RETRACTED ARTICLE: Management of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

Effect of cerebral oxygen saturation on postoperative nausea and vomiting in female laparoscopic surgery patients

BACKGROUND

The purpose of this study was to investigate effect of cerebral oxygen saturation (SCTO2) on postoperative nausea and vomiting (PONV) in female patients who underwent laparoscopic surgery.

METHODS

This study included 90 female patients who underwent laparoscopic surgery (60 cases of gynecological operations and 30 cases of gallbladder operations). All patients were allocated into 3 groups of 30 patients each: group A (gynecological laparoscopic surgery), group B (gynecological laparoscopic surgery with mannitol treatment) and group C (laparoscopic cholecystectomy surgery). Perioperative SCTO2, mean blood flow velocity of vertebral artery (VM), vascular resistance index of vertebral artery (RI), and PONV (within 48 hours after surgery) were investigated.

RESULTS

No differences in age, body weight, operation time, and hemoglobin levels were observed among the patients (P > .05). The SCTO2 values for groups B and C were lower than those for group A in both brain hemispheres at T4 and T5 (P < .05). The VM was higher in group B than in groups A and C at T3 (P < .05), but differences in VM were not observed between groups B and C at T4 or T5. However, the VM of group A was still lower than the other groups (P < .05), and no difference in VM was observed among the 3 groups at T6 (P > .05). The RI was higher in group C than in groups A and B at T4 (P < .05). The incidence of PONV within 48 hours after surgery was significantly higher in group A than in the other 2 groups (P < .05).

CONCLUSION

Strategies that maintain normal SCTO2 may reduce the incidence of PONV in female patients who underwent laparoscopy surgery by reducing perioperative intracranial pressure.

Contemporary acupressure therapy: Adroit cure for painless recovery of therapeutic ailments

Since time immemorial, complementary and alternative medicines (CAM) have played a significant role in human health care. CAM is known to have a strong reputation and reliability within every culture to provide basic health care treatment for patients. CAM acts as a better therapeutic option in human being for treating various diseases and improving quality of life with apt consideration to the economic aspects. Acupressure, one of the known CAM, originated in ancient China is based on the principal of acupoints activation across the meridians which correct the imbalance between Qi. Activation of specific points on the meridians is known to facilitate reduction of pain at the local sites. It also reduces the pain from other body parts. This review outlines various types, devices and mechanisms involved in the acupressure treatment.

The effect of intravenous dextrose administration for prevention of post-operative nausea and vomiting after laparoscopic cholecystectomy: A double-blind, randomised controlled trial

Background and Aims:

Post-operative nausea and vomiting (PONV) is a common and distressing complication after laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the effect of intravenous (IV) dextrose administration for the prophylaxis of PONV after LC.

Methods:

In a double-blind, randomised controlled trial, a total of 150 female patients who were scheduled for elective LC were randomly assigned into two groups (A and B). Thirty minutes before induction of anaesthesia, patients received an infusion of 500 cc lactated Ringer's solution (Group A) and 5% dextrose in lactated Ringer's solution (Group B) and over a period of 30 min. All patients rated their nausea and vomiting intensity using the verbal rating scale immediately at post-anaesthesia care unit (PACU) arrival; 30, 60, 90 and 120 min after arriving at the PACU and 6, 12 and 24 h after surgery.

Results:

There was a statistically significant time trend and group effect along with significant differences in time/group interaction effect in both groups for nausea and vomiting scores (P < 0.05). A low negative correlation coefficient was found (r = −0.394, P < 0.001) between blood glucose levels and nausea scores upon PACU arrival. Dextrose administration reduced the odds of vomiting events compared to placebo (estimate: −0.87, odds ratio = 0.42, 95% confidence interval: 0.28–0.64).

Conclusion:

Administration of IV dextrose before anaesthesia induction may be recommended as an effective, and safe method for the prophylaxis of PONV after LC.

