How to study postoperative nausea and vomiting

Incidence of nausea/vomiting following propofol sedation with adaptive servo-ventilation for atrial fibrillation ablation

Background

Postoperative nausea and vomiting (PONV) following atrial fibrillation (AF) ablation can cause considerable distress.

Aim

Continuous intravenous propofol sedation with adaptive servo-ventilation (ASV) with or without an analgesic, pentazocine, during AF ablation was studied in 272 consecutive patients with paroxysmal, persistent, and long-standing persistent AF. The study objectives were to determine the incidence of PONV after AF ablation and to assess the predictive value of factors for PONV using the area under the receiver operating characteristic curve (AUC).

Results

The present sedation maneuver was successfully accomplished with a low incidence of hypotension and without discontinuation of ablation or switching to general anesthesia, while maintaining an acceptable procedural time (102 ± 32 min). The incidence of PONV was 5.5% (15/272). Nausea occurred in nine patients after an average of 4.6 ± 3.5 h (range: 2-12 h) postablation, and vomiting with nausea occurred in six patients after an average of 4.5 ± 3.1 h (range: 1-9 h) postablation. The postablation interval did not differ significantly between the occurrence of nausea and nausea accompanied by vomiting. AUCs based on various factors, including the Apfel score, ranged from 0.55 to 0.67, indicating low accuracy in predicting PONV occurrence.

Conclusions

The incidence of PONV after propofol sedation with ASV was the lowest (5.5%) reported to date. Scoring systems, which included the Apfel score, were ineffective in predicting PONV. The low PONV incidence in addition to the efficacy of propofol sedation with ASV revealed the adequacy of this regimen for AF ablation.

Olanzapine as a prophylactic antiemetic for preventing postoperative nausea and vomiting after general anesthesia: A systematic review and meta-analysis

BACKGROUND

The antiemetic effectiveness of olanzapine, as a prophylactic off-label antiemetic drug, for Postoperative Nausea and Vomiting (PONV) is unknown. In this systematic review and meta-analysis, the authors evaluate the efficacy and side effects of olanzapine as a prophylactic antiemetic in adult patients who undergo general anesthesia and assess adverse effects.

METHODS

A systematic search was done on electronic bibliographic databases in July 2023. Randomized controlled trials of olanzapine as a prophylactic antiemetic for PONV in adults who underwent general anesthesia were included. The authors excluded non-RCTs and retracted studies. The authors set no date of publication or language limits. The outcomes were the incidence of PONV within 24 h postoperatively and the safety of olanzapine. The risk of bias was assessed according to the tool suggested by the National Heart, Lung, and Blood Institute.

RESULTS

Meta-analysis included 446 adult patients. Olanzapine reduced on average 38 % the incidence of PONV. The estimated risk ratio (95 % CI) of olanzapine versus control was 0.62 (0.42-0.90), p = 0.010, I2 = 67 %. In the subgroup meta-analysis, doses of olanzapine (10 mg) reduced on average 49 % of the incidence of PONV (RR = 0.51 [0.34-0.77], p = 0.001, I2 = 31 %).

CONCLUSIONS

This systematic review with meta-analysis indicated that olanzapine as a prophylactic antiemetic alone or combined with other antiemetic agents reduced the incidence of postoperative nausea and vomiting. However, this conclusion must be presented with some degree of uncertainty due to the small number of studies included. There was a lack of any evidence to draw conclusions on side effects.

Interpectoral and Pectoserratus Plane Block vs. Local Anesthetic Infiltration for Partial Mastectomy: A Prospective Randomized Trial

Background

Patients undergoing breast surgery are at risk of severe postoperative pain. Several opioid-sparing strategies exist to alleviate this condition. Regional anesthesia has long been a part of perioperative pain management for these patients.

Aim

This randomized study examined the benefits of interpectoral and pectoserratus plane block (IPP/PSP), also known as pectoralis nerve plain block, compared with advanced local anesthetic infiltration.

Methods

We analyzed 57 patients undergoing partial mastectomy with sentinel node dissection. They received either an ultrasound-guided IPP/PSP block performed preoperatively by an anesthetist or local anesthetic infiltration performed by the surgeon before and during the surgery.

Results

Pain measured with the numerical rating scale (NRS) indicated no statistically significant difference between the groups (IPP/PSP 1.67 vs. infiltration 1.97; p value 0.578). Intraoperative use of fentanyl was significantly lower in the IPP/PSP group (0.18 mg vs 0.21 mg; p value 0.041). There was no statistically significant difference in the length of stay in the PACU (166 min vs 175 min; p value 0.51). There were no differences in reported postoperative nausea and vomiting (PONV) between the groups. The difference in postoperative use of oxycodone in the PACU (p value 0.7) and the use of oxycodone within 24 hours postoperatively (p value 0.87) was not statistically significant.

Conclusions

Our study showed decreased intraoperative opioid use in the IPP/PSP group and no difference in postoperative pain scores up to 24 hours. Both groups reported low postoperative pain scores. This trial is registered with NCT04824599.

Postoperative pain management using an intravenous combination of ibuprofen and acetaminophen compared with acetaminophen alone after thyroidectomy: A prospective randomized controlled trial

BACKGROUND

Multiple medications are more effective than single agents for postoperative pain management. We investigated the analgesic effects of an intravenous combination of acetaminophen and ibuprofen immediately after thyroidectomy.

METHODS

In this double-blind clinical trial, 62 patients who underwent thyroidectomies were randomized to either the treatment (1000 mg acetaminophen, 300 mg ibuprofen) or control (1000 mg acetaminophen) group. Postoperative pain intensity was assessed using the visual analog scale (VAS) 0, 15, and 30 min after recovery room admission. Opioid rescue consumption was also recorded.

RESULTS

The VAS scores were significantly lower in the treatment than in the control group 15 [3 (2-4.3) vs. 5 (3-6); p = 0.015] and 30 [3 (2-4.3) vs. 4 (3-5); p = 0.018] min after recovery room admission, as were the opioid rescue dose requirements (p = 0.033).

CONCLUSIONS

Combined intravenous acetaminophen and ibuprofen may be better than acetaminophen alone for immediately acute postoperative pain after thyroidectomy.

The efficacy of gastric aspiration in reducing postoperative vomiting after oral and maxillofacial surgery: A meta-analysis

BACKGROUND

Gastric aspiration is applied in oral and maxillofacial procedures to reduce postoperative vomiting (POV), yet its clinical benefit remains largely uncertain. Our study aimed to determine the role of gastric aspiration in the amelioration of POV by a meta-analysis.

METHODS

With adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, global recognized databases, including PubMed, Embase, and Cochrane Central, were searched to obtain randomized controlled trials (RCTs) investigating the effects of gastric aspiration in oral and maxillofacial surgery. The incidence and the number of episodes of POV and the frequency of rescue antiemetic use were extracted as parametric data for pooled estimation. Funnel plots and Egger's test were utilized to assess bias. The recommendation of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

After detailed evaluation, 5 RCTs containing 274 participants were eventually included. The results of pooled estimation indicated that gastric aspiration could not reduce the incidence of POV (risk ratio [95% CI] = 0.94 [0.73, 1.21], P = .621), the number of episodes of POV (standard mean difference [95% CI] = -0.13 [-0.45, 0.19], P = .431) or the frequency of rescue antiemetic use (RR [95% CI] = 0.86 [0.49, 1.52], P = .609). No publication bias was detected by the funnel plot and Egger test. The overall recommendation of evidence was rated low regarding each outcome.

CONCLUSION

Based on current evidence, gastric aspiration is not recommended for oral and maxillofacial surgery. Meanwhile, more large-scale high-quality RCTs are needed.

Palonosetron versus ondansetron for prophylaxis of postoperative nausea and vomiting in laparoscopic cholecystectomy: a non-inferiority randomized controlled trial

BACKGROUND

We tested the hypothesis that, within the margin of 15% of risk difference, palonosetron is not inferior to ondansetron in reducing the incidence of postoperative nausea and vomiting (PONV) in laparoscopic cholecystectomy.

METHODS

We conducted a double-blind, non-inferiority, randomized, controlled trial of 212 patients aged 18 to 65 years undergoing laparoscopic cholecystectomy under general anesthesia in two secondary care hospitals. Patients were randomly assigned to receive either palonosetron (0.075.ßmg) or ondansetron (8.ßmg) intravenously at induction of anesthesia. Ondansetron (8.ßmg) was also administered 8 and 16.ßhours postoperatively. All anesthetic and surgical procedures were standardized. Patients were evaluated for 24.ßhours postoperatively for the occurrence of PONV.

