortality or cardiovascular morbidity? A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

The role of nitrous oxide in modern anaesthetic practice is contentious. One concern is that exposure to nitrous oxide may increase the risk of cardiovascular complications. ENIGMA II is a large randomized clinical trial currently underway which is investigating nitrous oxide and cardiovascular complications. Before the completion of this trial, we performed a systematic review and meta-analysis, using Cochrane methodology, on the outcomes that make up the composite primary outcome.

METHODS

We used conventional meta-analysis and trial sequential analysis (TSA). We reviewed 8282 abstracts and selected 138 that fulfilled our criteria for study type, population, and intervention. We attempted to contact the authors of all the selected publications to check for unpublished outcome data.

RESULTS

Thirteen trials had outcome data eligible for our outcomes. We assessed three of these trials as having a low risk of bias. Using conventional meta-analysis, the relative risk of short-term mortality in the nitrous oxide group was 1.38 [95% confidence interval (CI) 0.22-8.71] and the relative risk of long-term mortality in the nitrous oxide group was 0.94 (95% CI 0.80-1.10). In both cases, TSA demonstrated that the data were far too sparse to make any conclusions. There were insufficient data to perform meta-analysis for stroke, myocardial infarct, pulmonary embolus, or cardiac arrest.

CONCLUSION

This systematic review demonstrated that we currently do not have robust evidence for how nitrous oxide used as part of general anaesthesia affects mortality and cardiovascular complications.

Does Corticosteroid Have Any Beneficial Effect on Voice Change after Thyroidectomy?

Voice alteration is one of the most common complications after thyroidectomy. It has a serious effect on social communication and economic and psychosocial status of patients. It has been hypothesized that inflammation and edema in the surgery site has a major role in voice change after thyroidectomy. This randomized clinical trial study was design to evaluate the effect of a single preoperative dose of steroid on voice change after thyroidectomy. This is a prospective randomized clinical trial with registration no. IRCT201106306925N. From all definitive candidates for total thyroidectomy, eligible patients were selected after exclusion of 12 criteria. Selected cases were randomly allocated to two groups. One group received intravenous dexamethasone pre-operatively. Other group received placebo. Voice change was evaluated by Voice Impairment Score (VIS) postoperatively. Sixty-four patients were entered in the study and divided into two groups (dexamethasone and placebo). VIS was significantly different at the first day after surgery between dexamethasone (five) and controls (13; P < 0.001). This difference was seen after 7 days but without statistically significance (one vs three; P = 0.397). VIS score significantly decreased on the seventh day related to the first day ( P < 0.001) in both groups. There were no significant dexamethasone complications in either group. Preoperative dexamethasone may decrease voice change after thyroidectomy.

Pharmacologic management of postoperative nausea and vomiting

INTRODUCTION

As advances in the safety and efficacy of surgery and anesthesia have been made, other complications such as postoperative nausea and vomiting (PONV) have become more apparent. PONV occurs after 30% of all surgeries, and incidences as high as 80% have been reported among patients at high risk.

AREAS COVERED

This review provides a brief overview of the etiology and mechanisms of emesis and of known risk factors for PONV. It also covers pharmacologic therapies, appropriate management strategies, prophylactic strategies, multimodal therapy and rescue treatment.

EXPERT OPINION

The main triggers for PONV are general anesthesia with inhalational anesthetics and opioids. When given to susceptible patients, e.g., females, the risk may be as high as 80%. In such patients, opioid-free regional anesthesia would be the most logical approach. However, if general anesthesia is needed, we prefer total intravenous anesthesia as it eliminates the use of inhalational anesthetics and reduces the risk for PONV. Importantly, efficacy of antiemetic interventions is independent as long as interventions have different mechanisms. Thus, for practical purposes, we prefer to titrate the use of antiemetics according to the validated Apfel simplified risk score. If a patient has 0, 1, 2, 3 or 4 of the four risk factors, we apply a similar number of antiemetic strategies.

Anesthetic considerations and surgical caveats for awake airway surgery

The evolution of novel techniques for the treatment of laryngeal pathology has led to a significant expansion of the role of diagnostic assessment and the range of laryngeal procedures performed. These procedures typically benefit from an anesthetic approach that diverges from a standard general endotracheal or laryngeal mask airway-based inhalational anesthetic. The shared airway, need for intraoperative assessment of vocal cord function, risk of airway fire, and desire for rapid emergence and discharge are all important factors. In this article the authors undertake a collaborative anesthesia-surgical discussion of anesthetic management for airway procedures that are optimally performed with a spontaneously breathing, cooperative patient. An overview of pharmacologic approaches to airway anesthesia and cooperative sedation, followed by a discussion on the surgical requirements and anesthetic goals of commonly performed procedures, are presented.