5HT3 Antagonists versus Dexamethasone in the Prevention of PONV in Patients Undergoing Laparoscopic Cholecystectomy: A Meta-Analysis of RCTs

Background. 5HT3 antagonist, an antiemetic alternative to dexamethasone, is an effective drug for the prevention of postoperative nausea and vomiting (PONV). Methods. PubMed and The Cochrane Library (from inception to June 2016) were searched for relevant RCTs (randomized controlled trials). Results. Seven trials, totaling 682 patients, were included in this meta-analysis. This meta-analysis demonstrated that 5HT3 antagonist was as effective as dexamethasone in preventing PONV (RR, 1.12; 95% CI, [0.86, 1.45]; P = 0.40) within 24 hours of laparoscopic cholecystectomy, and no significant heterogeneity was observed among the studies (I² = 0%; P = 0.98). During the early postoperative period (0-6 h), 5HT3 antagonists were superior to dexamethasone in reducing POV (RR, 0.31; 95% CI, [0.11, 0.93]; P = 0.04), while, in other postoperative stages (6-12 h, 12-24 h, and 0-24 h), it was not more effective in the prevention of POV than dexamethasone. And no significant difference was found in the prevention of PON between 5HT3 antagonists and dexamethasone at different postoperative periods (0-6 h, 6-12 h, 12-24 h, and 0-24 h). Conclusions. As a result, it is advisable to encourage 5HT3 antagonists as an alternative to dexamethasone for the prevention of PONV in patients undergoing laparoscopic cholecystectomy.

Evaluation of the effect of ketamine on remifentanil-induced hyperalgesia: a double-blind, randomized study

STUDY OBJECTIVE

Opioids are associated with hyperalgesia that can reduce their analgesic effect. The aim of this study was to determine whether the addition of ketamine reduces remifentanil-induced hyperalgesia; improves its analgesic effect; and alters interleukin 6 (IL-6), IL-8, and IL-10 levels.

DESIGN

This is a prospective, randomized, double-blind study.

SETTING

The setting is in a operating room and ward in a university hospital.

PATIENTS

There are 56 patients, aged ≥18 years, American Society of Anesthesiologists I or II, who underwent laparoscopic cholecystectomy.

INTERVENTIONS

Anesthesia was induced with remifentanil, 50% oxygen, and isoflurane. Patients randomized to group 1 received remifentanil (0.4 μg/kg per minute) and ketamine (5 μg/kg per minute), and patients randomized to group 2 received remifentanil (0.4 μg/kg per minute) and saline solution. Postoperative analgesia was achieved using morphine via patient-controlled analgesia.

MEASUREMENTS

The measurements were postoperative pain intensity during 24 hours; morphine consumption; time to first morphine supplementation; hyperalgesia (using monofilaments and an algometer) and allodynia (using a soft brush) in the thenar eminence of the nondominant hand and in the periumbilical region 24 hours after surgery; extent of hyperalgesia using a 300-g monofilament near the periumbilical region 24 hours after surgery; and serum levels of IL-6, IL-8, and IL-10.

MAIN RESULTS

Groups were similar for baseline characteristics. There were no differences in pain intensity, time to first request of morphine, and total 24 hours dose of morphine between groups. There was a difference in hyperalgesia using monofilaments 24 hours after the surgery in the thenar eminence of the nondominant hand, with a better profile for the experimental group. However, there were no differences in hyperalgesia using an algometer, in allodynia using a soft brush; in extent of hyperalgesia; or in levels of IL-6, IL-8, and IL-10.

CONCLUSIONS

It was not possible to demonstrate that the addition of ketamine (5 μg/kg per minute) is effective in preventing or reducing remifentanil-induced postoperative hyperalgesia in laparoscopic cholecystectomy.

Comparison of low and standard pressure gas injection at abdominal cavity on postoperative nausea and vomiting in laparoscopic cholecystectomy

Background and Objective: Postoperative nausea and vomiting (PONV) is the main concern for 40-70% of patients undergoing laparoscopic cholecystectomy. Our objective was to compare carbon dioxide gas at low pressure and standard pressure for the occurrence of PONV on patients undergoing laparoscopic cholecystectomy.

