An update on the management of postoperative nausea and vomiting

[Perioperative Management: From the Operating Room to Postanesthesia Care Unit/to the Normal Ward]

The early postoperative period is of increasing importance in modern operative medicine with a continuously increasing surgical spectrum and patients with increasingly complex comorbidities. Even with optimal preoperative evaluation and intraoperative care, postoperative complications are not uncommon. The fastest possible diagnosis, including possible differential diagnoses and any combined disorders, is essential in order to initiate the indicated therapeutic measures. The spatial correlate of the postoperative phase is the post-anaesthesia care unit (PACU). The qualification of the medical staff and spatial structure must meet the recommended minimum and must be in line with the existing operational structures. Good interdisciplinary and interprofessional communication reduces the loss of information and a good error reporting culture helps to reduce critical incidents.

Anaesthesia as an influence in tumour progression

Purpose

Tumour growth and the formation of metastases are essential elements in the progression of cancer. The centre of treatment is the surgical resection of primary solid tumours. But even if the tumour can be removed without microscopic residual cells, local recurrences and distant metastases occur and determine the patient’s fate. During the operation, tumour cells are shed from the primary tumour and released into the circulation. These circulating tumour cells might play an important role in the formation of new tumour sites. Therefore, a functional innate and adaptive immune system is essential, especially in this perioperative period. Anaesthesia influences consciousness and pain perception and interacts directly with the immune system and tumour cells.

Methods

Review of the current literature concerning intra- and postoperative anaesthetic decisions and tumour progression.

Results

There are beneficial aspects for patient survival associated with total intravenous anaesthesia, the use of regional anaesthetics and the avoidance of allogeneic red blood cell transfusions. Alternatives such as irradiated intraoperative blood salvage and preoperative iron supplementation may be advantageous in cases where transfusions are limited or not wanted. The immunosuppressive properties of opioids are theoretical, but strong evidence to avoid them does not exist. The application of nonsteroidal anti-inflammatory drugs and postoperative nausea and vomiting prophylaxis do not impair the patient’s survival and may even have a positive effect on tumour regression.

Conclusion

Anaesthesia does play an important part in the perioperative period in order to improve the cancer-related outcome. Further research is necessary to make more concrete recommendations.

The acupoint herbal plaster for the prevention and treatment of postoperative nausea and vomiting after PLIF with general anesthesia: study protocol for a multicenter randomized controlled trial

Background

Postoperative nausea and vomiting (PONV) are common in posterior lumbar intervertebral fusion (PLIF) patients undergoing general anesthesia. The previous clinical observation has shown that a traditional acupoint herbal plaster (AHP) is beneficial to patients with PONV. This trial aims to assess the effect of the AHP for the prevention and treatment of PONV after PLIF in patients with general anesthesia.

Methods

A multicenter, parallel, randomized controlled trial (RCT) will be conducted. A total of 166 participants will be randomized to either a treatment group receiving an AHP or a control groups receiving an acupoint placebo plaster (APP) in a 1:1 ratio. The primary outcomes are the first occurrence and frequency of nausea and vomiting. The secondary outcomes include the severity grading of nausea and vomiting using a visual analog scale (VAS) measurement system, quality of life, and serological indicators. The safety evaluation is mainly about adverse events and skin reactions’ observation. Assessments will be carried out at the baseline, day 1, and day 2 (the end of the intervention). The central randomization system in the clinical trial (http://124.205.181.142:8082/xwtf/) will be used to conduct random allocation.

Discussion

This scientific methodology design of the trial is expected to provide clinical evidence to support the AHP for the prevention and treatment of PONV.

Trial registration

This study is retrospectively registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn) on 19 April 2018. ID: ChiCTR1800015768.

[Complications and emergencies in the recovery room]

The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.

Complications associated with PlasmaBlade TnA during tonsillectomy and adenoidectomy from 2010 to 2020: A MAUDE study

PURPOSE

The pulsed-electron avalanche knife (PEAK) PlasmaBlade TnA (Medtronic, n.d.) is a relatively new electrosurgical technology that is used widely in head and neck surgery (Medtronic Manuals, n.d.). This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to PEAK PlasmaBlade TnA during tonsillectomy and adenoidectomy.

MATERIALS AND METHODS

The US Food and Drug Administration's Manufacture and User Facility Device Experience database was queried for reports of PlasmaBlade TnA adverse events from June 6, 2009, to August 30, 2020. Data were extracted from reports pertaining to tonsillectomy with or without adenoidectomy.

RESULTS

128 reports were identified, from which 163 adverse events were extracted. Of these, 23 (14.6%) were related to patients, and 140 (85.4%) were related to device malfunction. The most frequently reported patient-related adverse event was a burn injury (17 [73.9%]). The most common device malfunctions were dislodgment of device component (39 [27.9%]), followed by tip ignition (32 [22.9%]), damaged tip or wire during operation (28 [20%]), and melted device (24 [17.1%]).

CONCLUSIONS

PEAK PlasmaBlade TnA have demonstrated utility in tonsillectomy with or without adenoidectomy but are associated with adverse events. Interventions aimed at improving both physician and patient education may help reduce adverse events attributed to improper use. Further study is needed to clarify optimal approaches to education.

The efficacy of ultrasound-guided erector spinae plane block after mastectomy and immediate breast reconstruction with a tissue expander: a randomized clinical trial

Background

We aimed to investigate the analgesic efficacy of an erector spinae plane block (ESPB) in immediate breast reconstruction (IBR) with a tissue expander.

Methods

Adult women undergoing IBR with a tissue expander after mastectomy were randomly assigned to either intravenous patient-controlled analgesia (IV-PCA) alone (group P) or IV-PCA plus ESPB (group E). The primary outcome was the total amount of opioid consumption during 24 hours postoperatively between the two groups. Secondary outcomes were patient satisfaction, pain score at rest and on shoulder movement using numerical rating scale, incidences of postoperative nausea and vomiting (PONV), and a short form of the brief pain inventory (BPI-SF) at 3 and 6 months after surgery between the groups.

