Association between intra-operative fentanyl dosing and postoperative nausea/vomiting and pain: A prospective cohort study

The Effects of Perioperative Corticosteroids on Postoperative Complications After Pancreatoduodenectomy: A Debated Topic of Systematic Review and Meta-analysis

BACKGROUND

The intraoperative administration of corticosteroids has been shown to improve postoperative outcomes in patients undergoing surgery; however, the impact of corticosteroids on complications following pancreatoduodenectomy (PD) remains controversial.

OBJECTIVE

This study aimed to evaluate the efficacy of perioperative corticosteroids on postoperative complications after PD.

MATERIALS AND METHODS

A comprehensive search was conducted using the PubMed, Embase, and Web of Science databases for studies published prior to 1 July 2024. Of 7418 articles identified, a total of 5 studies were eligible for inclusion in this meta-analysis. The primary outcome was incidence of postoperative major complications (PMCs), while the additional outcomes were incidences of postoperative pancreatic fistulas (POPFs), infection, delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), bile leakage, reoperation, and 30-day mortality. The study was registered in the PROSPERO database (CRD42024524936).

RESULTS

Finally, 5 studies involving 1449 patients (537 with corticosteroids and 912 without corticosteroids) were analyzed. Intraoperative corticosteroids were not associated with any improvement in PMCs (p = 0.41). The incidence of POPF (p = 0.12), infectious complications (p = 0.15), or DGE (p = 0.81) were not significantly different between the two groups. No obvious differences were found in the incidence of PPH (p = 0.42), bile leakage (p = 0.68), 30-day mortality (p = 0.99), or reoperation (p = 0.26).

CONCLUSION

Perioperative corticosteroids did not significantly demonstrate any protective advantage in terms of postoperative complications after PD. This finding may serve as a reference for the perioperative use of corticosteroids in pancreatic surgery. Well-designed clinical trials are warranted in the near future in order to provide high-level evidence.

A Randomized Controlled Non-Inferiority Trial Evaluating Opioid-Free versus Opioid-Sparing Analgesia for Orbital Fracture Reconstruction Under General Anesthesia

Background and Objectives

Opioid-minimizing strategies are making their appearance in enhanced recovery after surgery. This study is aimed to explore the potential advantages of opioid-free analgesia (OFA) compared to opioid-sparing analgesia (OSA) in patients undergoing orbital fracture reconstruction.

Methods

In this prospective, single-center, randomized controlled study, we randomly recruited 122 patients undergoing orbital fracture reconstruction under general anesthesia. Patients received total intravenous anesthesia with a flexible laryngeal mask airway, and multimodal analgesia with either OSA or OFA methods. The OSA group (n = 61) received low doses of fentanyl and nonsteroidal anti-inflammatory drugs (NSAIDs), and the OFA group (n = 61) received medial canthus peribulbar block (MCPB) combined with NSAIDs. The primary outcomes consisted of area-under-the-curve (AUC) of the numerical rating scale (NRS) pain score, and the incidence of postoperative nausea and vomiting (PONV) through the first 24h.

Results

Compared to the OSA group, the OFA group demonstrated non-inferiority in postoperative analgesia through the first 24 postoperative hours (difference of the medians, -6; 95% confidence interval [CI], -12 to 6), but failed to meet the non-inferiority criterion in the incidence of PONV (difference ratio, 3%; 95% CI, -7% to 14%). The Quality of Recovery-40 questionnaire (QoR-40) scores on postoperative day 1 was significantly higher in group OFA compared to group OSA (188 [178 to 196] vs 181 [169 to 191], respectively; P = 0.005).

Conclusion

In orbital fracture reconstruction, both OFA and OSA strategies provide effective postoperative pain relief, but OFA using MCPB combined NSAIDs enhances the quality of early postoperative recovery.

Registered

Chinese Clinical Trial Registry ChiCTR1900028088.