RESULTS

A high incidence of PONV was observed at 2...6.ßhours postoperatively, with a rate of 36.8% (95% confidence interval [CI] 28.2...46.3) in the palonosetron group, as compared to 43.4% (95% CI 34.4...52.9) in the ondansetron group. The risk difference (95% CI) between palonosetron and ondansetron for PONV was 0 (-10.9 to 10.9) at 0...2.ßhours, -6.6 (-19.4 to 6.5) at 2...6.ßhours, -0.9 (-11.0 to 9.2) at 6...12.ßhours, and -2.8 (-9.6 to 3.6) at 12...24.ßhours. There was no statistically significant difference between the palonosetron and ondansetron groups in the use of rescue medication (dimenhydrinate). There were no adverse events associated with the medications under study.

CONCLUSION

Palonosetron is not inferior to ondansetron in patients at risk of PONV undergoing laparoscopic cholecystectomy, providing a good option for PONV prophylaxis, as it can be administered in a single dose.

Preoperative versus intraoperative antiemetic strategies in patients undergoing laparoscopic cholecystectomy: A randomised double-blind study

BACKGROUND

Previous studies have determined ondansetron's efficacy in preventing and treating postoperative nausea and vomiting (PONV). However, evidence regarding the timing of drug administration in relation to the surgical procedure remains vague.

OBJECTIVE

To compare the preoperative and intraoperative administration of ondansetron on the incidence of PONV.

DESIGN

Single-centred, randomised, double-blind trial. Patients were recruited between November 2018 and April 2021. Follow-up for PONV and retching was up to 24 h.

SETTING

Aretaieio University Hospital, Greece.

PATIENTS

A total of 121 patients undergoing elective laparoscopic cholecystectomy gave written consent.

INTERVENTIONS

Patients were randomly allocated to the preoperative or the intraoperative group. The preoperative group received 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 1 hour before induction of anaesthesia and 100 ml of 0.9% saline 30 min before end of surgery. The intraoperative group received 100 ml of 0.9% saline 1 h before induction of anaesthesia and 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 30 min before end of surgery.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of nausea and/or vomiting combined at 24 h.

RESULTS

No difference was found between the two groups regarding either the incidence of nausea and vomiting at 24 h (1.7% for the preoperative group versus 5.3% for the intraoperative group, P  = 0.31) or the incidence of nausea, vomiting and retching combined (5.3% for the preoperative group versus 10.5% for the intraoperative group, P  = 0.30). There was no difference between the groups in the pain intensity at rest or with coughing in the post anaesthesia care unit, at 4, 8 and 24 h postoperatively ( P  = 0.961, 0.929, 0.748 and 0.883 at rest, and 0.974, 0.220, 0.235 and 0.317 with coughing, respectively).

CONCLUSION

Under the current study design, we found no difference in the incidence of PONV between the administration of ondansetron 1 h before induction of anaesthesia and the intraoperative administration of ondansetron 30 min before the end of surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03023306.

Olanzapine as an add-on, pre-operative anti-emetic drug for postoperative nausea or vomiting: a randomised controlled trial

Postoperative nausea or vomiting occurs in up to 40% in patients with multiple risk factors, despite prophylaxis. Olanzapine is an antipsychotic drug that is used to prevent nausea and vomiting in palliative care and to treat chemotherapy-induced nausea and vomiting. This study aimed to examine whether pre-operative olanzapine, as a prophylactic anti-emetic added to intra-operative dexamethasone, ondansetron and total intravenous anaesthesia, reduced the incidence of postoperative nausea or vomiting. We performed a multiply-blinded randomised controlled trial in patients aged 18-60 years with cancer at high risk of postoperative nausea or vomiting (three or four risk factors according to the Apfel criteria) plus a previous history of chemotherapy-induced nausea and vomiting. Patients were allocated at random to receive 10 mg olanzapine or placebo orally 1 h before surgery in addition to a two-drug regimen (dexamethasone and ondansetron) and propofol anaesthesia to prevent postoperative nausea or vomiting. The primary outcome was the incidence of postoperative nausea or vomiting in the first 24 h after surgery. In total, 100 patients were enrolled; 47 in the olanzapine group and 49 in the control group completed the study. The baseline characteristics of the groups were similar. The incidence of postoperative nausea or vomiting in the first 24 h after surgery was lower in the olanzapine group (12/47, 26%) than in the control group (31/49, 63%) (p = 0.008, RR 0.40 (95%CI 0.21-0.79)). Adding pre-operative oral olanzapine to intra-operative dexamethasone and ondansetron was highly effective in reducing the risk of postoperative nausea or vomiting in the first 24 hours after surgery in patients with a previous history of chemotherapy-induced nausea and vomiting and at least three Apfel risk factors for postoperative nausea or vomiting.

Effects of sugammadex versus neostigmine on postoperative nausea and vomiting after general anesthesia in adult patients:a single-center retrospective study

We aimed to compare the effect of sugammadex to that of neostigmine with respect to the occurrence of postoperative nausea and vomiting (PONV) during the first 24 h following general anesthesia. This retrospective cohort study included patients who underwent elective surgery under general anesthesia in 2020 at an academic medical center in Seoul, South Korea. The exposure groups were determined according to whether the patient received sugammadex or neostigmine as a reversal agent. The primary outcome was PONV occurrence during the first 24 h postoperatively (overall). The association between the type of reversal agent and primary outcome was investigated using logistic regression while adjusting for confounding variables using stabilized inverse probability of treatment weighting (sIPTW). Of the 10,912 patients included in this study, 5,918 (54.2%) received sugammadex. Sugammadex was associated with a significantly lower incidence of overall PONV (15.8% vs. 17.7%; odds ratio, 0.87; 95% confidence interval [CI], 0.79-0.97; P = 0.010) after sIPTW. In conclusion, compared with neostigmine/glycopyrrolate, sugammadex use has a lower risk of PONV during the first 24 h following general anesthesia.

Comparison of the Effectiveness of Palonosetron and Ramosetron in Preventing Postoperative Nausea and Vomiting: Updated Systematic Review and Meta-Analysis with Trial Sequential Analysis

This updated systematic review and meta-analysis with trial sequential analysis aimed to compare the efficacy of the perioperative administration of palonosetron with that of ramosetron in preventing postoperative nausea and vomiting (PONV). A total of 17 randomized controlled trials comparing the efficacy of the perioperative administration of palonosetron to that of ramosetron for preventing PONV were included. The primary outcomes were the incidences of postoperative nausea (PON), postoperative vomiting (POV), and PONV, which were measured in early, late, and overall phases. Subgroup analysis was performed on the basis of the administration time of the 5-HT3 receptor antagonist and divided into two phases: early phase and the end of surgery. A total of 17 studies with 1823 patients were included in the final analysis. The incidence of retching (relative risk [RR] = 0.525; 95% confidence interval [CI] = 0.390 to 0.707) and late POV (RR = 0.604; 95% CI = 0.404 to 0.903) was significantly lower in the palonosetron group than in the ramosetron group. No significant differences were demonstrated in the incidence of PON, PONV, complete response, use of antiemetics, and adverse effects. Subgroup analysis showed that palonosetron was superior to ramosetron in terms of early PON, late PON, overall POV, and use of rescue antiemetics when they were administered early; in terms of retching, regardless of the timing of administration. Ramosetron was superior to palonosetron in terms of early PON when they were administered late. The prophylactic administration of palonosetron was more effective than that of ramosetron in preventing the development of retching and late POV. In this meta-analysis, no significant differences in PONV prevention between the two drugs were demonstrated. Further studies are required to validate the outcomes of our study.

Evaluation of penehyclidine for prevention of post operative nausea and vomitting in patients undergoing total thyroidectomy under total intravenous anaesthesia with propofol-remifentanil

Backgroud

Postoperative nausea and vomiting (PONV) is one of the most common complications after total thyroidectomy under general anesthesia. Total intravenous anesthesia (TIVA) has been documented to prevent PONV in patients undergoing total thyroidectomy. Penehyclidine, an anticholinergic agent with an elimination half-life of over 10 h, is widely used as premedication to reduce glandular secretion. This study aimed to explore the preventative effects of penehyclidine with propofol-remifentanil-TIVA to single-TIVA on PONV in patients undergoing total thyroidectomy.

Methods

A total of 100 patients scheduled for total thyroidectomy were randomly assigned to either the penehyclidine group (n = 50) or TIVA group (n = 50). Propofol and remifentanil were was used for TIVA in all patients. No patients who received premedication. Patients were administrated with either 5 ml of normal saline or 0.5 mg of penehyclidine soon after anesthesia induction. The incidence of nausea and vomiting, the severity of nausea, the requirement of rescue antiemetics, and adverse effects were investigated during the first 24 h in two time periods (0–2 h and 2–24 h).