Results

Fifty eight patients completed the study. At 24 hours postoperatively, total opioid consumption was significantly less in group E than in group P (285.0 ± 92.0, 95% confidence interval [CI] 250.1 to 320.0 vs. 223.2 ± 83.4, 95% CI 191.5 to 254.9, P = 0.005). Intraoperative and cumulative PCA fentanyl consumption at 3, 6, 9, and 24 hours were also less in group E than in group P (P = 0.004, P = 0.048, P = 0.020, P = 0.036, and P < 0.001, respectively). Patient satisfaction was higher in group E (6.9 ± 1.8 vs. 7.8 ± 1.4, P = 0.042). The incidences of PONV was similar.

Conclusions

The ESPB decreased postoperative opioid consumption and increased patient satisfaction without significant complications after IBR with a tissue expander after mastectomy.

A history of severe nausea and vomiting during pregnancy predicts a higher incidence of postoperative nausea and vomiting after breast cancer surgery without breast reconstruction

BACKGROUND

Postoperative nausea and vomiting (PONV) occur in up to 30 percent of patients after breast cancer surgery despite routine administration of antiemetic prophylaxis. A history of nausea and vomiting during pregnancy (NVP) has been reported as a risk factor of intraoperative nausea and vomiting in caesarean delivery. Nevertheless, whether a history of severe nausea and vomiting during pregnancy (SNVP) is associated with a higher occurrence of PONV remains unclear.

METHODS

In this study, 121 sequential female patients who were scheduled to undergo breast cancer surgery were assigned to study group (30 cases, with SNVP) or control group (91 cases, with mild NVP (MNVP)). The incidence of PONV and the need for rescue antiemetic were recorded in post-anesthesia care unit (PACU), at 6 h, 12 h, 24 h, and 36 h after operation. Moreover, postoperative pain, level of satisfaction, and the relationship of ER/PR status in breast cancer tissue with SNVP and PONV were also investigated.

RESULTS

Data from 115 patients were analyzed. The incidence of PONV in the SNVP group was significantly higher than that in the MNVP group at 6 h (P < 0.005), 12 h (P < 0.05), and 24 h after the operation (P < 0.05). The incidence of PONV in the MNVP group was approximately 30% lower than in the SNVP group. Besides, more severe PONV, a larger number of demands for rescue antiemetic, fewer patient satisfaction scores, and more dizziness were observed in the SNVP group. Yet, no relationship was found between ER/PR status of breast cancer tissue and SNVP or PONV.

CONCLUSIONS

Compared to patients with MNVP, those with a history of SNVP experienced a higher incidence of PONV and severe PONV, presented with a larger number of requirements for postoperative antiemetic and a lower level of satisfaction.

Is a split-dose intravenous dexamethasone regimen superior to a single high dose in reducing pain and improving function after total hip arthroplasty? A randomized blinded placebo-controlled trial

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Methods

A total of 165 patients were randomly assigned into three groups: two perioperative saline injections (Group A, placebo), a single preoperative dose of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative doses of 10 mg dexamethasone (Group C). Patients, surgeons, and staff collecting outcome data were blinded to allocation. The primary outcome was postoperative pain level reported on a ten-point Numerical Rating Scale (NRS) at rest and during activity. The use of analgesic and antiemetic rescue, incidence of postoperative nausea and vomiting (PONV), CRP and interleukin-6 (IL-6) levels, range of motion (ROM), length of stay (LOS), patient satisfaction, and the incidence of surgical site infection (SSI) and gastrointestinal bleeding (GIB) in the three months postoperatively, were also compared.

Results

The pain scores at rest were significantly lower in Groups B and C than in Group A on postoperative days 1 and 2. The dynamic pain scores and CRP and IL-6 levels were significantly lower for Groups B and C compared to Group A on postoperative days 1, 2, and 3. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, improved ROM, shorter LOS, and reported higher satisfaction than in Group A. Patients in Group C had significantly lower dynamic pain scores and IL-6 and CRP levels on postoperative days 2 and 3, and higher ROM and satisfaction on postoperative day 3 than in Group B. No SSI or GIB occurred in any group.

Conclusion

Perioperative dexamethasone provides short-term advantages in reducing pain, PONV, and inflammation, and increasing range of motion in the early postoperative period after THA. A split-dose regimen was superior to a single high dose in reducing pain and inflammation, and increasing ROM, with better patient satisfaction. Level of evidence: I Cite this article: Bone Joint J 2020;102-B(11):1497–1504.

Effectiveness of Propofol versus Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Ear, Nose, and Throat Surgery in Tikur Anbessa Specialized Hospital and Yekatit 12th Hospital, Addis Ababa, Ethiopia

BACKGROUND

Postoperative nausea and vomiting (PONV) remain as common and unpleasant and highly distressful experience following ear, nose, and throat surgery. During ENT surgery, the incidence of PONV could be significantly reduced in patients who receive dexamethasone and propofol as prophylaxis. However, the comparative effectiveness of the two drugs has not been assessed. The aim of this study was to compare the effectiveness of propofol and dexamethasone for prevention of PONV in ear, nose, and throat surgery.

METHODS

This study was conducted in 80 patients, with ASA I and II, aged 18-65 years, and scheduled for ENT surgery between December 20, 2017, and March 20, 2018. Patients were randomly assigned to Group A and Group B. Immediately after the procedure, Group A patients received single dose of intravenous (IV) dexamethasone (10 mg/kg) and Group B patients were given propofol (0.5 mg/kg, IV), and equal follow-up was employed. The incidence of PONV was noted at 6th, 12th, and 24th hour of drug administration. Independent t-test and Mann-Whitney test were used for comparison of symmetric numerical and asymmetric data between groups, respectively. Categorical data were analyzed with the chi-square test, and p value of < 0.05 was considered as level of significance.