Olanzapine for the prevention of postoperative nausea and vomiting after gynecologic laparoscopic surgery: a randomized controlled trial

Purpose

This study was designed to investigate the prophylactic effect of oral olanzapine in postoperative nausea and vomiting after gynecologic laparoscopic surgery.

Methods

ASA I-II, aged 18-75 years, planned to undergo gynecologic laparoscopic surgery with general anesthesia in adult female patients. Using the randomized numbers table, the patients were placed in two groups. Oral olanzapine 5 mg or placebo was given 1 h before anesthesia. All patients received standard antiemetic prophylaxis with dexamethasone and granisetron. The primary outcome was nausea and/or vomiting in the 24 h after the postoperative.

Results

A total of 250 patients were randomized, and 241 were analyzed. The primary outcome occurred in 10 of 120 patients (8.3%) in the olanzapine group and 23 of 121 patients (19.2%) in the placebo group (p = 0.014). According to Kaplan-Meier analysis, the probabilities of nausea and/or vomiting in the 24 h after the postoperative in the olanzapine group were lower than in the placebo group (log-rank p = 0.014). In a multivariate Cox analysis, the variables of use of olanzapine [hazard ratio (HR): 0.35, 95% confidence interval (CI): 0.16-0.79; p = 0.012] and use of vasoactive drugs (HR: 2.48, 95% CI: 1.07-5.75; p = 0.034) were independently associated with nausea and/or vomiting in the 24 h after the postoperative.

Conclusion

Our data suggest that olanzapine relative to placebo decreased the risk of nausea and/or vomiting in the 24 h after gynecologic laparoscopic surgery.

Trial registration

The trial was registered prior to patient enrollment at The Chinese Clinical Trial Registry (https://www.chictr.org.cn/showproj.html?proj=166900, link to registry page, Principal investigator: Nanjin Chen, Date of registration: 25 April 2022).

Is Intravenous Dextrose Infusion During Emergence From Anesthesia Effective in Improving the PONV in Gynecologic Laparoscopy? A Randomized Controlled Trial

STUDY OBJECTIVE

This study aimed to explore the relationship between intravenous 5% dextrose infusion during emergence from anesthesia to postoperative nausea and vomiting (PONV) in patients after gynecologic laparoscopic surgery.

DESIGN

This was a double-blind randomized controlled trial. Participants were randomized into the experimental group and control group using a computer-generated random number generator. Intervenors and measurers were blinded to group assignments of the study.

SETTING

A single academic tertiary medical center.

PATIENTS

Patients undergoing gynecologic laparoscopic surgery.

INTERVENTIONS

On completion of surgery, participants were randomized into the test group (receive 5% dextrose) and control group (receive Ringer's lactate solution).

MEASUREMENTS AND MAIN RESULTS

The primary outcome of the present study was the incidence of PONV. Other outcomes included postoperative rescue analgesic and rescue antiemetic, postoperative pain response, and recovery time of postanesthesia care unit. Baseline characteristics were statistically similar between the 2 groups of participants. There were 49 of 105 patients experienced PONV within 24 hours postoperatively. The overall incidence of PONV within 24 hours postoperatively was not significantly different (45.5% vs 48%; relative risk [RR], 0.95; 95% confidence interval [CI], 0.67-1.37; p = .794). However, fewer patients experienced PONV in the test group than in the control group during 0 to 1 hours (6.0% vs 20.0%; RR, 0.85; 95% CI, 0.73-0.99; p = .024) and 1 to 3 hours (14.5% vs 32.0%; RR, 0.80; 95% CI, 0.64-0.99; p = .033) postoperatively. In addition, recovery time in the postanesthesia care unit was less in the test group (17.07 ± 6.36 vs 22.04 ± 7.33; mean difference, -4.97; 95% CI, -7.62 to -2.32; p <.001) and pain score was lower in the test group during 0 to 0.5 hours postoperatively (2.29 ± 1.74 vs 3.08 ± 1.64; mean difference, -0.79; 95% CI, -1.45 to -0.13; p = .019).