Results

The overall PONV incidence during the 24 h after surgery was significantly lower in the penehyclidine group compared with the TIVA group (12% vs 36%, P < 0.005). Besides, the incidence of nausea and the incidence of vomiting were significantly lower in the penehyclidine group compared with the TIVA group at 2–24 h after surgery. However, there was no significant difference between the two groups at 0–2 h after surgery.

Conclusions

Administration of penehyclidine under TIVA with propofol-remifentanil is more effective for prevention of PONV than TIVA alone, especially 2–24 h after total thyroidectomy.

Trial registration

https://www.chictr.org.cn/edit.aspx?pid=132463&htm=4 (Ref: ChiCTR2100050278, the full date of first registration: 25/08/2021).

Effect of the preoperative physical status on postoperative nausea and vomiting risk: a matched cohort study

BACKGROUND

The American Society of Anesthesiologists Physical Status Classification System is commonly used for preoperative assessment. Patient physical status before surgery can play an important role in postoperative nausea and vomiting. However, the relationship between the physical status classification and postoperative nausea and vomiting has not been well defined.

METHODS

Adults aged ≥ 18 years who underwent procedures under anesthesia between 2015 and 2020 were included in the study. We analyzed the relationship of postoperative nausea and vomiting with physical status classification score using propensity score matching and Cox hazard regression. Differences in intraoperative use of vasopressor and inotropes and invasive monitoring were investigated according to the classification.

RESULTS

A total of 163,500 patients were included in the study. After matching, classification 1 versus 2 included 43,400 patients; 1 versus ≤ 3, 13,287 patients; 2 versus ≤ 3, 23,530 patients (absolute standardized difference, 0-0.06). Patients with physical status classification ≤ 3 had a significantly lower postoperative nausea and vomiting risk than those with classification 1-2 (physical status classification 1 vs. ≤ 3, hazard ratio 0.76 [0.71-0.82], P < 0.001; 2 versus ≤ 3, hazard ratio 0.86 [0.82-0.91], P < 0.001). Intraoperative use of vasopressor or inotrope and invasive monitoring were noted more in the high physical status classification than the low physical status classification (absolute standardized difference [0.19-1.25]).

CONCLUSION

There were differences in intraoperative invasive monitoring and use of vasopressor or inotrope among the classifications, and a score of 3 or higher reduced the risk of postoperative nausea and vomiting more than a score of 1-2.

Usefulness of criteria for intraoperative Management of Postoperative Nausea and Vomiting

Background

Postoperative nausea and vomiting (PONV) delays postoperative recovery, prolongs hospital stays, and hinders patients’ return to society, thus making it a major cause of increased healthcare costs. It is also the most troubling postoperative complication in female patients undergoing surgery. However, in Japan, guidelines for the management of PONV have not been established, and the management protocol for PONV is left to each institution and anesthesiologist. Therefore, we developed criteria for intraoperative management of PONV.

Methods

In female surgical patients, the usefulness of the criteria was evaluated by comparing the implementation rate of intraoperative management and PONV incidence before and after the establishment of the criteria. An Apfel simplified score (Apfel score) ≥2 was set as an indication for intraoperative management of PONV.

Results

The implementation rate of intraoperative management increased from 91.2 to 96.0% after the introduction of the criteria. In patients with an Apfel score of 2, the intraoperative management implementation rate significantly increased from 81.1 to 94.7% (p = 0.016), while PONV incidence significantly decreased from 44.6 to 34.1% after the introduction of the criteria (p = 0.040).

Conclusions

The criteria for intraoperative management of PONV increased the implementation rate of intraoperative management and decreased PONV incidence, indicating the usefulness of the criteria.

The effect of timing and dosing of 5% and 10% Dextrose versus Saline on postoperative nausea and vomiting in high-risk women following ambulatory surgeries: a randomized double-blind controlled trial

BACKGROUND

A common complication after outpatient surgeries is postoperative nausea and vomiting (PONV) which is concomitant with high levels of patient distress and dissatisfaction. Perioperative dextrose-containing fluid administration has been used as a non-pharmacologic preventive measure against postoperative nausea and vomiting (PONV). However, its efficacy remains unclear. This study aimed to compare different concentrations of dextrose solution on PONV for 24 hours after surgery.

METHODS

A randomized double-blind controlled study of 120 women were divided into three equal groups. Group C, was infused with IV 0.9% saline 100 ml/h for 2 hours (200 ml) starting 1 hour before anesthesia and ending during surgery. Group D5%, was infused with dextrose 5%. Group D10%, was infused with D10%. PONV within 24 hours was compared between groups by PONV score. Other outcomes were the antiemetic drugs needed, VAS score, total fentanyl consumption, hemodynamic data, unplanned admission, and complications RESULTS: The incidence of nausea and vomiting was significantly reduced in dextrose 10% and 5% patients in comparison to the control group (5 patients (12.5%), 18 (42.5%), and 39 (87.5%) respectively). The request for antiemetic drugs decreased significantly in groups D10% and 5% than in group C (36 patients did not receive any antiemetics (90%), 29 (72.5%) and 19 (47.5%) respectively, P-value=0.002). Postoperative pain prevalence in patients with PONV was significantly different only at 24 h, P-value=0.03.

CONCLUSIONS

There was a potential role for preoperative IV infusion of dextrose 10% solution that significantly reduces the incidence and severity of PONV and pain in patients at high risk for PONV.

The preventive and relieving effects of ginger on postoperative nausea and vomiting: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Postoperative nausea and vomiting are common uncomfortable symptoms experienced by patients. Besides drugs, non-pharmaceutical therapies such as herbal medicine therapy are available. Ginger has played a therapeutic role in patients undergoing chemotherapy and pregnant women, but results from postoperative patients are inconsistent.

OBJECTIVES

The aim of this study was to examine and evaluate the preventive effect of ginger on postoperative nausea and vomiting.

DESIGN

A systematic review and meta-analysis of randomized controlled trials METHODS: Two independent researchers searched Chinese and English databases from their inception dates to November 2020. The Chinese databases used were CNKI and SinoMed, and the English databases used were PubMed, Embase, and the Cochrane Library. We only included randomized controlled trials. The primary outcomes were nausea score, presented as standard mean difference, and the number of vomiting episodes, presented as risk ratio. The secondary outcomes were side effects and antiemetic drug use, presented as risk ratios. We used the random-effects model.

RESULTS

Fourteen randomized trials with a total of 1,506 patients were pooled. At the different time points, the control group had higher postoperative nausea scores than the experimental group, and the differences were significant between the ginger and placebo groups at 2, 6, and 12 h after operation, with standard mean differences and 95% confidence intervals of -1.10 and -1.95 to -0.25, -1.54 and -3.05 to -0.03, and -2.04 and -3.67 to -0.41, respectively. Except in the recovery room, no statistically significant correlation was found between ginger intake and postoperative vomiting, postoperative nausea and vomiting, or antiemetic drug use.

CONCLUSION

The results of this meta-analysis demonstrate that ginger can reduce postoperative nausea but showed no significant difference in the incidence rates of postoperative vomiting, postoperative nausea and vomiting, and antiemetic drug use. More high-quality and rigorous trials are needed to elucidate the relationship between ginger intake and the reduction in the incidence of postoperative nausea and vomiting.

PROTOCOL REGISTRATION

CRD42020220916.

Efficacy of evidence-based institutional protocol for prevention of postoperative nausea and vomiting: A prospective observational study

BACKGROUND

Postoperative nausea and vomiting (PONV) is the second most common complaint in the postoperative period, often resulting in increased post anaesthesia care unit (PACU) and hospital stay. Translation of knowledge into consistent practice was considered a major gap. Hence, the present study was undertaken to test the efficacy of locally developed evidence-based institutional protocol for prevention of PONV.

METHODS

Phase I consisted of determining the baseline incidence of PONV before introduction of the institutional protocol for PONV prophylaxis. In phase II, educational sessions for anaesthesiologists for PONV prevention and treatment were conducted, after which an institutional protocol was introduced. In phase III, this protocol was implemented, and the incidence of PONV was recorded using the same methodology as in phase I. The rate of adherence to the institutional protocol was also recorded.