RESULTS

The incidences of PONV throughout the 24-hour postoperative period were 35% in the propofol group and 25% in the dexamethasone group. Statistical significance was found in incidence of PONV (0% versus 22.5%) and use of antiemetic (0% versus 5%) between dexamethasone and propofol groups, respectively, at 12-24 hours. Over 24 hours, 5% in dexamethasone group and 12.5% in propofol group developed moderate PONV, while none of the participants felt severe PONV.

CONCLUSIONS

Dexamethasone was more effective than propofol to prevent PONV with lower requirements of rescue antiemetics.

[Comparison of palonosetron-dexamethasone and ondansetron-dexamethasone for prevention of postoperative nausea and vomiting in middle ear surgery: a randomized clinical trial]

BACKGROUND

Postoperative nausea and vomiting is the second most common complaint in the postoperative period after pain. The incidence of postoperative nausea and vomiting was 60-80% in middle ear surgeries in the absence of antiemetic prophylaxis. Because of this high incidence of postoperative nausea and vomiting, we aimed to assess the effect of palonosetron-dexamethasone and ondansetron-dexamethasone combination for the prevention of postoperative nausea and vomiting in patients of middle ear surgery.

METHODS

Sixty-four patients, scheduled for middle ear surgery, were randomized into two groups to receive the palonosetron-dexamethasone and ondansetron-dexamethasone combination intravenously before induction of anesthesia. Anesthesia technique was standardized in all patients. Postoperatively, the incidences and severity of nausea and vomiting, the requirement of rescue antiemetic, side effects and patient satisfaction score were recorded.

RESULTS

Demographics were similar in the study groups. The incidence difference of nausea was statistically significant between groups O and P at a time interval of 2-6hours only (p=0.026). The incidence and severity of vomiting were not statistically significant between groups O and P during the whole study period. The overall incidence of postoperative nausea and vomiting (0-24hours postoperatively) was 37.5% in group O and 9.4% in group P (p=0.016). Absolute risk reduction with palonosetron-dexamethasone was 28%, the relative risk reduction was 75%, and the number-needed-to-treat was 4. The patient's satisfaction score was higher in group P than group O (p=0.016). The frequency of rescue medication was more common in group O than in group P patients (p=0.026).

CONCLUSION

The combination of palonosetron-dexamethasone is superior to ondansetron-dexamethasone for the prevention of postoperative nausea and vomiting after middle ear surgeries.

Comparison of palonosetron-dexamethasone and ondansetron-dexamethasone for prevention of postoperative nausea and vomiting in middle ear surgery: a randomized clinical trial

Background

Postoperative nausea and vomiting is the second most common complaint in the postoperative period after pain. The incidence of postoperative nausea and vomiting was 60–80% in middle ear surgeries in the absence of antiemetic prophylaxis. Because of this high incidence of postoperative nausea and vomiting, we aimed to assess the effect of palonosetron-dexamethasone and ondansetron-dexamethasone combination for the prevention of postoperative nausea and vomiting in patients of middle ear surgery.

Methods

Sixty-four patients, scheduled for middle ear surgery, were randomized into two groups to receive the palonosetron-dexamethasone and ondansetron-dexamethasone combination intravenously before induction of anesthesia. Anesthesia technique was standardized in all patients. Postoperatively, the incidences and severity of nausea and vomiting, the requirement of rescue antiemetic, side effects and patient satisfaction score were recorded.

Results

Demographics were similar in the study groups. The incidence difference of nausea was statistically significant between groups O and P at a time interval of 2–6 hours only (p = 0.026). The incidence and severity of vomiting were not statistically significant between groups O and P during the whole study period. The overall incidence of postoperative nausea and vomiting (0–24 hours postoperatively) was 37.5% in group O and 9.4% in group P (p = 0.016). Absolute risk reduction with palonosetron–dexamethasone was 28%, the relative risk reduction was 75%, and the number-needed-to-treat was 4. The patient’s satisfaction score was higher in group P than group O (p = 0.016). The frequency of rescue medication was more common in group O than in group P patients (p = 0.026).

Conclusion

The combination of palonosetron-dexamethasone is superior to ondansetron-dexamethasone for the prevention of postoperative nausea and vomiting after middle ear surgeries.

Risk factors of postoperative nausea and vomiting after total hip arthroplasty or total knee arthroplasty: a retrospective study

Background

Postoperative nausea and vomiting (PONV) is a common complication after total hip/knee arthroplasty (THA/TKA) that affects patient satisfaction and postoperative recovery. It has been reported that patients undergoing THA/TKA experience PONV at a frequency of 20–83%. This study investigates the occurrence of PONV in patients and analyzes the risk factors.

Methods

Patients undergoing primary THA/TKA under general anesthesia from October 1, 2017, to May 1, 2018, were included. Data on patient-related factors were collected before THA/TKA. Anesthesia- and surgery-related factors were recorded postoperatively. Risk factors were analyzed using binary logistic regression.

Results

A stronger association of motion sickness and PONV was found at six hours after bilateral THA/TKA [nausea: odds ratio (OR) =14.648, 3.939–54.470; vomiting: OR =8.405, 2.482–28.466]. At 6–24 hours after bilateral THA/TKA, patients who had a history of migraines tended to experience nausea (OR =12.589, 1.978–80.105). Patients with lower body mass index (BMI) were more likely to experience PONV at 24–72 hours (nausea: OR =0.767, 0.616–0.954; vomiting: OR =0.666, 0.450–0.983) after bilateral THA/TKA.

Conclusions

The incidence of PONV after primary bilateral THA/TKA was higher than that after unilateral THA/TKA. The risk factors vary at different time points after surgery, and a history of motion sickness is the most critical factor affecting PONV.

Validation of the translation and cross-cultural adaptation into Spanish of the Postoperative Nausea and Vomiting Intensity Scale

INTRODUCTION

Postoperative nausea and vomiting (PONV) is a common problem in patients undergoing surgical procedures, generating patient dissatisfaction and increasing hospital costs. The Postoperative Nausea and Vomiting Intensity Scale identifies clinically significant cases; however, it has not been validated in Spanish.