CONCLUSION

In patients after gynecologic laparoscopic surgery, postanesthesia 5% dextrose infusion may be useful in improving the early management of PONV and pain response and may warrant further study.

Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial

BACKGROUND

Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA.

METHODS

In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME).

RESULTS

There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0-25] mg vs 16 [0-30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05).

CONCLUSIONS

In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids.

CLINICAL TRIAL REGISTRATION

NCT0507270.

Effect of dexmedetomidine on postoperative nausea and vomiting in female patients undergoing radical thoracoscopic lung cancer resection

Introduction: Postoperative nausea and vomiting (PONV) is a prevalent postsurgical complication. The objective of our study was to compare the effect of different doses of dexmedetomidine on PONV in female patients undergoing radical thoracoscopic lung cancer resection. Methods: A total of 164 female patients undergoing elective thoracoscopic radical lung cancer surgery were enrolled and assigned to one of four groups. Patients received 0.2 μg/kg/h, 0.4 μg/kg/h, 0.8 μg/kg/h dexmedetomidine and normal saline in the Dex1, Dex2, Dex3 and Control groups, respectively. The primary outcome was the incidence of PONV during 48 h postoperatively. The second outcomes included the incidence of PONV and postoperative vomiting (POV) at four time points postoperatively (T1: PACU retention period; T2: PACU discharge to postoperative 12 h; T3: postoperative 12 h-postoperative 24 h; T4: postoperative 24 h-postoperative 48 h), the area under the curve of PONV grade (PONVAUC), PONV grade, POV grade and other postoperative recovery indicators. Results: The incidence of PONV differed among the four groups. The Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (72.50%). The incidence of PONV at T2 in the Dex1 group (11.90%) and Dex2 group (9.76%) was lower than that in the Control group (42.50%). The incidence of PONV at T3 in the Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (62.50%). The PONVAUC was lower in the Dex2 group than in the Control group. The incidence of POV at T3 in the Dex2 and Dex3 groups was lower than that in the Control group. The consumption of remifentanil, norepinephrine, PACU dwell time, VAS scores, postoperative PCA press frequency, and the time for the first postoperative oral intake were different among the four groups. The regression model shows that the Dex2 group is a protective factor for PONV. Conclusion: Dexmedetomidine can reduce the incidence of PONV and accelerate postoperative recovery in female patients undergoing radical thoracoscopic lung cancer resection. Compared with the other two dosages, 0.4 μg/kg/h dexmedetomidine is preferable. Clinical Trial Registration: chictr.org.cn, identifier ChiCTR2300071831.

The nuts and bolts of multimodal anaesthesia in the 21st century: a primer for clinicians

PURPOSE OF REVIEW

This review article explores the application of multimodal anaesthesia in general anaesthesia, particularly in conjunction with locoregional anaesthesia, specifically focusing on the importance of EEG monitoring. We provide an evidence-based guide for implementing multimodal anaesthesia, encompassing drug combinations, dosages, and EEG monitoring techniques, to ensure reliable intraoperative anaesthesia while minimizing adverse effects and improving patient outcomes.

RECENT FINDINGS

Opioid-free and multimodal general anaesthesia have significantly reduced opioid addiction and chronic postoperative pain. However, the evidence supporting the effectiveness of these approaches is limited. This review attempts to integrate research from broader neuroscientific fields to generate new clinical hypotheses. It discusses the correlation between high-dose intraoperative opioids and increased postoperative opioid consumption and their impact on pain indices and readmission rates. Additionally, it explores the relationship between multimodal anaesthesia and pain processing models and investigates the potential effects of nonpharmacological interventions on preoperative anxiety and postoperative pain.

SUMMARY

The integration of EEG monitoring is crucial for guiding adequate multimodal anaesthesia and preventing excessive anaesthesia dosing. Furthermore, the review investigates the impact of combining regional and opioid-sparing general anaesthesia on perioperative EEG readings and anaesthetic depth. The findings have significant implications for clinical practice in optimizing multimodal anaesthesia techniques (Supplementary Digital Content 1: Video Abstract, http://links.lww.com/COAN/A96 ).