RESULTS

The incidence of postoperative nausea (PON) dropped significantly from 32.5% in phase I to 20% in phase III (p = 0.033). Similarly, the incidence of postoperative vomiting (POV) decreased from 20.5% in phase I to 9.1% in phase III (p = 0.016). Of all anaesthesiologists, 78.18% were noted to adhere to the protocol in phase III. Incidence of PON and POV was significantly less in patients in whom PONV prophylaxis was administered in adherence to protocol (8.3% vs 57.7%, p < 0.001; 3.6% vs 26.9%, p < 0.001, respectively).

CONCLUSION

Evidence-based institutional protocols are effective in significantly reducing the incidence of PONV in adults undergoing noncardiac surgery under anaesthesia.

CLINICAL TRIAL NUMBER AND REGISTRY URL

The trial was registered with Clinical Trials Registry of India (http:/ctri.nic.in) (CTRI/2015/12/006432).

Midazolam versus dexamethasone-ondansetron in preventing post-operative nausea-vomiting in patients undergoing laparoscopic surgeries

BACKGROUND

Midazolam reduces post-operative nausea and vomiting (PONV) when compared to a placebo or when used as an adjuvant to other antiemetics. The present study was designed to compare midazolam with a combination of dexamethasone-ondansetron in preventing PONV.

METHODS

One hundred and twenty patients undergoing laparoscopic surgeries having 2 or more risk factors for PONV (simplified Apfel score) were randomised into 2 groups of 60 each. Patients in group D received 8-mg dexamethasone and 4-mg ondansetron for PONV prophylaxis while those in group M received 2-mg midazolam towards the end of surgery. The proportion of patients (frequency) who had PONV, post-operative nausea (PON) and post-operative vomiting (POV) was noted over 24 hours over the following intervals: 0-2 hours, 2-24 hours and 0-24 hours.

RESULTS

The frequency of PONV at 24 hours in group D and group M was 30% and 33.3% respectively and was not significantly different (P = .70). There was no difference in the time to achieve post-anaesthesia discharge score of ≥9 between the two groups {5 minutes (5, 5) in group D; 5 minutes (1.25, 5) in group M, P = .48}. Ten patients in group D and 11 in group M required a rescue antiemetic over 24 hours (P = .81). The frequency of PON, POV and PONV as well as the median PONV score was similar at all time periods.

CONCLUSION

Midazolam does not result in significantly different frequency of PONV than a combination of dexamethasone-ondansetron.

Postoperative Nausea and Vomiting After Craniotomy: An Evidence-based Review of General Considerations, Risk Factors, and Management

One of the most common and distressing symptoms after craniotomy is postoperative nausea and vomiting (PONV). PONV could generate delayed postanesthesia care and hospitalization discharge, lower patient satisfaction, and an increase in overall hospitalization costs. The incidence of reported PONV after craniotomy is 22% to 70% without prophylaxis, and a multimodal regimen of medication has been recommended. We conducted a comprehensive literature review of the clinical evidence related to PONV prevention and management after craniotomy. All clinical trials in adult populations relevant to PONV after craniotomy available in English language and indexed in PubMed, Google Scholar and Cochrane Library databases from January 1997 up to September 2018 were retrieved using a combination of free-text words related to PONV in craniotomy. After screening manuscripts identified in the initial search, 23 clinical trials investigating systemic pharmacological intervention versus placebo or active control in patients undergoing craniotomy under general anesthesia met the criteria for inclusion in this comprehensive narrative review. The pathophysiology and mechanisms of PONV after craniotomy could be multifactorial in etiology. Therefore, based on current evidence, PONV management after craniotomy should focus on perioperative patient assessment, surgical, and anesthesia-related risk factors and the selection of systemic pharmacological considerations to reduce its incidence and complications. A multimodal regimen of medication targeting different chemoreceptors in the vomiting center is recommended. Ondansetron and dexamethasone, or their combination, are the most frequently used and effective agents. Further randomized clinical trials comparing different regimens that significantly reduce the incidence of PONV in craniotomy would provide relevant evidence-based data for PONV management in this patient population.

Prevalence of Nausea-Vomiting and Coping Strategies in Patients Undergoing Outpatient Surgery

PURPOSE

The present study aimed to determine the prevalence and coping strategies for postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) in patients undergoing outpatient surgery.

DESIGN

A descriptive research design was used.

METHODS

This descriptive study was carried out with 350 patients who were admitted within the scope of outpatient surgery of the ear, nose, and throat; orthopaedics, urology, and general surgery departments of a university hospital between July 3, 2017 and March 6, 2018. A patient diagnosis form consisting of 34 items developed by the researcher and nausea-vomiting diary were used to collect data.

FINDINGS

The results showed that 30.6% of the patients had PONV and 26.3% had PDNV. Of the 92 patients with postdischarge nausea, 26.1% experienced mild, 44.6% moderate, 20.7% high, and 8.7% severe nausea. Among the strategies for coping with PDNV, the patients preferred resting (49%), going outdoors (23.4%), eating something (17%), and drinking something (10.6%). A statistically significant difference was found between postdischarge nausea and risk factors for nausea-vomiting, such as female gender, history of nausea-vomiting, nausea in the postanesthesia care unit, and opioid use in the postanesthesia care unit (P < .05).

CONCLUSIONS

This study shows that approximately a quarter of patients who undergo outpatient surgery will experience nausea and vomiting immediately after surgery as well as at home after discharge. Assessment of risk factors for PONV/PDNV was discovered to be an important factor in the care of perioperative patients. Therefore, the risk scoring system is expected to contribute to reducing PONV/PDNV incidence and improving patient coping strategies and satisfaction.

Interpretation of the four risk factors for postoperative nausea and vomiting in the Apfel simplified risk score: an analysis of published studies

PURPOSE

The Apfel simplified risk score, developed in 1999, is the most widely used tool for risk stratification of postoperative nausea and vomiting (PONV). It includes four risk factors: female sex, non-smoking status, history of PONV or motion sickness, and use of postoperative opioids. Nevertheless, there is considerable heterogeneity in the definition and application of these risk factors in PONV research. Our aim was to determine how these risk factors are implemented in studies employing the Apfel score.

METHODS

Citations of the index Apfel score paper between 1 September 1999 and 1 September 2019 were identified in the Scopus database. Original full-text reports in English measuring all four risk factors were eligible for inclusion. Data collected included the definition, timing, and collection method of the four risk factors.

RESULTS

Of the identified studies, 255 of the 535 reported all four risk factors, with calculated Apfel risk scores reported in 116 of the 255 (46%) papers. Smoking, PONV, motion sickness, and postoperative opioid use were defined in four (2%), zero (0%), one (0.4%), and seven (3%) papers, respectively. Postoperative opioid use was defined as "anticipated" in 138 (54%) studies and "actual" in 72 (18%) studies and was unclear in 45 (28%) studies.

CONCLUSIONS

Significant variation exists in how the Apfel risk factors are defined and applied in PONV research, particularly with respect to postoperative opioid use. More guidance in the application of this tool may optimize risk estimation and PONV prophylaxis, and potentially improve research quality.

Comparison of the Effects of Sugammadex, Neostigmine, and Pyridostigmine on Postoperative Nausea and Vomiting: A Propensity Matched Study of Five Hospitals

Thus far, few studies have compared the effects of sugammadex and cholinesterase inhibitors on postoperative nausea and vomiting (PONV), and the results have been controversial. Here, we compared the effects of sugammadex, neostigmine, and pyridostigmine on PONV by means of a five hospital analysis with propensity score matching. We analyzed adults aged ≥ 18 years who underwent general anesthesia between January 2014 and December 2019. Following propensity score matching, 7793 patients were included in each of the neostigmine and sugammadex matched patient groups (absolute standardized difference (ASD), 0.01–0.07), and 10,197 patients were included in each of the pyridostigmine and sugammadex matched patient groups (ASD, 0.01–0.02), while 19,377 patients were included in each of the pyridostigmine and neostigmine matched patient groups. (ASD, 0.01–0.19). The odds of PONV were low in the sugammadex group (odds ratio, 0.65; 95% confidence interval, 0.59–0.72; p < 0.0001) and pyridostigmine group (odds ratio, 0.22; 95% confidence interval, 0.20–0.24; p < 0.0001) compared to the neostigmine group, while there was no difference between sugammadex and pyridostigmine (odds ratio, 0.95; 95% confidence interval, 0.86–1.04; p = 0.281). Therefore, sugammadex and pyridostigmine may lower the incidence of PONV compared to neostigmine in patients undergoing general anesthesia.

A Comparative Study Between Ondansetron and Gabapentin for Prevention of Postoperative Nausea and Vomiting Following Maxillofacial Surgery

Background and Aim

Gabapentin is an antiepileptic drug with antiemetic properties. We evaluated prophylactic oral gabapentin as compared with ondansetron for postoperative nausea and vomiting (PONV) in patients undergoing maxillo facial surgery.