OBJECTIVE

To carry out a cross-cultural adaptation of the PONV Intensity Scale into Spanish and validate it for use in the postoperative period of patients undergoing elective non-cardiac and non-intracranial surgery.

MATERIALS AND METHODS

Cross-sectional validation study of a diagnostic test. The NVPO Intensity Scale was culturally adapted to Spanish and administered to 393 adult hospitalized patients at 6 postoperative hours. The data were compared with the Apfel Scale and nausea measured on a visual analogue scale (VAS). Internal consistency and inter-observer concordance were calculated.

RESULTS

59.8% of patients presented NVPO, of which 14.5% were clinically significant. An acceptable internal consistency was obtained for the NVPO Intensity Scale (Cronbach's alpha 0.7) and a high inter-observer correlation (Kappa 0.9, 95% CI 0.86-0.92), statistically significant, for the overall scale. The correlation with VAS was high (Rho Spearman 0.9). The mean VAS and Apfel scale score was significantly higher in patients with clinically significant PONV.

CONCLUSIONS

The PONV Intensity Scale adapted to Spanish is a valid and reliable instrument for monitoring and evaluating postoperative nausea and vomiting.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Anesthesia Considerations and Infection Precautions for Trauma and Acute Care Cases During the COVID-19 Pandemic: Recommendations From a Task Force of the Chinese Society of Anesthesiology

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide. During the ongoing COVID-19 epidemic, most hospitals have postponed elective surgeries. However, some emergency surgeries, especially for trauma patients, are inevitable. For patients with suspected or confirmed COVID-19, a standard protocol addressing preoperative preparation, intraoperative management, and postoperative surveillance should be implemented to avoid nosocomial infection and ensure the safety of patients and the health care workforce. With reference to the guidelines and recommendations issued by the National Health Commission and Chinese Society of Anesthesiology, this article provides recommendations for anesthesia management of trauma and emergency surgery cases during the COVID-19 pandemic.

A comparison of noninvasive and invasive acupuncture in preventing postoperative nausea and vomiting: A protocol for systematic review and Bayesian network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a main complication of surgery, and by now, drugs cannot prevent it completely. Some meta-analyses have proved acupuncture therapy can prevent PONV. However, it is still controversial whether noninvasive acupuncture therapies are comparable with invasive ones. This study uses Bayesian network meta-analysis to compare the effectiveness of different forms of acupuncture in preventing PONV.

METHODS

PubMed/Medline, Cochrane library, Web of Science, Ebsco, Ovid/Embase, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and China Biology Medicine disc will be searched from inception to May 2020. All randomized control trails meet the criterion will be included. Quality evaluation of included studies will be implemented with Cochrane risk-of-bias tool. STATA 14.0 will be used to perform pairwise meta-analysis. Addis 1.16.8, R 3.6.3, OpenBUGS 3.2.3, and STATA 14.0 will be used to conduct network meta-analysis. The evidence will be assessed by the grading of recommendations assessment, development, and evaluation approach using GRADE Profiler 3.6.

RESULTS

The results of this review will be submitted to a peer-reviewed journal for publication and generate a comprehensive review of current evidence.

CONCLUSION

Our results will help to improve the clinical decision-making ability and policy-making in PONV domain.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered on INPLASY 202060108.

Comparing local tumescent anesthesia and spinal anesthesia methods during and after endovenous radiofrequency ablation of great saphenous vein

BACKGROUND

Local or spinal anesthesia methods can be used during radiofrequency ablation (RFA) of the great saphenous vein. There is a gap in the literature regarding comparing and contrasting the side effects of the mentioned two methods. This study aims to retrospectively compare the spinal anesthesia method with the local tumescent anesthesia method during RFA of the great saphenous vein that also includes mini-phlebectomy.

METHODS

We retrospectively analyzed patients who underwent RFA and mini-phlebectomy divided in two groups according to the anesthesia applied method, i.e. spinal anesthesia combined with tumescent anesthesia versus local tumescent anesthesia. Pain scores, the time length of preparation interval of anesthesia and the operation time, anesthesia-related side effects such as headache, nausea-vomiting, urinary retention, quality of life scores, postoperative occlusion rates, and complications related to the intervention such as phlebitis, deep vein thrombosis (DVT) were analyzed and compared by Mann Whitney U test, Wilcoxon signed ranks test, and χ² test.

RESULTS

Between June 2015 and June 2019 a great saphenous vein RFA ablation was performed in 175 patients. A total of 103 limbs were performed under spinal anesthesia combined with tumescent anesthesia and a total of 72 limbs were performed under local tumescent anesthesia. Mini phlebectomy was applied to all patients. Pain scores of the spinal anesthesia group were lower than the other group, and there was a significant difference. There was no significant difference between the operation lengths of both groups, but the preparation phase of anesthesia was shorter in local tumescent anesthesia patients, and the difference was significant. Anesthesia related side effects such as headache, nausea-vomiting, and urinary retention showed a significant difference between the two groups, and they were lower in the local tumescent anesthesia group. Preoperative quality of life scores of both groups decreased postoperatively. The postoperative occlusion rate of group 1 was 96.1%, and group 2 was 100% at three months, but the difference was not significant. We encountered three cases of phlebitis, two cases of DVT and two cases of bruising in group 1, and one case of bruising in group 2. There was no postoperative paresis or paresthesia in either groups.

CONCLUSIONS

This monocenter and retrospective report of 175 GSV RFA using tumescent local anesthesia or spinal anesthesia combined with local tumescent anesthesia demonstrated that both methods of anesthesia are effective. Although the pain scores are better with spinal anesthesia, the local tumescent anesthesia method is more efficient, requiring a shorter time, and is associated with fewer complications such as headache, nausea-vomiting, or urinary retention and deep venous thrombosis.

Impeding factors of early rehabilitation postoperatively after rheumatoid toe arthroplasty: a single-center retrospective cohort study

Introduction

Previous studies explored the benefits related to early ambulation postoperatively, but few focused on patients with rheumatoid arthritis (RA). We retrospectively evaluated the incidence and predictors of the inability to begin walking on the first postoperative day (POD) after toe arthroplasty for rheumatoid arthritis.