Intraoperative Sufentanil Consumption and the Risk of Postoperative Nausea and/or Vomiting: A Retrospective Observational Study

INTRODUCTION

Post-operative nausea and/or vomiting (PONV) is a common post-operative adverse reaction and has been associated with post-operative sufentanil injection. The assessment of the relationship between intraoperative opioid consumption and PONV has been understudied. This study examined the relationship between intraoperative sufentanil administration and PONV.

METHODS

This was a single-center retrospective observational study. Patients who underwent video-assisted thoracoscopic surgery under general anesthesia with the preoperative thoracic paravertebral block between January 2017 and June 2020 at the Peking University People's Hospital were recruited for this study. Patients were grouped into two groups according to whether or not PONV occurred on postoperative day 1 (POD1). The factors associated with PONV were analyzed using logistic regression.

RESULTS

A total of 2733 patients, 1510 males and 1223 females, were included in this study. Among them, 143 patients developed PONV, a 5.2% (143/2733) PONV incidence. Logistic regression analysis showed that female, nonsmoking, sufentanil patient-controlled intravenous analgesia (PCIA), POD1 opioids consumption, and a time-weighted average of intraoperative sufentanil (twSuf) were associated with PONV. All patients were further divided into four subgroups based on intraoperative twSuf. Logistic regression analysis revealed that twSuf higher than 0.21 μg kg-1 h-1 was an independent risk factor for PONV.

CONCLUSIONS

Intraoperative sufentanil injection with a twSuf higher than 0.21 μg kg-1 h-1 increased the risk of PONV in patients undergoing thoracoscopic surgery under general anesthesia after a preoperative thoracic paravertebral block.

Development and assessment of novel machine learning models to predict the probability of postoperative nausea and vomiting for patient-controlled analgesia

Postoperative nausea and vomiting (PONV) can lead to various postoperative complications. The risk assessment model of PONV is helpful in guiding treatment and reducing the incidence of PONV, whereas the published models of PONV do not have a high accuracy rate. This study aimed to collect data from patients in Sichuan Provincial People's Hospital to develop models for predicting PONV based on machine learning algorithms, and to evaluate the predictive performance of the models using the area under the receiver characteristic curve (AUC), accuracy, precision, recall rate, F1 value and area under the precision-recall curve (AUPRC). The AUC (0.947) of our best machine learning model was significantly higher than that of the past models. The best of these models was used for external validation on patients from Chengdu First People's Hospital, and the AUC was 0.821. The contributions of variables were also interpreted using SHapley Additive ExPlanation (SHAP). A history of motion sickness and/or PONV, sex, weight, history of surgery, infusion volume, intraoperative urine volume, age, BMI, height, and PCA_3.0 were the top ten most important variables for the model. The machine learning models of PONV provided a good preoperative prediction of PONV for intravenous patient-controlled analgesia.

Postoperative nausea and vomiting: risk factors, prediction tools, and algorithms

PURPOSE OF REVIEW

Postoperative/postdischarge nausea and vomiting (PONV/PDNV) remain relevant issues in perioperative care. Especially in ambulatory surgery, PONV can prevent discharge or lead to unplanned readmission.

RECENT FINDINGS

The evidence for the management of PONV is now quite good but is still inadequately implemented. A universal, multimodal rather than risk-adapted approach for PONV prophylaxis is now recommended. The evidence on PDNV is insufficient.

SUMMARY

PDNV management is based primarily on consequent prophylaxis and therapy of PONV.

Risk factors of postoperative nausea and vomiting following ambulatory surgery: A retrospective case-control study

Objective

To explore potential risk factors of postoperative nausea and vomiting (PONV) following ambulatory surgery.

Method

Clinical data of 1670 cases receiving ambulatory surgery in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from September 2017 to December 2019 were retrospectively analyzed. They were categorized to PONV group and non-PONV group, and perioperative data in both groups were analyzed for assessing risk factors of PONV following ambulatory laparoscopy.