Comparison of recovery characteristics, postoperative nausea and vomiting, and gastrointestinal motility with total intravenous anesthesia with propofol versus inhalation anesthesia with desflurane for laparoscopic cholecystectomy: A randomized controlled study

BACKGROUND

Clinical effects, recovery characteristics, and costs of total intravenous anesthesia with different inhalational anesthetics have been investigated and compared; however, there are no reported clinical studies focusing on the effects of anesthesia with propofol and desflurane in patients undergoing laparoscopic cholecystectomy.

OBJECTIVE

The aim of this study was to determine the effects of total intravenous anesthesia with propofol and alfentanil compared with those of desflurane and alfentanil on recovery characteristics, postoperative nausea and vomiting (PONV), duration of hospitalization, and gastrointestinal motility.

METHODS

Patients classified as American Society of Anesthesiologists physical status I or II undergoing elective laparoscopic cholecystectomy due to benign gallbladder disease were enrolled in the study. Patients were randomly assigned at a 1:1 ratio to receive total intravenous anesthesia with propofol (2-2.5 mg/kg) and alfentanil (20 μg/kg) or desflurane (4%-6%) and alfentanil (20 μg/kg). Perioperative management during premedication, intraoperative analgesia, relaxation, ventilation, and postoperative analgesia were carried out identically in the 2 groups. Extubation time, recovery time, PONV, postoperative antiemetic requirement, time to gastrointestinal motility and flatus, duration of hospitalization, and adverse effects were recorded. Postoperative pain was assessed using a visual analogue scale.

RESULTS

Sixty-eight patients were assessed for inclusion in the study; 5 were excluded because they chose open surgery and 3 did not complete the study because they left the hospital. Sixty patients (33 women, 27 men) completed the study. Recovery time was significantly shorter in the propofol group (n = 30) compared with the desflurane group (n = 30) (8.0 [0.77] vs 9.2 [0.66] min, respectively; P < 0.005). Fifteen patients (50.0%) in the propofol group and 20 patients (66.7%) in the desflurane group experienced nausea during the first 24 hours after surgery. The difference was not considered significant. In the propofol group, significantly fewer patients had vomiting episodes compared with those in the desflurane group (2 [6.7%] vs 16 [53.3%]; P < 0.005). Significantly fewer patients in the propofol group required analgesic medication in the first 24 hours after surgery compared with those in the desflurane group (10 [33.3%] vs 15 [50.0%]; P < 0.005). Patients in the propofol group experienced bowel movements in a significantly shorter period of time compared with patients in the desflurane group (8.30 [1.67] vs 9.76 [1.88] hours; P = 0.02). The mean time to flatus occurred significantly sooner after surgery in the propofol group than in the desflurane group (8.70 [1.79] vs 9.46 [2.09] hours; P = 0.01). The duration of hospitalization after surgery was significantly shorter in the propofol group than in the desflurane group (40.60 [3.49] vs 43.60 [3.56] hours; P = 0.03).

CONCLUSION

Total intravenous anesthesia with propofol and alfentanil was associated with a significantly reduced rate of PONV and analgesic consumption, shortened recovery time and duration of hospitalization, accelerated onset of bowel movements, and increased patient satisfaction compared with desflurane and alfentanil in these patients undergoing laparoscopic surgery who completed the study.

The relationship between patient risk factors and early versus late postoperative emetic symptoms

BACKGROUND

Postoperative nausea and vomiting (PONV) remain common complications after elective surgery. Prophylactic antiemetic drugs are frequently administered to patients with well known risk factors for developing PONV. We designed this prospective observational study to assess the relationship between common patient risk factors for developing PONV and the occurrence of early (0-24 h) versus late (24-72 h) emetic symptoms.

METHODS

One hundred thirty patients undergoing elective laparoscopic (n = 88) or plastic (n = 42) surgery were assigned a risk score for developing PONV based on the Apfel risk scoring system, which assigns one point each for female gender, nonsmoking status, history of PONV or motion sickness, and postoperative opioid use. It was assumed that all patients would receive an opioid analgesic in the postoperative period. The patients received 0, 1, 2, or 3 antiemetic drugs for prophylaxis. The occurrence of nausea, vomiting, and need for rescue antiemetics was assessed at specific time intervals from 0 to 6, 6-24, and 24-72 h after surgery. In addition, the impact of PONV on recovery of normal activities of daily living was assessed using a standardized patient questionnaire.