Methods

RA patients who underwent toe arthroplasty at one hospital were retrospectively reviewed. A total of 300 patients were included and divided into two groups: possible group (n = 191), who were able to walk on the first POD, and impossible group (n = 109), who were unable to walk on the first POD. Data were analyzed using odds ratios (OR) with 95% confidence intervals (CI) between various patient factors and the impossible group with logistic regression analysis.

Results

The incidence of postoperative nausea and vomiting before rehabilitation was significantly associated with the infeasibility of walking rehabilitation on the first POD [OR = 2.43, 95% CI 1.22–4.14, P = 0.003]. The number of rescue analgesics administered before rehabilitation and the supplementation of peripheral nerve block was also associated with the infeasibility of walking rehabilitation on the first POD [OR = 1.29, 95% CI 1.04–1.59, P = 0.003; OR = 0.41, 95% CI 0.20–0.79, P = 0.010, respectively].

Conclusion

The incidence of postoperative nausea and vomiting and inadequate postoperative pain management hindered early rehabilitation. Adding peripheral nerve block to general anesthesia had an advantage for postoperative rehabilitation after toe arthroplasty for rheumatoid arthritis.

Effectiveness of Aromatherapy for Relief of Pain, Nausea, and Vomiting after Percutaneous Nephrolithotomy: A Randomized Controlled Trial

BACKGROUND

Postoperative pain, nausea, and vomiting are common side effects of percutaneous nephrolithotomy. Nowadays, non-pharmacological and complementary therapies have been noticed. Therefore, a study was conducted to determine the effectiveness of lavender and clary sage on the pain, nausea, and vomiting after percutaneous nephrolithotomy.

METHODS

This is a randomized clinical trial study on 79 patients undergoing percutaneous nephrolithotomy. Patients were randomly divided into three groups of lavender aromatherapy (n = 27), clary sage aromatherapy (n = 26), and a control group (n = 26). Each of the intervention groups received the inhalation aromatherapy immediately and 3 and 6 h after the operation. Pain, nausea, and emetic episodes in patients of the three groups were measured before the intervention and 30 min after each intervention using a visual analog scale and checklist.

RESULTS

Pain decreased significantly in the clary sage aromatherapy group. Nausea had a downward trend in the two groups of aromatherapy. The lavender aromatherapy group had the lowest incidence of emetic episodes compared to the other groups.

CONCLUSION

Regarding the annoying pain, nausea, and vomiting after percutaneous nephrolithotomy for patients, and taking into account the complications of drug therapy, the use of complementary non-pharmacological methods can help increase the comfort of patients.

Acupuncture therapy on postoperative nausea and vomiting in abdominal operation: A Bayesian network meta analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after surgery. However, drugs cannot prevent it completely, and acupuncture therapy shows the potential in preventing PONV, yet the best choice hasn't been demonstrated.

OBJECTIVE

This network meta analysis aimed to evaluate the effectiveness of different acupuncture therapies used for preventing PONV in abdominal operation.

METHODS

Authors searched articles from PubMed/Medline, Cochrane library, Web of Science, Ebsco and Ovid/Embase, and established database from setup time to June 2019. Quality evaluation of included studies was performed with Cochrane risk-of-bias tool (ROB 2.0). Pairwise and network meta analysis were conducted by RevMan and Addis respectively.

RESULTS

Twenty studies with 2862 patients were included in this research. Pairwise meta analysis shows that compared with placebo, transcutaneous electric nerve stimulation had lower risk of postoperative nausea (PON) (odds ratio (OR) = 0.42, 95%confidence interval (CI): 0.30-0.60), postoperative vomiting (POV) (OR = 0.53, 95%CI: 0.36-0.78), PONVs (OR = 0.46, 95%CI: 0.31-0.68), and postoperative rescue (POR) (OR = 0.61, 95%CI: 0.41-0.90), Capsicum had lower risk of PON (OR = 0.16, 95%CI: 0.09-0.28), PONVs (OR = 0.23, 95%CI: 0.12-0.45), Acupressure had lower risk of POV (OR = 0.42, 95%CI: 0.25-0.70), POR (OR = 0.42, 95%CI: 0.27-0.64). In network meta analysis, compared with usual care, the probability rank suggested that Acupoint Injection showed lowest risk of PON (OR = 0.02, 95%CI: 0.00-0.11), POV (OR = 0.06, 95%CI: 0.01-0.49), Usual care for PONVs (OR = 0.31, 95%CI: 0.13-0.75), and Capsicum for POR (OR = 0.39, 95%CI: 0.07-2.33). Further study should be carried out to verify this result.

CONCLUSION

Both pairwise and network meta analysis showed acupuncture therapy was superior to placebo and usual care. Different acupuncture therapy regimens may have advantages in different aspects. And compared with POV, PON seems easier to control. Research results may provide guidance for the prevention of PONV.Systematic review registration: PROSPERO CRD42019147556.

Aggressive Prophylactic Treatments for Postoperative Nausea and Vomiting Improve Outcomes in Pediatric Adenotonsillectomy Procedure

OBJECTIVE

Postoperative nausea and vomiting (PONV) is an extremely common side effect of general anesthesia that is difficult to manage. We tested a hypothesis that an aggressive prophylactic intervention with additional antiemetic drugs will reduce the incidence of PONV in a high-risk pediatric population undergoing adenotonsillectomy.

METHODS

In this retrospective study, pediatric patients undergoing adenotonsillectomy were screened for their risk factors for PONV. Patients who had 3 or more risk factors were identified as high risk and received either scopolamine patch preoperatively (for patients over 40 kg body weight) or diphenhydramine immediately postextubation in addition to ondansetron and dexamethasone, which are given routinely. Incidences of PONV within the first 60 minutes of a postanesthesia care unit (PACU) stay were collected and analyzed.