Results

There were 156/1,670 (9.3%) PONV cases, and the female and male incidence in recruited cases was 12.0% and 6.0%, respectively. Analyses on perioperative data of them identified that female gender [adjusted odds ratio (aOR) = 2.060, P < 0.001], operation time >1 h (aOR = 1.554, P = 0.011), postoperative pain at rest (aOR = 1.909, P = 0.013) and postoperative pain during activities (aOR = 3.512, P < 0.001) were independent risk factors of PONV following ambulatory surgery. Furthermore, postoperative pain at rest and during activities were linearly, positively correlated to the incidence of PONV.

Conclusion

Female gender, operation time >1 h and postoperative pain are closely related with the incidence of PONV following ambulatory surgery. Alleviating postoperative pain properly is one of the methods to reduce risk factors of PONV following ambulatory surgery.

Effects of Systemic Lidocaine Versus Dexmedetomidine on the Recovery Quality and Analgesia After Thyroid Cancer Surgery: A Randomized Controlled Trial

INTRODUCTION

Surgical management is commonly used for thyroid cancer. We evaluated the effects of systemic lidocaine versus dexmedetomidine on the recovery quality and analgesia after thyroid cancer surgery.

METHODS

A total of 120 patients with thyroid cancer were randomly allocated to group L (received lidocaine 1.5 mg/kg loading, continuously infused 1.5 mg/kg per hour), group D (received dexmedetomidine 0.5 µg/kg loading, continuously infused 0.5 µg/kg per hour) and group C (received normal saline), with 40 cases in each group. Anaesthesia induction and maintenance were performed using target-controlled infusions (TCIs) of propofol and remifentanil. The primary outcome of the quality of recovery-15 (QoR-15) score was recorded on the day before surgery and postoperative day 1 (POD1). Secondary outcomes included the consumption of remifentanil during surgery, time to first required rescue analgesia, number of patients requiring rescue analgesia, postoperative cumulative consumption of tramadol, visual analogue scale (VAS) pain score, incidence of postoperative nausea or vomiting (PONV) and side effects.

RESULTS

The total score of the QoR-15 at POD1 (median, IQR) was higher in group L (128.0, 122.0-132.8) and group D (127.5, 122.5-132.5) compared to group C (118.5, 113.0-123.5) (P = 0.000). Compared to group C, systemic lidocaine and dexmedetomidine reduced cumulative consumption of remifentanil and VAS pain score (P = 0.000). The time to first required rescue analgesia (mean, SD) was longer in group L (8.1 h, 1.2 h) and group D (8.5 h, 1.9 h) than group C (5.9 h, 0.9 h) (P = 0.000). The number of patients requiring rescue analgesia was lower in group L (8/40, 20%) and group D (6/40, 15%) than group C (16/40, 40%) (P = 0.029), and cumulative consumption of tramadol (mean, SD) was lower in group L (44.0 mg, 17.1 mg) and group D (51.7 mg, 14.1 mg) than group C (73.9 mg, 18.4 mg) (P = 0.000). The incidence of PONV in group L (7/40, 17.5%) and group D (9/40, 22.5%) was lower than group C (18/40, 45.0%) (P = 0.016). Bradycardia (heart rate  less than 50 beats/min or lower) was noted in 25 patients (25/40, 62.5%), which was reversed by intravenous administration of atropine 0.5 mg.

CONCLUSION

Systemic lidocaine and dexmedetomidine had similar effects on enhancing the quality of recovery, alleviating the intensity of pain and reducing the incidence of PONV after thyroid cancer surgery. However, dexmedetomidine may result in bradycardia. Therefore, lidocaine was superior to dexmedetomidine.

TRIAL REGISTRATION

ChiCTR.org.cn (ChiCTR2000038442). Registered on September 22, 2020.