Settings and Design

A double-blind, randomized study in a teaching hospital.

Materials and Methods

Seventy patients of ASA physical status I and II, scheduled to undergo maxillofacial surgery, were randomly assigned into two groups to receive 300 mg gabapentin or 8 mg ondansetron 1 h before surgery. Standard anaesthesia technique was used in all patients. Students' t test for difference of means between two groups was used for continuous variables. Chi square or Fisher's exact test was used for comparing proportion between two groups. Kaplan-Meier survival analysis was performed to compare the time to event observed between ondansetron and gabapentin groups. Log-rank test was performed to detect statistical significance of time to events between two groups.

Results

There was no significant difference in incidence of PONV between two groups within 2 h postoperatively. No incidence of PONV was observed in gabapentin group within 2-24 h as compared to ondansetron group in which PONV was observed in five cases.

Conclusion

Gabapentin effectively suppresses PONV in maxillo facial surgery.

[Risk factors for post-caesarean nausea and vomiting: a prospective prognostic study]

BACKGROUND

Postoperative Nausea and Vomiting (PONV) risk factors have not been defined for obstetric patients. In this study, our objective was to identify potential risk factors for PONV after cesarean sections performed under spinal anesthesia.

METHODS

One cohort of patients submitted to cesarean under spinal anesthesia was used to investigate potential risk factors for PONV. The best numerical risk factors were dichotomized using chi-squared method. A conditional independence (incremental association method) casual network was used to select the best predictors for PONV.

RESULTS

Two hundred and fifty of 260 patients remained in the study. Odds ratio for PONV of younger maternal age (< 25 years: 2.9 [1.49-5.96]), lower spinal bupivacaine dose (< 13 mg, inf [2.4-inf]), lower spinal morphine dose (< 80 mg, 0.03 [0-0.97]), history of motion sickness (2.5 [1.27-5.25]), significant nausea during the first trimester (0.3 [0.16-0.64]), intraoperative nausea and vomiting (8.2 [3.67-20.47]), and lower gestational age (< 38 weeks, 2.0 [1.01-4.08]) were statistically significant. The causal network selected absence of significant nausea during the first gestational trimester, intraoperative nausea, and gestational age < 38 weeks as the main direct risk factors for PONV.

CONCLUSIONS

Intraoperative nausea and maternal age < 25 years were the main risk factors for PONV after cesareans under spinal anesthesia. Absence of self-reported nausea during the first trimester was a protective factor for post-cesarean nausea and vomiting.

Risk factors for post-caesarean nausea and vomiting: a prospective prognostic study

Background

Postoperative Nausea and Vomiting (PONV) risk factors have not been defined for obstetric patients. In this study, our objective was to identify potential risk factors for PONV after cesarean sections performed under spinal anesthesia.

Methods

One cohort of patients submitted to cesarean under spinal anesthesia was used to investigate potential risk factors for PONV. The best numerical risk factors were dichotomized using chi-squared method. A conditional independence (incremental association method) casual network was used to select the best predictors for PONV.

Results

Two hundred and fifty of 260 patients remained in the study. Odds ratio for PONV of younger maternal age (< 25 years: 2.9 [1.49−5.96]), lower spinal bupivacaine dose (< 13 mg, inf [2.4-inf]), lower spinal morphine dose (< 80 mg, 0.03 [0−0.97]), history of motion sickness (2.5 [1.27−5.25]), significant nausea during the first trimester (0.3 [0.16−0.64]), intraoperative nausea and vomiting (8.2 [3.67−20.47]), and lower gestational age (< 38 weeks, 2.0 [1.01−4.08]) were statistically significant. The causal network selected absence of significant nausea during the first gestational trimester, intraoperative nausea, and gestational age < 38 weeks as the main direct risk factors for PONV.

Conclusions

Intraoperative nausea and maternal age < 25 years were the main risk factors for PONV after cesareans under spinal anesthesia. Absence of self-reported nausea during the first trimester was a protective factor for post-cesarean nausea and vomiting.

Assessment of postoperative nausea and vomiting after bariatric surgery using a validated questionnaire

BACKGROUND

Postoperative nausea and vomiting (PONV) is known to occur after bariatric surgery, with over two thirds of patients affected. However, variability exists in how to objectively measure PONV.

OBJECTIVES

The goals of the present study were to use a validated, patient-centered scoring tool, the Rhodes Index of Nausea, Vomiting, and Retching to measure the severity of PONV after bariatric surgery, to directly compare PONV between patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), and to identify risk factors for the development of PONV after bariatric surgery.

SETTING

Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri, United States of America.

METHODS

The Washington University Weight Loss Surgery team prospectively surveyed patients from January 1, 2017 to December 1, 2018 at the following 6 different timepoints: postoperative day (POD) 0, POD 1, POD 2, POD 3 to 4, the first postoperative outpatient visit (POV 1: POD 5-25), and the second postoperative visit (POV 2: POD 25-50). At each timepoint, a cumulative Rhodes score was calculated from the sum of 8 questions. The American Society for Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to collect patient demographic characteristics and perioperative clinical data.

RESULTS

A total of 274 patients met study criteria and completed 605 Rhodes questionnaires. Two hundred fifty Rhodes questionnaires were completed by patients after SG and 355 were completed by patients after LRYGB. Total Rhodes scores are statistically higher in LSG patients compared with patients who underwent LRYGB (LSG = 5.45 ± 6.27; LRYGB = 3.08 ± 4.19, P = .0002). Additionally, at the earlier timepoints, scores were higher among patients who underwent LSG than those who had undergone LRYGB as follows: POD 0 (LSG = 6.96 ± 6.50; LRYGB = 2.89 ± 2.90, P = .0115), POD 1 (LSG = 8.20 ± 6.76; LRYGB = 2.88 ± 3.44, P < .0001), and POD 2 (LSG = 4.05 ± 4.88; LRYGB = 2.06 ± 3.43, P = .05). On subset analysis, examining patients who either underwent an LSG or LRYGB, both procedures had a statistically significant PONV peak emerge on POV 2. Last, overall Rhodes scores were statistically higher in female patients compared with male patients (female: 4.43 ± 5.46; male: 2.35 ± 3.90, P = .021). Although the magnitude of the difference varied somewhat across POD time intervals, the difference was most pronounced at POV 2.

CONCLUSIONS

This is the largest study using a validated nausea and vomiting questionnaire to objectively measure PONV after bariatric surgery. The factors found to be most associated with increased PONV were LSG and female sex. Ultimately, these data can help bariatric surgery programs, including Washington University Weight Loss Surgery, identify patients who may require more intensive treatment of PONV, particularly POD 0 to 2, and help to identify patients that continue to struggle with PONV in the later surgical recovery phase.

Effects of intravenous dextrose on preventing postoperative nausea and vomiting: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

It is reported that postoperative nausea and vomiting, common general anesthesia complications, may be prevented by perioperative intravenous dextrose administration, but with controversial clinical effectiveness.

OBJECTIVE

To evaluate perioperative intravenous dextrose for preventing postoperative nausea and vomiting through a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis.

DATA SOURCES

MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, clinicaltrials.gov, and the University Hospital Medical Information Network Clinical Trials Registry were searched from inception until 22 June 2019.

ELIGIBILITY CRITERIA

Trials investigating intravenous dextrose effects vs. placebos on postoperative nausea and vomiting in patients who underwent general anesthesia.

RESULTS

Eleven trials (1,250 patients) were included. All participants were ASA1-2. The nine trials included laparoscopic surgeries, and 92.2% of the participants were women. The timing of dextrose infusion was before, during, and after surgery in three, five, and three trials, respectively. Our results revealed intravenous dextrose administration significantly reduced postoperative nausea, but not vomiting, during early and late postoperative periods (risk ratio [95% confidence interval], early nausea: 0.76 [0.59-0.99], late nausea: 0.65 [0.48-0.89]; early vomiting: 1.00 [0.81-1.25], late vomiting: 0.96 [0.43-2.16]). Evidence quality was downgraded to low because the trial sequential analysis indicated more trials are needed for firm conclusions.

CONCLUSIONS

Compared with placebos, perioperative intravenous dextrose administration may decrease postoperative nausea but not vomiting.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (registration number: UMIN000030901).

A pharmacological profile of intravenous amisulpride for the treatment of postoperative nausea and vomiting

INTRODUCTION

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 the pain. New antiemetics of different classes are still needed to help manage PONV effectively, especially the treatment of established PONV after the failure of common prophylactic antiemetics such as 5-HT₃-antagonists and corticosteroids. Intravenous amisulpride, a drug with a long history of safe use in oral form as an antipsychotic, has recently been approved in the US (trade name: Barhemsys) as an intravenous antiemetic for the prevention and treatment of PONV.