RESULTS

Overall postoperative vomiting rates during the first hour of a PACU stay were 4.3% for the group that was treated with dexamethasone and ondansetron only and 3.9% for the group that was treated with additional antiemetic drugs. Aggressive prophylactic management of PONV did reduce the rate of nausea and vomiting in a group of high-risk patients (p < 0.0001). The postoperative antiemetic drug usage was also decreased during the first 60 minutes of a PACU stay. However, the approach did not reduce the overall rate of PONV for the entire study population (p = 0.1612 for nausea and p = 0.0678 for vomiting).

CONCLUSION

Aggressive intraoperative management of PONV with additional antiemetic drugs are beneficial in high-risk pediatric population. Intraoperative diphenhydramine usage decreased the rate of PONV. However, preoperative scopolamine patch prevention did not improve PONV, which may be related to the drug's longer onset of action. Our result suggests that current clinical practice is undertreating PONV in pediatric patients receiving general anesthesia.

Chronic Atypical Antipsychotic Use Is Associated With Reduced Need for Postoperative Nausea and Vomiting Rescue in the Postanesthesia Care Unit: A Propensity-Matched Retrospective Observational Study

BACKGROUND

Atypical antipsychotics are efficacious for chemoprophylaxis against chemotherapy-induced nausea and vomiting, but perioperative investigations have been scant. We sought to examine the association between chronic atypical antipsychotic therapy and the likelihood of postoperative nausea and vomiting.

METHODS

In this single-center, propensity-matched, retrospective, observational study, elective noncardiac surgical cases from January 2014 to December 2017 were examined with regard to the primary outcome of rescue antiemetic administration in the postanesthesia care unit as a measure of postoperative nausea and vomiting. Chronic administration of olanzapine, aripiprazole, and risperidone was the exposure of interest. Other independent variables included outpatient antiemetics, modified Apfel score, age, American Society of Anesthesiologists physical status score, case length, and exposures to emetogenic and chemoprophylactic agents. Logistic regression was performed using case-level data. Conditional logistic regression was performed after 1:2 propensity matching, sampling without replacement. Monte Carlo simulation was performed to compute the mean patient-level treatment effect on the treated.

RESULTS

Of 13,660 cases, 154 cases with patients receiving atypical antipsychotics were matched against 308 cases without, representing 115 and 273 unique patients, respectively. In a well-balanced cohort, the mean patient-level odds of being administered rescue antiemetic was lower for patients chronically taking the 3 atypical antipsychotics under consideration as compared to those not on atypical antipsychotics, with an odds ratio of 0.29 (95% CI, 0.11-0.75; P = .015).

CONCLUSIONS

Chronic atypical antipsychotic therapy is associated with reduced risk of postanesthesia care unit antiemetic administration. These findings support the need for prospective studies to establish the safety and efficacy of postoperative nausea and vomiting chemoprophylaxis with these agents.

Efficacy of local infiltration analgesia with ropivacaine for postoperative pain management in cervical laminoplasty: a retrospective study

Poor postoperative pain control impairs patient recovery and lengthens the duration of hospitalization after various surgeries. Local infiltration analgesia(LIA) has become an effective method for managing postoperative pain. This study aimed to investigate the efficacy of LIA with ropivacaine for postoperative pain control after cervical laminoplasty. In total, 68 patients undergoing cervical laminoplasty were included for retrospective review and divided into ropivacaine and control groups. The visual analogue scale (VAS) score, postoperative analgesic consumption, operative duration, intraoperative blood loss volume, incision length, hospitalization duration and incidence of complications were analyzed. In the ropivacaine group, the VAS score was 3.2 ± 1.4 at 4 hours postoperatively, which was lower than that of the control group(4.0 ± 1.4, P = 0.024). At 8, 12 and 24 hours after surgery, a significant difference was detected in the VAS score between the two groups(P ≤ 0.015). Sufentanil consumption was less in the ropivacaine group than in the control group in the first 4 hours postoperatively (25.6 ± 6.3 µg vs 32.2 ± 6.8 µg, P < 0.001), and similar results were observed in the first 8, 12, 24, 48 and 72 hours postoperatively(P < 0.001). Fewer patients required rescue analgesia in the ropivacaine group(8/33 vs 18/35 at 4–8 hours, P = 0.021; 9/33 vs 21/35 at 8–12 hours, P = 0.007). The hospitalization duration and time to ambulation were shorter in the ropivacaine group(8.5 ± 1.4 vs 9.6 ± 1.6 for postoperative duration, P = 0.002; 2.9 ± 0.7 vs 3.5 ± 0.8 for time to ambulation, P = 0.001). The incidence of nausea and vomiting was lower in the ropivacaine group than in the control group(30.3% vs 54.3%, P = 0.046). In conclusion, LIA with ropivacaine could effectively reduce postoperative pain, and postoperative analgesic consumption, and promote recovery after cervical laminoplasty.

Usefulness of ANI (analgesia nociception index) monitoring for outpatient saphenectomy surgery outcomes: an observational study

The Analgesia Nociception Index (ANI), derived from heart rate variability is a proposed guide to obtain an adequate control of the analgesic component during anaesthesia. This single blind observational study was designed to evaluate the relationship between intraoperative ANI values and length of stay in Day Surgery Units (DSU) in patients undergoing varicose vein intervention. 131 patients (ASA I-II) scheduled for elective varicose vein surgery were studied. A propofol closed-loop TCI was used to maintain a specific level of BIS. To control analgesia, a remifentanil TCI was used, modifying the target according to hemodynamic changes. Patients were included in the ANI > 50 sub-group or in the ANI < 50 sub-group depending on whether the ANI value was greater than 50 for at least 60% of the anaesthesia maintenance period (AMP) or not. The primary endpoint was the length of stay in DSU. Other variables studied were ANI values, duration of the AMP, remifentanil TCI target average, postoperative pain, rescue-analgesia needs and postoperative nausea and vomiting (PONV) were analysed. Statistical analysis of length of stay in DSU was performed with Mann-Whitney test. ANI > 50 sub-group showed a lower length of stay in the DSU [165 min (118-212) vs 186.5 min (119-254), p = 0.0425]. Discharge timing from DSU was statistically different among study sub-groups (p = 0.005). An adequate nociception level measured by ANI during varicose vein surgery might reduce the length of stay at DSU. Further studies are needed to assess the usefulness of ANI in other anaesthesia conditions.