Dexamethasone for the treatment of established postoperative nausea and vomiting: A randomised dose finding trial

BACKGROUND

Dexamethasone is widely used for the prevention of postoperative nausea and vomiting (PONV) but little is known about its efficacy for the treatment of established PONV.

OBJECTIVE

To test the antiemetic efficacy of intravenous dexamethasone for the treatment of established PONV in adults undergoing surgery under general anaesthesia and to determine whether there is dose-responsiveness.

DESIGN

The DexPonv trial is a multicentre, placebo-controlled, randomised, double-blind, dose-finding study. Inclusion of patients was between September 2012 and November 2017. Follow-up for PONV symptoms was for 24 h. Thirty days postoperatively, patients were contacted by study nurses for any information on postoperative bleeding and infection.

SETTING

Four public hospitals in Switzerland.

PATIENTS

A total of 803 adults scheduled for elective surgery without any antiemetic prophylaxis signed the consent form; 714 were included. Among those, 319 had PONV and 281 patients were eventually randomised (intention to treat population and safety set). The per protocol set consisted of 260 patients.

INTERVENTIONS

Patients with PONV symptoms (including retching) were randomised to a single intravenous dose of dexamethasone 3, 6 or 12 mg or matching placebo.

MAIN OUTCOME MEASURES

The primary endpoint was the absence of further nausea or vomiting (including retching), within 24 h after administration of the study drug.

RESULTS

Dexamethasone was ineffective during the first 24 h, whatever the dosage, compared to placebo, even when the model was adjusted for known risk factors (P = 0.170). There were no differences in the time to treatment failure or the quality of sleep during the first night. There was a positive correlation between the dose of dexamethasone and blood glucose concentrations (P < 0.001), but not with bleeding risk, wound infections or other adverse effects.

CONCLUSION

This randomised trial failed to show antiemetic efficacy of any of the tested intravenous regimens of dexamethasone for the treatment of established PONV in adults undergoing surgery under general anaesthesia.

TRIAL REGISTRATION

clinicaltrials.gov (NCT01975727).

Ultrasound-guided bilateral superficial cervical plexus block enhances the quality of recovery of uremia patients with secondary hyperparathyroidism following parathyroidectomy: a randomized controlled trial

Background

Parathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy.

Methods

Eighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded.

Results

The scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 (P = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group (P = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia (P = 0.018), fewer patients requiring rescue analgesia (P = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group (P = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery (P = 0.000).

Conclusion

Ultrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy.

Trial registration

ChiCTR1900027185 . (Prospective registered). Initial registration date was 04/11/2019.

Factors Associated With the Risk of Developing Moderate to Severe Acute Postoperative Pain After Primary Total Knee Arthroplasty: Results From the PAIN OUT Registry

BACKGROUND

Total knee arthroplasty (TKA) is one of the most common procedures in orthopedic surgery and not always matches with patient's expectations of pain relief and function improvement. The aim of this study was to assess risk factors for developing moderate to severe acute postoperative pain (APOP) after TKA using the PAIN OUT questionnaire.

METHODS

Prospective, multicentre, international cohort study within the PAIN OUT project. Patients' outcomes were measured with 11-point numerical rating scales (0 = null, 10 = worst possible). Patient and analgesic/anesthetic treatment were assessed. Odds ratio for moderate-severe pain was calculated for each variable and if they were statistically significant in the univariate logistic model, variables were fitted into a multivariate logistic regression model. The effect size was assessed by Cohen's d coefficient.

RESULTS

In total, 968 patients were evaluated. The multivariate model identified chronic preoperative pain (P < .001), general anesthesia (P = .020), and receiving chronic opioids before (P = .020) or after the surgery (P < .001) as factors associated with moderate-severe APOP. No protective factors were observed.

CONCLUSIONS

Our model identified several risk factors for APOP. From our results, preoperative chronic pain, general anesthesia and the use of opioid analgesics could be predictors for higher APOP. These findings may help establish new strategies for the treatment of pain in TKR. More studies should be carried out to identify acute pain predictors and to develop better strategies of pain management for risk patients.