Methods: This double- blind trial was conducted on 50 women patients aged between 18 to 60 years with acute cholecystectomy. The patients were divided into two groups: low pressure (LP) (received LP gas, 7-9 mmHg) and standard pressure (SP) (received SP gas, 14-15 mmHg). Nausea and vomiting in patients at hours 0-4, 4-8, 8-12, 12-24 after the surgery were recorded.

Results: The frequency of PONV in the LP and SP groups did not demonstrate statistically significant different (P > 0.05). Nevertheless the frequency of shoulder pain after 4 hours at the LP group compared with SP group was significantly different (P < 0.023).

Conclusions: The use of low pressure gas compared to standard pressure gas to create pneumoperitoneum could not reduce the PONV whereas the frequency of shoulder pain in LP group was reduced. Low pressure gas was associated with reduction of surgeon visibility and subsequently more prolonged surgery duration.

Intraperitoneal bupivacaine effect on postoperative nausea and vomiting following laparoscopic cholecystectomy

Background:

Postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC) has multifactorial etiology. Pain and use of opioids are among the important factors.

Objectives:

The present study aimed to evaluate the efficacy of intrapritoneal (IP) injection of bupivacaine on PONV.

Patients and Methods:

This was a double-blind randomized clinical trial, conducted on 66 patients aged 20-60, ASA I or II, candidates for LC. Patients were randomly assigned to two groups. Bupivacaine group received 20 mL bupivacaine 0.25% in the gallbladder bed, before and after cholecystectomy and the control group did not. The incidence of nausea and postoperative pain intensity was measured with Visual analogue scale (VAS) at 1, 2, 3 and 4 hours after operation, at rest and when coughing and changing positions. Nausea and vomiting occurrence were assessed at the same times.

Results:

There were no demographic data differences between groups. No differences were found between the two groups, in terms of incidence of nausea and vomiting. Furthermore, both groups were similar with respect to opioid consumption, during four hours post-operation.

Conclusions:

Intraperitoneal bupivacaine administration at the beginning and end of laparoscopic cholecystectomy reduced only visceral and shoulder pains at the 4th postoperative hour, but had no effect on reducing neither PONV, nor opioid demand, during the first four postoperative hours.

Assessment of the effect of ketamine in combination with remifentanil on postoperative pain

BACKGROUND AND OBJECTIVES

The combination of ketamine and remifentanil seems to be associated with better analgesia and duration. The aim of this study was to evaluate whether a ketamine-remifentanil combination promotes improved postoperative analgesia.

METHODS

Prospective, randomized, double blind study of 40 patients undergoing video laparoscopic cholecystectomy. Anesthesia was performed with remifentanil, propofol, atracurium, and 50% oxygen. Group 1 (GI) patients received remifentanil (0.4 mcg.kg(-1).min(-1)) and ketamine (5 mcg.kg(-1).min(-1)) and Group 2 (G2) received remifentanil (0.4 mcg.kg(-1).min(-1)) and saline solution. Morphine 0.1mg.kg(-1) was administered at the end of the procedure, and postoperative pain was treated with morphine via PCA. We evaluated the severity of postoperative pain by a numerical scale from zero to 10 during 24 hours. We registered the time to the first analgesic supplementation, amount of morphine used in the first 24 hours, and adverse effects.

RESULTS

There was a decrease in pain severity between extubation and other times evaluated in G1 and G2. There was no significant difference in pain intensity between the groups. There was no difference between G1 (22±24.9 min) and G2 (21.5±28.1min) regarding time to first dose of morphine and dose supplement of morphine consumed in G1 (29±18.4mg) and G2 (25.1±13.3mg).

CONCLUSION

The combination of ketamine (5 mcg.kg(-1).min(-1)) and remifentanil (0.4mcg.kg(-1).min(-1)) for cholecystectomy did not alter the severity of postoperative pain, time to first analgesic supplementation or dose of morphine in 24hours.

Assessment of the effect of ketamine in combination with remifentanil on postoperative pain

BACKGROUND AND OBJECTIVES

The combination of ketamine and remifentanil seems to be associated with better analgesia and duration. The aim of this study was to evaluate whether a ketamine- remifentanil combination promotes improved postoperative analgesia.