AREAS COVERED

This review article summarizes the published data on the clinical pharmacology, safety, and efficacy of intravenous amisulpride as an antiemetic, supplemented by published data on oral amisulpride, where relevant to the intravenous form. Literature was obtained via the PubMed search terms 'intravenous amisulpride' and 'amisulpride AND safety.' Both primary and secondary pharmacology are covered, along with clinical pharmacokinetics (distribution, metabolism, and excretion). The review of clinical safety and efficacy includes data from four studies in the prevention of PONV, two in the treatment of PONV and two investigating effects on the QT interval of the electrocardiogram in healthy volunteers.

EXPERT OPINION

Given the importance of sufficient PONV prevention for patients and the healthcare system, the availability of intravenous amisulpride is helpful, restoring the dopamine-antagonist class as a potential mainstay in both combination prophylaxis and treatment.

Comparison of palonosetron and ondansetron to prevent postoperative nausea and vomiting in women using intravenous patient-controlled analgesia

Background

We compared the effects of palonosetron with ondansetron for preventing postoperative nausea and vomiting (PONV) during the first 24 h after surgery in women receiving intravenous patient-controlled analgesia (IV-PCA) with fentanyl for pain control.

Methods

In this prospective, randomized, double-blinded study, 204 healthy patients who were undergoing elective surgery with general anesthesia were enrolled. In the palonosetron group (n = 102), 0.075 mg bolus was given intravenously (i.v.) 30 min before the end of surgery and 8 ml saline was added to the IV-PCA. In the ondansetron group (n = 102), 8 mg bolus i.v. was given 30 min before the end of surgery and 16 mg of ondansetron was added to the IV-PCA. The incidence of PONV, severity of nausea, and use of rescue anti-emetics were evaluated 6 and 24 h after the operation.

Results

The incidences of nausea (55.6%) and vomiting (14.1%) in the palonosetron group did not differ from those (58.3 and 19.8%) in the ondansetron group during the first 24 h after surgery (P > 0.05). No significant differences were observed in the severity of nausea and use of rescue anti-emetics between the two groups (P > 0.05).

Conclusions

The effects of palonosetron in preventing PONV were not different from those of ondansetron during the first 24 h postoperatively in women receiving IV-PCA with fentanyl.

Intraoperative Multipoint Acupuncture for Reducing Postoperative Nausea and Vomiting in High-Risk Children: A Case Series

Acupuncture studies have demonstrated varying effects on pediatric postoperative nausea and vomiting (PONV). Unanswered questions include whether the type of therapy, number of points used, or timing of treatments vary the effect of acupuncture. We present a case series of intraoperative multipoint acupuncture treatments for high-risk pediatric patients. Fourteen patients were included, and 19 treatments were provided. Twelve patients (85.7%) had previous PONV. Patients who received intraoperative acupunctur e reported no early phase PONV, and 3 patients (15.8%) reported late-phase PONV. One patient required postoperative antiemetics. Intraoperative multipoint acupuncture may be a safe and efficacious adjunct for PONV in high-risk pediatric patients.

Palonosetron versus ondansetron for prevention of nausea and vomiting after total abdominal hysterectomy under spinal anesthesia with intrathecal morphine: a double-blind, randomized controlled trial

Background

Hysterectomy is a widely performed surgery and neuraxial anesthesia with intrathecal morphine provides superior quality of recovery. Postoperative nausea and vomiting (PONV) is a frequent problem with intrathecal morphine use. Although palonosetron is effective for prevention of PONV after general anesthesia, its efficacy after neuraxial anesthesia has not been established. This study was conducted to compare the use of palonosetron with ondansetron for PONV prophylaxis in patients at a high risk of PONV during total abdominal hysterectomy (TAH) under spinal anesthesia with intrathecal morphine.

Methods

This prospective, randomized double-blind study conducted at São Rafael Hospital involved 140 American Society of Anesthesiologists physical status I or II women who underwent TAH under spinal anesthesia with intrathecal morphine and who had at least 3 risk factors for PONV based on Apfel’s simplified score. The patients were randomized into two groups: one received palonosetron whereas the other received ondansetron. All patients received spinal anesthesia with intrathecal morphine, as well as dexamethasone plus palonosetron or ondansetron for PONV prophylaxis. The overall incidence of PONV, incidence of early- and late-onset nausea and vomiting, severity of nausea, and use of rescue antiemetics were recorded.

Results

The overall incidence of PONV was 42.9% in the palonosetron group and 52.9% in the ondansetron group (p > 0.05). No significant differences existed in the incidence of early- and late-onset nausea or early-onset vomiting between the two groups. The incidence of late-onset vomiting was significantly lower in the palonosetron group.

Conclusions

Palonosetron exhibited efficacy similar to that of ondansetron for reducing the overall incidence of PONV after TAH under spinal anesthesia with intrathecal morphine; however, palonosetron reduced the incidence of late-onset vomiting significantly better than ondansetron.

Trial registration

RBR-4gnm8n (ensaiosclinicos.gov.br), date of registration: August 18, 2014.

Incidence, Timing, and Factors Associated with Postoperative Nausea and Vomiting in the Ambulatory Surgery Setting

PURPOSE

To examine incidence, timing, and factors associated with postoperative nausea and vomiting (PONV) in patients recovering in the ambulatory postanesthesia care unit (PACU).

DESIGN

Descriptive correlational, cross-sectional.

METHODS

Data were collected prospectively, including patient, surgery, anesthesia, and postoperative factors associated with PONV. Independent predictors of nausea were determined using logistic regression.

FINDINGS

In 139 randomly selected patients, 10.8% had nausea and 2.9% vomited. On arrival to the PACU, 3 patients had nausea, which increased incrementally to 10 during the next 90 minutes, declining to 3 by 150 minutes. These patients had significantly more hydration and longer PACU stays. Fifty-three percent had nausea at discharge. Younger age and gastroesophageal reflux disease were significantly and independently associated with nausea.

CONCLUSIONS

PONV is relatively infrequent, but remains a distressing problem resulting in negative surgical experiences and increased cost. Future research is warranted to examine gastroesophageal reflux disease as a novel risk factor.

Comparison of ondansetron, tropisetron, and palonosetron for the prevention of postoperative nausea and vomiting after middle ear surgery

Background

Postoperative nausea and vomiting (PONV) are 2 of the most frequent adverse effects of anesthesia. PONV prolongs hospital stays and also delays the recovery of patients.

Objective

In this study, the effects of ondansetron, tropisetron, and palonosetron on PONV in patients who had undergone middle ear surgeries such as mastoidectomy or tympanoplasty were compared.

Methods

The study included 165 American Society of Anesthesiologists grade 1 and 2 patients aged 18 to 65 years. Patients were randomized into 3 groups by a closed envelope method. Neither the patients nor the nurses administering the treatments knew which patient belonged to which group. The anesthetic technique was standardized for all groups. During skin closure, 0.075 mg palonosetron, 5 mg tropisetron, and 8 mg ondansetron were administered intravenously to the palonosetron, tropisetron, and ondansetron groups, respectively. After completion of the surgery, the patients were followed for 48 hours. Diclofenac sodium (100 mg IM) was administered to patients experiencing pain and metoclopramide chloride (10 mg IM) was administered to patients with nausea or vomiting. Potential side effects such as headache and constipation were recorded in the postanesthesia care unit and ear, nose, and throat clinic.

Results

There was no significant difference in the effects of all 3 antiemetic agents on the severity of PONV (P = 0.081). At 48 hours postoperatively, the incidence of PONV was significantly lower in the palonosteron group (38.2%) than the ondansetron group (63.6%) and tropisetron group (61.8%) (P = 0.011). At 48 hours postoperatively, the incidence of postoperative nausea was significantly lower in the palonosetron group (32.7%) than in the ondansetron group (63.6%) and the tropisetron group (56.4%) (P = .003). The incidence of PONV between hours 12 and 24 postoperatively was significantly higher in the ondansetron group (27.3%) than in the palonosetron group (9.1%) (P = 0.013). The antiemetic requirement in the first hour after surgery was significantly higher in the tropisetron group (25.5%) than in the palonosetron group (7.3%) (P = .019).

Conclusions

The results of the current study support those of earlier studies that suggest that palonosetron was statistically more effective than the other 2 formulations in the prevention of PONV in patients who have undergone middle ear surgery. (Curr Ther Res Clin Exp. 2019; 80:XXXXXX).