Risk factors for postoperative nausea and vomiting after thoracoscopic pulmonary wedge resection: pitfalls of an increased fentanyl dose

Background

Thoracoscopic pulmonary wedge resection (TPWR) is a surgical procedure that can maintain lung function and is less physically invasive to a patient. However, the risk factors for postoperative nausea and vomiting (PONV) following TPWR remain unknown. We aimed to evaluate multiple risk factors of PONV after TPWR and the impact of PONV on postoperative outcomes.

Methods

We retrospectively reviewed consecutive patients who underwent TPWR for malignant pulmonary tumors at our institution between October 2017 and March 2020. We assessed the differences in the clinical and perioperative parameters between the PONV and non-PONV groups.

Results

We reviewed 160 patients, of whom 27 (16.9%) had PONV. Sixteen (59.3%) patients with PONV required postoperative antiemetics. Failed mobilization was associated with PONV requiring postoperative antiemetics (P=0.048). In the multivariate analysis, increased fentanyl dose was an independent risk factor for PONV (P=0.022). Using the receiver operating characteristic curve, the optimal cut-off value for PONV was 3.58 µg/kg/hr (area under the curve =0.665; sensitivity =85.2%; specificity =53.4%; 95% confidence interval: 0.562–0.768; P=0.007). For example, in a case of a 50-kg patient who underwent a 70-min operation (our median operative time), the total dose of fentanyl within 208 µg was the cut-off value for preventing PONV.

Conclusions

An increased dose of fentanyl/kg/h was the strongest risk factor for PONV during TPWR. The optimal cut-off value for PONV was 3.58 µg/kg/hr. It is important to avoid the inadvertent administration of intraoperative fentanyl.

Postoperative Vomiting Following Laparoscopic Cholecystectomy Is Associated with Intraoperative Fluid Administration: A Retrospective Cohort Study

Potential risk factors for postoperative vomiting (POV) are important for daily anesthesia practice. To identify the risk factors associated with POV we retrospectively reviewed 553 adult patients who underwent scheduled simple laparoscopic cholecystectomy under sevoflurane-based general anesthesia between January and December 2018. Patients who experienced POV were predominantly women, had lower body weight, and higher ASA (American Society of Anesthesiologists) physical status. The POV group showed female sex predominance, lower body weight, and higher ASA physical status, with a significant difference when compared with the non-POV group. In univariate analysis, female sex and Apfel scores of 2, 3, and 4 were associated with a higher POV incidence. Age > 70 years, higher body weight, and ASA physical status III were associated with a lower POV incidence. In multivariate logistic regression, sex, age, Apfel score, and intraoperative crystalloid infusion rate were POV predictive factors. Receiver operating characteristic analysis showed a negative association between the intraoperative crystalloid infusion rate and POV occurrence with an area under the curve of 0.73 (p = 0.001). The cutoff intraoperative crystalloid infusion rate was 2 mL/kg/h with 82% sensitivity and 49% specificity (≥2 mL/kg/h was associated with a lower POV incidence vs. <2 mL/kg/h (OR, 95% CI; 0.52 [0.33–0.83])). To decrease POV in these patients, identifying high-risk factors and an intraoperative crystalloid administration of ≥2 mL/kg/h should be considered in patients undergoing LC under sevoflurane-based general anesthesia.

The safety of early administration of oral fluid following general anesthesia in children undergoing tonsillectomy: a prospective randomized controlled trial

Background

The feasibility and safety of administrating a small amount of oral fluid to children in the early recovery period following tonsillectomy under general anesthesia to reduce the thirst and its associated restlessness remain unknown.

Methods

This study was approved by the institutional ethics committee and adhered to the CONSORT guidelines. Pediatric patients undergoing tonsillectomy who met the inclusion and exclusion criteria of our study were randomized into the study and control groups. In the study group, patients were given a small amount of water instantly after recovering from general anesthesia, which included the recovery of the cough and deglutition reflex, and attaining grade V of muscle strength. The control group was given a small amount of water at 4 to 6 h after the operation. The incidence of nausea and vomiting and the degree of thirst relief were measured and compared between the two groups.