METHODS

Prospective, randomized, double blind study of 40 patients undergoing video laparoscopic cholecystectomy. Anesthesia was performed with remifentanil, propofol, atracurium, and 50% oxygen. Group 1 (GI) patients received remifentanil (0.4 mcg.kg(-1).min(-1)) and ketamine (5 mcg.kg(-1).min(-1)) and Group 2 (G2) received remifentanil (0.4 mcg.kg(-1).min(-1)) and saline solution. Morphine 0.1 mg.kg(-1) was administered at the end of the procedure, and postoperative pain was treated with morphine via PCA. We evaluated the severity of postoperative pain by a numerical scale from zero to 10 during 24 hours. We registered the time to the first analgesic supplementation, amount of morphine used in the first 24 hours, and adverse effects.

RESULTS

There was a decrease in pain severity between extubation and other times evaluated in G1 and G2. There was no significant difference in pain intensity between the groups. There was no difference between G1 (22 ± 24.9 min) and G2 (21.5 ± 28.1 min) regarding time to first dose of morphine and dose supplement of morphine consumed in G1 (29 ± 18.4 mg) and G2 (25.1 ± 13.3 mg).

CONCLUSION

The combination of ketamine (5 mcg.kg(-1).min(-1)) and remifentanil (0.4 mcg.kg(-1).min(-1)) for cholecystectomy did not alter the severity of postoperative pain, time to first analgesic supplementation or dose of morphine in 24 hours.

Ondansetron combined with ST36 (Zusanli) acupuncture point injection for postoperative vomiting

BACKGROUND

Ondansetron, sometimes combined with acustimulation at PC6 (Neiguan), is commonly used for preventing postoperative nausea and vomiting, but PC6 is not the only point that can be used for this purpose.

OBJECTIVES

To evaluate the combined effects of ondansetron and ST36 (Zusanli) acupuncture point injection on postoperative vomiting (POV) after laparoscopic surgery.

METHODS

A randomised, patient and assessor-blinded, placebo-controlled clinical study was conducted. One hundred and sixty patients undergoing laparoscopic surgery were randomly assigned to one of four groups: (1) group P (placebo-control): intravenous normal saline+bilateral non-acupuncture point injection of vitamin B1 (n=40); (2) group O (ondansetron): intravenous ondansetron+bilateral ST36 sham injection (n=40); (3) group A (acupuncture point injection): intravenous normal saline+bilateral acupuncture point injection at ST36 of vitamin B1 (n=40); (4) group C (combination): intravenous ondansetron+bilateral acupuncture point injection at ST36 of vitamin B1 (n=40). Interventions were made on arrival at the postanaesthesia care unit. The primary outcome was the incidence of POV within 24 h after the operation. Secondary outcomes included severity of vomiting, incidence of rescue treatment, patients' satisfaction and the first anal exsufflation time 24 h after the operation.

RESULTS

The incidence of POV within 24 h postoperative period in each group was P 33%; O 11%, A 9% and C 6%. Outcomes for all intervention groups were significantly better than that for placebo (p<0.01). For the three interventions compared with placebo, the numbers needed to treat (NNTs) were O, NNT=5; A, NNT=5 and C, NNT=4. The secondary outcomes also demonstrated greater benefits of the combined regimen, with improvement seen in all the measures.

CONCLUSIONS

Ondansetron, acupuncture, and ondansetron and acupuncture combined are effective prophylaxis for POV.

Total intravenous anesthesia with propofol reduces postoperative nausea and vomiting in patients undergoing robot-assisted laparoscopic radical prostatectomy: a prospective randomized trial

PURPOSE

We investigated the effect of total intravenous anesthesia (TIVA) with propofol on postoperative nausea and vomiting (PONV) after robot-assisted laparoscopic radical prostatectomy (RLRP) in patients at low risk of developing PONV, in comparison to balanced anesthesia with desflurane.