RESULTS

One or more prophylactic antiemetics were administered to 87%, 90%, and 95% of the patients in the two, three, and four Apfel risk-factor groups, respectively. In the presence of three or four risk factors, >/=2 antiemetics were administered to 56% and 75% of the patients, respectively. Vomiting was reported in 11% and 22% of patients in the three and four risk factor groups compared with 6% in the two risk factor group at 0-6 h, and 13% and 27% (vs 0%) at 6-24 h, respectively. However, in the 24-72 h postoperative period, the incidences of emesis were low and did not differ in the three risk groups (9%, 5%, and 11%, respectively). The occurrence of moderate-to-severe nausea was increased in the higher risk groups at 0-6 h and 6-24 h (19%-28% vs 6% and 20%-30% vs 9%, respectively). However, the incidences of nausea in the 24-72 h period in the three and four risk factor groups were not different from the two-risk factor group (5% and 8% vs 6%, respectively). The need for rescue antiemetics and interference of emetic symptoms with normal activities was greater in the four risk factor group compared with the two and three risk factor groups.

CONCLUSION

Despite the frequent use of multiple antiemetic drugs for prophylaxis, an Apfel risk score of three or four (vs 2) was associated with a higher incidence of emetic sequelae in the first 24 h after surgery. However, the occurrence of late (24-72 h) emetic symptoms was low and appeared to be unrelated to the patient's Apfel risk score.

[Nausea and vomiting in the postoperative phase. Expert- and evidence-based recommendations for prophylaxis and therapy]

There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries. This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics; assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions is mainly dependent on the patient's individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk, generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV. Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The group suggests algorithms where prophylactic interventions are mainly dependent on the patient's risk for PONV. These algorithms should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.

[Dolasetron and shivering. A prospective randomized placebo-controlled pharmaco-economic evaluation]

BACKGROUND AND GOAL

Forced by the current economical situation, German hospitals have to reconsider their clinical productivity. When caregivers introduce new therapeutic concepts medical quality should either be improved without increasing costs or when reducing costs medical quality should be maintained. In the surgical field postoperative shivering reduces both patient comfort and medical quality. We therefore investigated the clinical pathway prevention of shivering with dolasetron in a prospective, randomized, placebo-controlled analysis of cost-effectiveness.

MATERIAL AND METHODS

After written informed consent we randomized 40 patients scheduled for lumbar disc hernia repair or head and neck surgery into two groups: patients of group D received dolasetron 1 mg/kg body weight during surgery whereas patients of group K received 100 ml saline as placebo. Primary endpoints were the incidence of shivering, the length of stay in the postanesthesia care unit and process-associated costs. Secondary endpoint was the influence on perioperative thermoregulation.

RESULTS

We observed postanesthetic shivering in 5 patients belonging to group D in comparison to 15 patients receiving the placebo (p<0.05). The length of stay in the postanesthesia care unit was shorter in patients allocated to dolasetron (mean+/-SD; group D: 43+/-16 min, group K 62+/-18 min, p<0.05). There was a significant saving in process-associated personnel costs (personnel costs in group D EUR 41.26+/-14, personnel costs in group K EUR 53.15+/-15) but in contrast the process-associated material costs were significantly increased (group D EUR 17.16+/-3, group K EUR 0.73+/-1, p<0.05).

CONCLUSIONS

The optimization of the clinical process and medical quality induced by a prophylaxis against shivering and postoperative nausea and vomiting compensates for the increased use of pharmaceutical resources in our setting.

Propofol–remifentanil-based anaesthesia vs. sevoflurane–fentanyl-based anaesthesia for immediate postoperative ophthalmic evaluation following strabismus surgery

BACKGROUND AND OBJECTIVE

Following strabismus surgery, immediate postoperative ophthalmic evaluation may be desired. Thus, an anaesthetic technique allowing rapid recovery of ocular motility is required. Saccadic eye movements is a biophysical monitor of ocular motility and may be used to assess recovery from anaesthesia. The aim of this study is to compare the time to the recovery of saccadic eye movements in patients, following one of two anaesthetic techniques: Propofol-remifentanil-based anaesthesia vs. sevoflurane-fentanyl-based anaesthesia.