Results

Three hundred patients were randomized into each group. There was no significant difference in the incidence of nausea and vomiting at 20 min after drinking water between the two groups (P > 0.05). The thirst score of children over 5 years old in the study group was significantly lower than that of the control group (P < 0.05).

Conclusion

Early administration of a small amount of oral fluid to children following tonsillectomy and recovering from general anesthesia is not only safe but also effective in reducing postoperative thirst.

Trial registration

Current Controlled Trials ChiCTR1800020058, 12-12-2018.

Lessons from the Analysis of a Retrospective Cohort of Patients Who Underwent Large Open Abdominal Surgery Under Total Intravenous Opioid-Free Anesthesia

Background

Opioid-free anesthesia (OFA) is a new method of anesthesia based on a paradigm shift. Under general anesthesia, the physiology and/or the pathophysiological variations clinically observed are more a reflection of a systemic reaction to the stress (surgical and anesthesia stresses) than a true reflection of pain.

Objective

To report the results of a large monocenter, retrospective, non-interventional observational study of all consecutive patients who received a total intravenous (IV)-OFA protocol for the surgical management of major open abdominal and urological surgery.

Patients and Methods

We retrospectively extracted the anesthesia files of 311 consecutive patients (regional anesthesia excluded). No opioids were administered to any of these patients during the surgery. IV morphine administered in the recovery room was the primary endpoint of the study. The secondary endpoints included the amount of opioid required during the first two postoperative days, as well as the maximum pain intensity.

Results

Only very small doses of IV morphine were administered. The mean total morphine titration was 2 mg (1.9 ± 2.9 mg), corresponding to control of the maximal level of pain to 2.1 ± 2.6 as evaluated with a numerical scale in the postoperative care unit. Similarly, we observed a very low level of morphine consumption during the first two postoperative days.

Conclusions

These results highlight the safety and the feasibility of our total IV-OFA protocol, thus confirming this new paradigm. Under general anesthesia, the cardiovascular and inflammatory response to the stress could be reliably managed through a multimodal approach without a need for opioids. In the postoperative period, very low doses of opioids were required.

Electronic supplementary material

The online version of this article (10.1007/s40801-020-00218-3) contains supplementary material, which is available to authorized users.

Opioid free anesthesia: evidence for short and long-term outcome

The introduction of synthetic opioids in clinical practice played a major role in the history of anesthesiology. For years, anesthesiologists have been thinking that opioids are needed for intraoperative anesthesia. However, we now know that opioids (especially synthetic short-acting molecules) are definitely not ideal analgesics and may even be counterproductive, increasing postoperative pain. As well, opioids have revealed important drawbacks associated to poor perioperative outcomes. As a matter of fact, efforts in postoperative pain management in the last 30 years were driven by the idea of reducing/eliminating opioids from the postoperative period. However, a modern concept of anesthesia should eliminate opioids already intra-operatively towards a balanced, opioid-free approach (opioid-free anesthesia - OFA). In OFA drugs and techniques historically proven for their efficacy are combined in rational and defined protocols. They include ketamine, alpha-2 agonists, lidocaine, magnesium, anti-inflammatory drugs and regional anesthesia. Promising results have been obtained on perioperative outcome. For sure, analgesia is not reduced with OFA, but it is effective and with less opioid-related side effects. These benefits may be of particular importance in some high-risk patients, like OSAS, obese and chronic opioid-users/abusers. OFA may also increase patient-reported outcomes; despite it is difficult to specifically rule out the effect of intraoperative opioids. Finally, few data are available on long-term outcomes (persistent pain and opioid abuse, cancer outcome). New studies and data are required to elaborate the optimal approach for each patient/surgery, but interest and publication are increasing and may open the road to the wider adoption of OFA.