Uso da realimentação pós-operatória ultra precoce e seu impacto na redução de fluidos endovenosos

RESUMO Objetivo: investigar em uma série de casos de pacientes submetidos a operações de médio porte em cirurgia geral, o uso da conduta de realimentação pós-operatória “ultra precoce”(dieta oral líquida oferecida na recuperação pós-anestésica), avaliando-se o volume de fluidos endovenosos recebidos no pós-operatório por estes pacientes, assim como a ocorrência de complicações e o tempo de internação hospitalar. Métodos: estudo prospectivo, observacional. Avaliou-se a aderência à rotina de realimentação “ultra precoce”, abreviação do jejum pré-operatório, volume de hidratação venosa perioperatório, tempo de internação e morbidade operatória. Resultados: um total de 154 pacientes com média da idade de 46±15 anos, foram acompanhados. Realimentação “ultra precoce” foi realizada em 144 casos (93,5%). Pacientes que não receberam realimentação “ultra precoce” receberam volume significativamente maior de fluidos endovenosos no pós-operatório do que pacientes realimentados de maneira “ultra precoce” (500ml versus 200ml, p=0,018). O tempo de internação foi de 2,4±2,79 dias (realimentação convencional) versus 1,45±1,83 dias (realimentação “ultra precoce”), sem diferença estatística (p=0,133).Não houve diferença no percentual de complicações gerais (p=0,291), vômitos (p=0,696) ou infecção do sítio cirúrgico (p=0,534). Conclusão: a realimentação “ultra precoce” apresentou-se como uma conduta de elevada aderência em operações de médio porte em Cirurgia Geral nesta série de casos e, esteve relacionada a infusão de volume significativamente menor de fluidos endovenosos no pós-operatório, com índices baixos de complicações e sem impacto no tempo de internação.

Perioperative Administration of Emend® (Aprepitant) at a Tertiary Care Children's Hospital: A 12-Month Survey

Introduction

Aprepitant (Emend^®) is a novel antiemetic agent that works through antagonism of neurokinin-1 (NK-1) receptors. To date, there are limited data regarding its use to prevent postoperative nausea and vomiting (PONV) in children. We retrospectively reviewed our initial 12-months experience with aprepitant after it was made available for perioperative use.

Methods

The anesthetic records of patients who received aprepitant were retrospectively reviewed and demographic, surgical, and medication data retrieved.

Results

The study cohort included 31 patients (15 male and 16 female) ranging in age from 4 to 27 years (15.7 ± 7.4 years) and in weight from 14.4 to 175.7 kilograms (59.3 ± 30.2 kgs). Most of the patients (30 of 31) received the capsule form and 1 received the liquid. The average dose of aprepitant administered was 0.9 ± 0.6 mg/kg; however, only one patient received dosing expressed as mg/kg, and the majority received a 40 mg capsule. All of the patients in the cohort had either a previous history of PONV or risk factors for PONV. PONV occurred in the PACU in 1 patient and during the first 24 postoperative hours in 3 additional patients. No adverse effects related to aprepitant use were noted.

Conclusion

Aprepitant was easily added to the preoperative regimen for pediatric patients who may require it. Our approach limited overuse and subsequent cost concerns. Future studies with a comparator group and a greater sample size are needed to demonstrate its efficacy, especially in comparison to time-honored agents such as ondansetron. No adverse effects were noted in our limited study cohort.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acupressure the PC6 point for alleviating postoperative nausea and vomiting: A systematic review protocol

BACKGROUND

Postoperative nausea and vomiting (PONV) are common complications following surgery and anesthesia, conventional drugs can carry some side effect in treating PONV. Acupressure PC6 point has been widely used in clinical, but there still exist controversy towards its effectiveness and safety. We, therefore, design this study to systematically assess the effectiveness and safety of acupressure PC6 point for treating PONV.

METHODS AND ANALYSIS

Nine online databases will be searched from their inception to May 2019. We will include randomized controlled trials (RCTs) involving patients with PONV and receiving acupressure PC6 point treatment. Two independent reviewers will be responsible for the selection of studies, data extraction and risk of bias assessment. RevMan V.5.3 software will be used for data synthesis with either a fixed effects model or random effects model depending on the heterogeneity test. Evidence quality will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation system (GRADE). The primary outcome is incidence of postoperative nausea (PON), postoperative vomiting (POV) and PONV events during 0 to 6 hours and after 6 hours of the treatment. The secondary outcome is the number of people who use emergency drugs and the number of people with adverse reactions. A meta-analysis will be conducted if no considerable heterogeneity is detected. The results will be presented as risk ratios with 95% confidence interval (CIs) for dichotomous data and weighted mean differences or standardized mean differences with 95% CIs for continuous data.

RESULTS

This study will provide a high-quality evidence to assess the effectiveness and safety of acupressure PC6 point for patient with PONV.

CONCLUSION

This review will provide up-date evidence of whether acupressure of PC6 point is an effective and safe intervention for PONV. PROSPERO registration number: CRD42019135598.

A randomized placebo-controlled study of aromatherapy for the treatment of postoperative nausea and vomiting

OBJECTIVE

The purpose of this study was to compare the aromatherapy treatment effects on PONV patients using ginger, lavender and rose oils and a placebo.

DESIGN

A randomized 4-armed placebo controlled study.

SETTING

Gaziosmanpasa University, School of Medicine, Health Research and Application Center.

INTERVENTION

The total of 184 patients were randomized into 4 groups: Aromatherapy with lavender essential oil (Lavender group), with rose essential oil (Rose group), with ginger essential oil (Ginger group) or with pure water (Placebo group).