Outcomes in video laryngoscopy studies from 2007 to 2017: systematic review and analysis of primary and secondary endpoints for a core set of outcomes in video laryngoscopy research

BACKGROUND

Airway management is crucial and, probably, even the most important key competence in anaesthesiology, which directly influences patient safety and outcome. However, high-quality research is rarely published and studies usually have different primary or secondary endpoints which impedes clear unbiased comparisons between studies. The aim of the present study was to gather and analyse primary and secondary endpoints in video laryngoscopy studies being published over the last ten years and to create a core set of uniform or homogeneous outcomes (COS).

METHODS

Retrospective analysis. Data were identified by using MEDLINE® database and the terms "video laryngoscopy" and "video laryngoscope" limited to the years 2007 to 2017. A total of 3351 studies were identified by the applied search strategy in PubMed. Papers were screened by two anaesthesiologists independently to identify study endpoints. The DELPHI method was used for consensus finding.

RESULTS

In the 372 studies analysed and included, 49 different outcome categories/columns were reported. The items "time to intubation" (65.86%), "laryngeal view grade" (44.89%), "successful intubation rate" (36.56%), "number of intubation attempts" (23.39%), "complications" (21.24%), and "successful first-pass intubation rate" (19.09%) were reported most frequently. A total of 19 specific parameters is recommended.

CONCLUSIONS

In recent video laryngoscopy studies, many different and inhomogeneous parameters were used as outcome descriptors/endpoints. Based on these findings, we recommend that 19 specific parameters (e.g., "time to intubation" (inserting the laryngoscope to first ventilation), "laryngeal view grade" (C&L and POGO), "successful intubation rate", etc.) should be used in coming research to facilitate future comparisons of video laryngoscopy studies.

Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery

BACKGROUND

Nonintubated video-assisted thoracic surgery (VATS) has been widely developed during the recent years. Cough reflex is an inevitably encountered problem while approaching lung lesions, and it may induce major bleeding. Sevoflurane anesthesia may attenuate cough reflex by inhibiting the pulmonary irritant receptors. However, the incidence of postoperative nausea and vomiting (PONV) in inhalational anesthesia is higher than in the propofol-based total intravenous anesthesia (TIVA). We investigated the effect of sevoflurane combination with propofol-based TIVA on cough reflex and PONV in nonintubated VATS.

METHODS

Ninety patients undergoing nonintubated VATS with laryngeal mask airway (LMA) and spontaneous breathing were randomly assigned for TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 45), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane (P/S) group (n = 45), 1% sevoflurane anesthesia was added to propofol and fentanyl anesthesia. The primary outcome measurements were cough reflex. In addition, the incidence of PONV and extubation time were investigated.

RESULTS

Patients with cough reflex were significantly fewer in the P/S group than in the TIVA group (10/45 vs 34/45; P < .001). The cough severity (35/5/5/0 vs 11/17/17/0; P < .001) and limb movement (40/5/0/0 vs 28/17/0/0; P < .001) were lower in the P/S group than in the TIVA group. Besides, incremental fentanyl bolus for cough reflex was 5 (0 [0-1]) in the P/S group and 17 (0 [0-3]) in the TIVA group (P < .05). And there was no conversion to general anesthesia, postoperative hemorrhage, aspiration pneumonia, or PONV in the 2 groups. Besides, there was no significant difference in extubation time (TIVA: 5.04 ± 2.88 vs P/S: 4.44 ± 2.98 minutes; P = .33).

CONCLUSION

Sevoflurane attenuated cough reflex under propofol-based TIVA and did not increase the incidence of PONV and extubation time in nonintubated VATS.

Aprepitant as a fourth antiemetic prophylactic strategy in high-risk patients: a double-blind, randomized trial

BACKGROUND

Post-operative nausea and vomiting (PONV) is one of the most important causes of patient discomfort after laparoscopic surgeries despite the use of a multimodal pharmacological approach. This study assessed whether the addition of aprepitant to a multimodal regimen would further decrease the incidence of PONV in high-risk patients.

METHODS

Apfel-score three or four patients, scheduled for laparoscopic procedures to treat abdominal or pelvic cancer, were randomized to receive oral starch (control group) or 80 mg of oral aprepitant (treatment group) before induction of anaesthesia in a double-blind study. All patients received 4-8 mg of intravenous dexamethasone (at induction) and 4-8 mg of ondansetron (at the end) and a standardized total intravenous anaesthesia (TIVA) technique combined with neuraxial blockade. PONV was defined as any episode of nausea, vomiting or retching in the first 24 h after anaesthesia.

RESULTS

Sixty-six patients completed the study. Vomiting occurred in 13/32 (40.6%) patients in the control group and in 1/34 (2.9%) patients in the treatment group (P = 0.0002, 95%CI: 18-54%) in the first 24 h after anaesthesia. Severe nausea occurred in two (6.3%) patients, and severe vomiting occurred in four (12.5%) patients in the control group. One patient presented with severe vomiting in the treatment group in the first 24 post-operative hours.

CONCLUSION

Eighty milligrams of aprepitant added to a three-drug multimodal prophylaxis strategy can bring benefits to a high-risk population by reducing PONV episodes and rescue antiemetic requirements. This study was registered in the ClinicalTrials.gov (NCT 02357693) database.

Aromatherapy for treatment of postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common, unpleasant phenomenon and current therapies are not always effective for all patients. Aromatherapy has been suggested as an addition to the available treatment strategies. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

The main objective was to establish the efficacy and safety of aromatherapy comparable to standard pharmacological treatments for PONV in adults and children.

SEARCH METHODS

We searched CENTRAL; MEDLINE; Embase; CINAHL; CAM on PubMed; Informit; LILACS; and ISI Web of Science as well as grey literature sources and the reference lists of retrieved articles up to March 2017. The original search was performed in August 2011.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and controlled clinical trials (CCTs) where aromatherapy was used to treat PONV. Interventions were all types of aromatherapy compared to placebo or with standard antiemetics. Primary outcomes were severity and duration of PONV. Secondary outcomes were adverse reactions, use of rescue antiemetics and patient satisfaction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias in the included studies and extracted data. For dichotomous outcome variables, we used a random-effects model and calculated risk ratio (RR) with associated 95% confidence interval (95% CI). For continuous outcome variables, we used a random-effects model and calculated standardized mean difference (SMD) with associated 95% CI. We used the GRADE software to compile 'Summary of findings' tables.

MAIN RESULTS

We included seven new studies with 663 participants in the 2017 update; five RCTs and two CCTs. These were added to the nine previously included studies (six RCTs and three CCTs with a total of 373 participants) for a total of 16 included studies and 1036 participants in this updated review. The mean age and range data for all participants were not reported for all studies. We identified two registered trials that met the inclusion criteria for this review; however there are no results for these studies yet.Overall, the GRADE assessment of evidence quality ranged from moderate to very low. The method of randomization in 11 of the 12 included RCTs was explicitly stated and adequate. Incomplete or methodologically diverse reporting of data affected the completeness of the analysis. Data on additional aromatherapies were added in the 2017 update (blended aromatherapy products, and peppermint products). Heterogeneity of outcome measures and time points between studies affected the completeness of the analysis.In the summary of the findings of six studies, we did not find aromatherapy to be effective in reducing nausea severity in comparison to placebo (SMD -0.22, 95% CI -0.63 to 0.18, P value = 0.28, 241 participants, level of evidence: low). Those participants receiving aromatherapy were no more likely to be free of nausea at the end of the treatment period than those receiving placebo (RR 3.25, 95% CI 0.31 to 34.33, P value = 0.33, 4 trials, 193 participants, evidence level: very low), however they were less likely to require rescue antiemetics (RR 0.60, 95% CI 0.37 to 0.97, P value = 0.04, 7 trials, 609 participants, evidence level: low). There were no data reported on adverse events or patient satisfaction for this comparison.A specific comparison of peppermint aromatherapy to placebo did not show evidence of an effect on nausea severity at five minutes post-treatment in the pooled results (SMD -0.18, 95% CI -0.86 to 0.49, P value = 0.59, 4 trials, 115 participants, evidence level: low). There were no data reported on nausea duration, use of rescue antiemetics, adverse events or patient satisfaction for this comparison.When we pooled studies comparing isopropyl alcohol to standard antiemetic treatment in a GRADE summary of findings, in terms of nausea duration, there was a significant effect on the time in minutes to a 50% reduction in nausea scores (SMD -1.10, 95% CI -1.43 to -0.78, P value < 0.00001, 3 trials, 176 participants, evidence level: moderate). Fewer participants who received isopropyl alcohol required rescue antiemetics (RR 0.67, 95% CI 0.46 to 0.98, P value = 0.04, 215 participants, 4 trials, evidence level: moderate). Two studies with 172 participants measured patient satisfaction; there were high levels of satisfaction across both aromatherapy and standard treatment groups and no differences found (evidence level: low). There were no data reported on nausea severity or adverse events for this comparison.There was no difference in effectiveness between isopropyl alcohol vapour inhalation and placebo for reducing the proportion of participants requiring rescue antiemetics (RR 0.39, 95% CI 0.12 to 1.24, P value = 0.11, 291 participants, 4 trials, evidence level: very low). There were no data reported on nausea severity, nausea duration, adverse events or patient satisfaction for this comparison.