METHODS

Fifty adult patients undergoing strabismus surgery were randomly assigned to one of two groups: patients in Group R received induction and maintenance of anaesthesia with propofol and remifentanil, while patients in Group S received induction of anaesthesia with propofol and fentanyl and maintenance of anaesthesia with sevoflurane. Recovery from anaesthesia was measured from the time all anaesthetics were turned off and was assessed every 2 min. Recovery time was attained when patients were able to generate brisk saccadic eye movements. At recovery time, the ophthalmic evaluation was started.

RESULTS

The mean recovery time of saccadic eye movements was significantly shorter in the Group R when compared to the Group S (12.1 +/- 4.3 min vs. 21.5 +/- 4.7 min, respectively, P < 0.0001). More patients in Group S experienced nausea and vomiting postoperatively as compared to Group R (9/25 vs. 2/25, respectively, P = 0.037).

CONCLUSIONS

Propofol-remifentanil-based anaesthesia may be a useful technique in strabismus surgery when immediate postoperative ophthalmic evaluation is desired. When compared to sevoflurane maintenance of anaesthesia, it allows for a more rapid recovery from anaesthesia as judged by recovery of saccadic eye movements and a decreased incidence of postoperative nausea and vomiting.

Klinischer Behandlungspfad „laparoskopische Prostatektomie“

METHODS

In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure.

RESULTS

There were no anesthesia-related deviations from clinical pathways and both forms of anesthesia management were equally well tolerated by the patients. No significant difference was observed regarding hemodynamic measurements or PONV. The patients in the desflurane/ remifentanil group recovered more rapidly (p=0.037) and had more pain. The amount of analgesic agents given immediately following anesthesia was significantly higher than in the TIVA group (p=0.017). The median anesthesia costs per minute for laparoscopic prostatectomy in the propofol group were 2.79 EUR (minimum cost 2.41 EUR, maximum cost 3.21 EUR) and in the desflurane group 2.68 EUR (minimum cost 2.45 EUR, maximum cost 3.39 EUR). The total anesthesia costs for both groups were within the proceeds matrix range for diagnosis-related groups (DRG). However, the cost analysis for medication was slightly higher than the proceeds matrix range for DRGs.

CONCLUSION

Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.

Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under spinal anaesthesia: a randomized study of ondansetron prophylaxis

BACKGROUND AND OBJECTIVE

Patients undergoing total abdominal hysterectomy under general anaesthesia have a high risk of developing postoperative nausea and vomiting (PONV). The aim of this study was to evaluate the incidence of PONV in patients undergoing total abdominal hysterectomy under spinal anaesthesia with intravenous patient-controlled analgesia (PCA) using morphine and to compare its incidence with and without antiemetic prophylaxis.

METHODS

Thirty-four patients undergoing total abdominal hysterectomy under spinal anaesthesia with i.v. PCA morphine postoperatively were divided into two groups. The first (n = 17) received ondansetron prophylaxis near the end of surgery while the second (n = 17) received no prophylaxis. Morphine consumption, emetic episodes (on a 3-point scale), patient satisfaction (visual analogue score), sedation and pruritus were evaluated 2, 4, 6, 9, 12, 18 and 24h postoperatively.

RESULTS

Patient characteristics, postoperative morphine consumption (43.3 +/- 7.6 vs. 40.3 +/- 12.3 mg) and peristaltic recovery time (16.9 +/- 5 vs. 18.4 +/- 5.2 h) were similar in both groups. Overall nausea and vomiting were significantly lower in the ondansetron prophylaxis group than in the group without prophylaxis (52.9% vs. 88.2%, P < 0.05). Though nausea alone was higher in the prophylaxis group (41.2% vs. 29.4%), nausea with vomiting was significantly lower in the prophylaxis group (11.8% vs. 58.8%, P < 0.01). Patients' satisfaction scores were higher in the ondansetron group at all times and the difference was significant (P < 0.05) 4 h postoperatively.

CONCLUSIONS

The incidence of PONV in patients undergoing total abdominal hysterectomy under spinal anaesthesia with i.v. PCA morphine is very high (88.2%). Antiemetic prophylaxis with ondansetron is highly recommended in this patients group resulting in a lower incidence of nausea and vomiting, and significantly improves patient' satisfaction and life quality in the early postoperative period.