MATERIALS AND METHODS

Sixty two patients were randomly assigned to the Des or TIVA group. Propofol and remifentanil were used for induction of anesthesia in both groups and for maintenance of the anesthesia in the TIVA group. In the Des group, anesthesia was maintained with desflurane and remifentanil. In both groups, postoperative pain was controlled using fentanyl-based intravenous patient controlled analgesia, and ramosetron 0.3 mg was administered at the end of surgery. The incidence of PONV, severity of nausea and pain, and requirements of rescue antiemetics and analgesics were recorded.

RESULTS

The incidence of nausea in the post-anesthetic care unit was 22.6% in the Des group and 6.5% in the TIVA (p=0.001) group. The incidence of nausea at postoperative 1-6 hours was 54.8% in the Des group and 16.1% in the TIVA group (p=0.001). At postoperative 6-48 hours, there were no significant differences in the incidence of nausea between groups.

CONCLUSION

In order to prevent PONV after RLRP in the early postoperative period, anesthesia using TIVA with propofol is required regardless of patient-related risk factors.

Ramosetron for the prevention of postoperative nausea and vomiting (PONV): a meta-analysis

Background

Postoperative nausea and vomiting (PONV) remains a challenge for patients and health professionals despite various newly developed prophylactic interventions. We reviewed the efficacy and safety of ramosetron in randomized controlled trials (RCTs) for the prevention of PONV.

Methods

We reviewed 18 randomized controlled trials investigating the efficacy and safety of ramosetron in comparison with placebo or any other drugs. Relevant studies were searched in the MEDLINE, SCOPUS, and the Cochrane database libraries. Our end points of concern were prevention of PONV and adverse effects as dichotomous data.

Results

The prophylactic effect of 0.3 mg ramosetron was observed in early PON (relative risk, RR: 0.4; 95% CI 0.3-0.6), early POV (RR: 0.3; 95% CI 0.1-0.6), late POV (RR: 0.3; 95% CI 0.1-0.6), but not late PON (RR: 0.7; 95% CI 0.5-1.0). Compared with placebo, the efficacy of 0.3 mg ramosetron in adults and 6 µg/kg in children were consistently beneficial in preventing PONV overall (RR: 0.4; 95% CI: 03-0.6). The effects of 0.3 mg ramosetron and 3 mg granisetron were similar. No serious side effects or adverse events resulted from ramosetron and other active drugs, and incidence was similar to those of the placebo group.

Conclusions

Ramosetron is effective and safe in children and adults without serious adverse effects compared with placebo or other active drugs, as shown in pooled data of RCTs, in terms of the prevention of PONV.

Involvement of mast cells in a mouse model of postoperative pain

Recent studies have indicated that nearly half of all surgical patients still have inadequate pain relief; therefore, it is becoming increasingly more important to understand the mechanisms involved in postoperative pain in order to be better treated. Previous studies have shown that incisions can cause mast cell degranulation. Thus, the aim of this study was to investigate the involvement of mast cells in a model of postoperative pain in mice. The depletion of mast cell mediators produced by pre-treatment with compound 48/80 (intraplantar (i.pl.)) widely (98 ± 23% of inhibition) and extensively (up to 96 h) prevented postoperative nociception and reduced histamine and serotonin levels (88 ± 4% and 68 ± 10%, respectively) in operated tissue. Furthermore, plantar surgery produced immense mast cell degranulation, as assessed by histology and confirmed by the increased levels of serotonin (three-fold higher) and histamine (fifteen-fold higher) in the perfused tissue, 1h after surgery. Accordingly, pre-treatment with the mast cell membrane stabilizer cromoglycate (200 μg/paw, i.pl.) prevented mechanical allodynia (inhibition of 96 ± 21%) and an increase in histamine (44 ± 10% of inhibition) and serotonin (73 ± 5% of inhibition) levels induced by plantar surgery. Finally, local treatment with H(1) (promethazine, 100 μg/paw, i.pl.), 5-HT(3) (ondansetron, 10 μg/paw, i.pl.) or 5-HT(2A) (ketanserin, 5 μg/paw, i.pl.) receptor antagonists partially decreased postoperative nociception in mice, but when co-administered together it completely reversed the mechanical allodynia in operated mice. Thus, mast cell activation mechanisms are interesting targets for the development of novel therapies to treat postoperative pain.