AUTHORS' CONCLUSIONS

Overall, for nausea severity at the end of treatment, aromatherapy may have similar effectiveness to placebo and similar numbers of participants were nausea-free. However, this finding is based on low-quality evidence and therefore very uncertain. Low-quality evidence also suggests that participants who received aromatherapy may need fewer antiemetic medications, but again, this is uncertain. Participants receiving either aromatherapy or antiemetic medications may report similar levels of satisfaction with their treatment, according to low-quality evidence.

Complications Following Radiofrequency Ablation of Benign Thyroid Nodules: A Systematic Review

Objective:

This systematic review examined whether radiofrequency ablation (RFA) is a safe treatment modality for benign thyroid nodules (BTNs).

Data Sources:

PubMed, Embase, and the Cochrane Library database were searched for articles that (a) targeted human beings and (b) had a study population with BTNs that were confirmed by fine-needle aspiration cytology and/or core needle biopsy.

Study Selection:

Thirty-two studies relating to 3409 patients were included in this systematic review.

Results:

Based on literatures, no deaths were associated with the procedure, serious complications were rare, and RFA appears to be a safe and well-tolerated treatment modality. However, a broad spectrum of complications offers insights into some undesirable complications, such as track needle seeding and Horner syndrome.

Conclusions:

RFA appears to be a safe and well-tolerated treatment modality for BTNs. More research is needed to characterize the complications of RFA for thyroid nodules.

Prevalence of and risk factors for intraoperative gastroesophageal reflux and postanesthetic vomiting and diarrhea in dogs undergoing general anesthesia

OBJECTIVE

To determine the prevalence of intraoperative gastroesophageal reflux (GER) and postanesthetic vomiting and diarrhea, and to evaluate risk factors associated with these gastrointestinal disorders (GID) in dogs undergoing general anesthesia.

DESIGN

Prospective observational study.

SETTING

University teaching hospital.

ANIMALS

Two hundred thirty-seven client-owned dogs undergoing general inhalant anesthesia for diagnostic or surgical purposes.

INTERVENTIONS

None MEASUREMENTS AND MAIN RESULTS: Patient, surgical, and anesthetic variables, and postanesthetic treatments administered in the immediate postanesthesia period were evaluated in relation to GID using univariate and multivariate logistic regression analysis (P < 0.05). Seventy-nine of the 237 (33.4%) dogs developed GID during the perianesthetic period. The prevalences of GER, vomiting, and diarrhea were 17.3%, 5.5%, and 10.5%, respectively. Intraabdominal surgery (P = 0.016; odds ratio [OR] 2.82, 95% confidence interval [CI]: 1.21-6.62), changes in body position (P = 0.003; OR 3.17, 95% CI: 1.47-6.85), and length of anesthesia (P = 0.052; OR 1.006, 95% CI: 1.000-1.013) were associated with GER. Changes in the ventilation mode during surgery (P = 0.011; OR 6.54, 95% CI: 1.8-23.8), length of anesthesia (P = 0.024; OR 1.001, 95% CI: 1.001-1.020), and rescue synthetic colloid support due to hypotension (P = 0.005; OR 6.9, 95% CI: 1.82-26.3) were positively associated with postanesthetic vomiting. On the contrary, dogs that received acepromazine as premedication were significantly less likely (P < 0.019; OR 12.3, 95% CI: 1.52-100) to vomit. Finally, length of anesthesia, changes in body position, changes in ventilation mode, or hypoxemia during the procedure tended to increase the risk (univariate model) of diarrhea during the recovery phase.

CONCLUSIONS

GID are common in dogs undergoing general anesthesia. Duration and characteristics of the procedure, anesthetic management, and changes in certain patient variables are significant risk factors for the presence of GID in the perioperative period.

Efficacy of sevoflurane as an adjuvant to propofol-based total intravenous anesthesia for attenuating secretions in ocular surgery

BACKGROUND

The incidence of nasal secretions into the operative field is as high as 5% in ophthalmic surgery under general anesthesia. It may induce postoperative endophthalmitis. Secretions under propofol-based total intravanous anesthesia (TIVA) are greater than sevoflurane anesthesia during surgery. Postoperative nausea and vomiting (PONV) after inhalational anesthesia is higher than TIVA and may increase intraocluar pressure. We investigated the effect of sevoflurane combination with propofol-based TIVA on nasopharyngeal secretions and PONV in ocular surgery.

METHODS

Fifty patients undergoing ocular operations were randomly assigned for propofol-based TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 25), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane group (n = 25), 1% sevoflurane anesthesia was added.

RESULTS

Nasopharyngeal excretion volume was significantly higher in the propofol-based TIVA group than in the propofol/sevoflurane group (31.0 ± 18.1 vs 13.7 ± 12.6 ml; P < .001). No significant difference in extubation time was noted (propofol-based TIVA: 6.4 ± 3.6 vs propofol/sevoflurane: 7.4 ± 3.0 minutes; P = .34). No postoperative endophthalmitis or PONV in both groups was observed.

CONCLUSION

Sevoflurane attenuated secretions under propofol-based TIVA and did not increase the incidence of PONV or prolonged extubation in ocular surgery.

Postoperative nausea and vomiting after thyroidectomy: a comparison between dexmedetomidine and remifentanil as part of balanced anesthesia

BACKGROUND

Postoperative nausea and vomiting (PONV) is the major complication related to general anesthesia, occurring in 60-80% of patients after thyroidectomy. The objective of this study was to compare the effects of an intraoperative dexmedetomidine infusion with remifentanil, as anesthetic adjuvants of balanced anesthesia, on PONV in patients undergoing thyroidectomy.

METHODS

Eighty patients scheduled for thyroidectomy were randomized into the following two groups: 1) The dexmedetomidine group (Group D), who received an initial loading dose of dexmedetomidine (1 µg/kg over 10 min) during the induction of anesthesia, followed by a continuous infusion at a rate of 0.3-0.5 µg/kg/h; 2) the remifentanil group (group R), who received remifentanil at an initial target effect site concentration of 4 ng/ml during the induction of anesthesia, followed by a target effect site concentration of 2-3 ng/ml. PONV was assessed during the first 24 hours in 2 time periods (0-2 h and 2-24 h). The pain intensity, sedation score, extubation time, and hemodynamics were also assessed.

RESULTS

During the 2 time periods, the incidence and severity of PONV in group D were significantly lower than in group R. In addition, the need for rescue antiemetics was significantly lower in group D than in group R. The effect of dexmedetomidine on postoperative pain relief (2-24 h) was superior to that of remifentanil. The hemodynamics were similar in both groups, whereas eye opening and extubation time were delayed in group D.

CONCLUSIONS

Adjuvant use of intraoperative dexmedetomidine infusion may be effective for the prevention of PONV.

Dexmedetomidine prevent postoperative nausea and vomiting on patients during general anesthesia: A PRISMA-compliant meta analysis of randomized controlled trials

BACKGROUND

Postoperative nausea and vomiting (PONV) is a frequent complication in postoperative period. The aim of this article was to evaluate the effect of dexmedetomidine on PONV.

METHOD

RevMan 5.3 software was applied for performing statistic analysis. Twenty-four trials with 2046 patients were included.

RESULTS

The PONV of the dexmedetomidine group was significantly lower compared with the placebo group (0.56, 95% CI: 0.46, 0.69). Subgroup analysis further confirmed the effect of dexmedetomidine (irrespective of administration mode) (P < 0.00001). Perioperative fentanyl consumption in dexmedetomidine group were also reduced significantly (P < 0.00001). Whereas, side effects such as bradycardia, hypotension increased in dexmedetomidine group (especially in loading dose mode and loading dose plus continuous infusion mode).

CONCLUSIONS

Dexmedetomidine administrated in continuous infusion mode has the advantage to prevent PONV as well as reduce side effects such as bradycardia and hypotension.