Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens

The Impact of Enhanced Recovery Protocols Regarding Postoperative Nausea and Vomiting Following Sleeve Gastrectomy under Triple Prophylaxis: A Controlled Randomized Study

Background

Following a sleeve gastrectomy, post-operative nausea and vomiting (PONV) is a typical issue. Furthermore, several prophylactic techniques have been developed, such as preventive antiemetic and accelerated recovery after surgery (ERAS). However, PONV has not entirely disappeared, and clinicians are still working to lower PONV incidence.

Aim

Our goal was to evaluate how adopting Enhanced Recovery Protocols (ERAS) affects postoperative nausea and vomiting (PONV) in comparison to standard care protocol after laparoscopic sleeve gastrectomy (LSG) while receiving triple antiemetic prophylaxis.

Objective

The objective of this study was to verify that the ERAS procedure is crucial for lowering PONV despite the use of an efficient and effective antiemetic.

Methods

This is a computer-generated randomized clinical trial. Haloperidol, dexamethasone, and ondansetron were administered to all patients undergoing elective LSG, 29 patients within an ERAS protocol, and 29 within a standard care protocol. The primary finding was the incidence of PONV within 36 hours following LSG. The time to initially administer rescue antiemetic medication, number of rescue antiemetic medication administrations, postoperative opioid consumption, oral fluid tolerance, complications, and QoR-15 questionnaire for quality of recovery were the secondary outcomes.

Results

Within the first 36 hours following LSG, the incidence of PONV in the ERAS group was 17.20%, while in the non-ERAS group, it was 51.7%, with P<0.012 and higher PONV severity (P<0.021) in the non-ERAS group. The ERAS group took a longer time (6 hours) for the first rescue antiemetic medicine than the Non-ERAS group (2 hours), with P<0.001 and significantly less number of patients (20.7%) needing rescue antiemetic, compared to the Non-ERAS group (65.5%), with P<0.001. The dosage of nalbuphine needed by the ERAS group was lower (2.7±2.8) than the non-ERAS group (19.9±6.0). Regarding the QoR-15 scores, there was a significant difference in the two groups' overall performance (P <0.001). Between the two groups, there were no significant complications following surgery.

Conclusion

This study reveals that even though triple antiemetic prophylaxis was used, the ERAS protocol had a beneficial effect on PONV when compared to the standard care approach.

Time to Start a New Enhanced Recovery After Surgery (ERAS): A Retrospective Cohort Study

BACKGROUND

The enhanced recovery after surgery (ERAS®) is a multimodal perioperative care pathway designed to reduce surgical stress and ultimately improve patient recovery and outcome. It can require significant resources but with proven benefits. The main goal of this study was to perform a diagnostic assessment of perioperative practice in a local colorectal surgical center.

METHODS

93 patients who underwent elective colorectal surgery from January to December 2022 were analyzed. Preadmission, preoperative, and postoperative data of all patients were collected in a database developed by the researchers, according to ERAS® guidelines. Descriptive statistics were employed to summarize demographic and clinical characteristics. Chi-square and T-test were performed to identify possible associations between categorical variables and postoperative complications.

RESULTS

Overall analysis showed deficient preoperative patient optimization, especially regarding nutritional counseling and supplementation, smoking and alcohol cessation, anemia treatment (9%), and pre-anesthetic medication (42%). Removal of invasive devices was significantly delayed (removal of urinary catheter average on the fourthday and surgical drain average on the fifth day) in the postoperatively period and oral intake (average onset on the sixth day). Both contribute to hospital length of stay (mean of 13 days) and a significant number of complications.

CONCLUSION

The results lead us to an individual and multidisciplinary reflection on current practices and outcomes. ERAS® program, already adopted by many centers, could have a positive impact on the immediate postoperative recovery of colorectal patients in Funchal Central Hospital and implementation seems necessary.

Effect of ondansetron for preventing postoperative nausea and vomiting after breast cancer surgery

OBJECTIVE

To evaluate the preventive effect of preoperative administration of ondansetron on postoperative nausea and vomiting (PONV) in patients receiving breast cancer surgery.

METHODS

Data from 225 patients who received modified radical mastectomy from January 2019 to December 2020 were retrospectively reviewed. The patients were divided into an ondansetron group and a control group according to whether they received preoperative ondansetron or not. The incidence of PONV, visual analog scale (VAS) score, the rescue analgesics use and rescue antiemetic use, as well as the patient satisfaction degree about their PONV were compared between the two groups.

RESULTS

The ondansetron group showed lower total incidence of PONV, lower VAS score at 6 h post-operation as well as less rescue antiemetic use than the control group (P<0.05). Patients in the ondansetron group were more satisfied with their PONV condition than those in the control group (P<0.05).

CONCLUSION

Preoperative administration of ondansetron can prevent PONV and relieve pain 2-24 hours after breast cancer surgery.

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.

Anesthesiologists' Role in Value-based Perioperative Care and Healthcare Transformation

Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.