MAIN OUTCOME MEASURES

Postoperative nausea (0-3 Likert type; 0=no nausea, 1=some, 2=a lot, 3=severe) and vomiting scores (0-3 Likert type; 0=no vomiting, 1 = 1 time, 2 = 2 or 3 time, 3 = 4 times and up) and antiemetic medication requirement.

RESULTS

The nausea scores at 15 min were statistically significantly different between the groups (p = 0.00). The postoperative nausea scores improved in 20 (43.5%) subjects in the placebo group, 38 (82.6%) subjects in the lavender group, 22 (47.8%) subjects in the rose group and 30 (65.2%) subjects in the ginger group (p = 0.00). There were statistically significant differences between the groups with regard to the vomiting and antiemetic drug requirements (p = 0.00).

CONCLUSION

The aromatherapy can be used as an alternative or complementary method for managing PONV. Specifically, the ginger and lavender essential oils were superior to the rose oil and pure water for the aromatherapy treatments. However, further studies with larger sample sizes are necessary to confirm these results.

Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the analgesic efficacy of dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plane (TAP) block for the patients after abdominal surgery.

METHODS

PubMed, CENTRAL, EMBASE, Web of science were searched to identify eligible randomized controlled trials (RCTs) that compared dexamethasone added to local anesthetics in ultrasound-guided TAP block with control for postoperative analgesia in adult patients undergoing abdominal surgery. Primary outcomes included postoperative pain intensity, the time to the first request for additional analgesics, and opioid consumption over 24 h after surgery. Secondary outcome was the incidence of postoperative nausea and vomiting. Analysis was performed by RevMan 5.3 software and the quality of evidence was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.

RESULTS

Nine RCTs involving 575 patients were included. Compared to the control, dexamethasone added to local anesthetics in ultrasound-guided TAP block significantly decreased visual analogue scale (VAS) scores at rest at 4h (mean difference [MD] = -1.01; 95% confidence intervals [CI], -1.29 to -0.73; P<0.00001; moderate quality of evidence), 6h (MD = -1.21; 95% CI, -1.74 to -0.69; P<0.00001; low quality of evidence), and 12h after surgery (MD = -0.79; 95% CI, -0.97 to -0.60; P<0.00001; moderate quality of evidence). No difference was found at 2h (MD = -0.64; 95% CI, -1.35 to 0.08; P = 0.08; low quality of evidence) and 24 h (MD = -0.41; 95% CI, -0.91 to 0.09; P = 0.11; moderate quality of evidence) in VAS scores. The time to the first request for additional analgesics was prolonged in the dexamethasone group (MD = 3.08; 95% CI, 2.37 to 3.78; P<0.00001; moderate quality of evidence). Opioid consumption over 24 h after surgery was also reduced (MD = -5.42; 95% CI, -8.20 to -2.63; P = 0.0001; low quality of evidence). Meanwhile, the incidence of postoperative nausea and vomiting was significantly decreased in the dexamethasone group (risk ratios [RR] = 0.40; 95% CI, 0.28 to 0.58; P<0.00001; high quality of evidence). No complications were reported in all the included studies.

CONCLUSIONS

Dexamethasone added to local anesthetics in ultrasound-guided TAP block was a safe and effective strategy for postoperative analgesia in adult patients undergoing abdominal surgery.

Implementation and maintenance of a pain management quality assurance program at intensive care units: 360 degree feedback of physicians, nurses and patients

Background

Pain management quality assurance programs (PMQP) have been successfully implemented in numerous hospitals across Europe. We aimed to evaluate the medium-term sustainability of a PMQP implemented at intensive care units (ICUs).

Methods

Two surveys, the first in 2012, immediately after introduction of the PMQP, and the second in 2015, were carried out amongst patients, physicians and nurses. Demographic parameters of all participants were assessed. Patients were asked after their pain levels during ICU stay. Staff members answered a questionnaire regarding familiarity with standards and processes of PMQP and self-perception of their knowledge as well as contentment with interdisciplinary communication.

Results

In total (2012/2015), 267 (125/142) patients, 113 (65/48) physicians and 510 (264/246) members of the nursing staff participated. Minimum and maximum pain levels of patients did not differ between both surveys. Patients’ tolerance of pain 24 hours before the survey was better (p = 0.023), and vomiting occurred less often (p = 0.037) in 2015. Physicians’ and nurses’ contentment with the own knowledge about pharmacological pain treatment had increased from 2012 to 2015 (p = 0.002 and 0.004). Satisfaction with communication between nurses and physicians was better in 2015 (p<0.001 and p = 0.002). Familiarity with PMQP standards and processes remained stable in both collectives.

Conclusion

The implementation of our PMQP achieved a high standard of care, guarantying a high patient and staff member satisfaction. Continuous education, ongoing training, regular updates and implementation of feedback-loops ensure continuity, in some parameters even an increase in knowledge and competencies. This is mirrored in high patient and staff member satisfaction.

Ginger (Zingiber officinale): An alternative for the prevention of postoperative nausea and vomiting. A meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a distressing outcome related to surgeries. Traditionally, ginger has been used in the treatment of nausea and vomiting for thousands of years. Recently, several randomized, placebo-controlled clinical trials (RCTs) have been conducted to evaluate the efficacy of ginger in PONV.

PURPOSE

To systematically evaluate the efficacy of ginger on postoperative nausea and vomiting (PONV) compared to placebo, based on RCTs.

STUDY DESIGN

The meta-analysis was reported following the PRISMA guidelines using the PICO format, and it was registered with the PROSPERO register.

METHODS

PubMed, Embase, the Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant studies. Human, placebo-controlled clinical studies of patients undergoing any types of surgery, receiving pharmacological doses of ginger per os were included. Only clinical trials with explicit description of the ginger preparation used were analysed. No language or publication year restrictions was applied.

RESULTS

Ten randomized trials including a total of 918 patients were pooled for the statistical analysis. The present meta-analysis supports that ginger has a significant effect on the severity of PONV based on visual analogue scale (VAS) results: in a fixed effects model the pooled standardized mean difference (SMD) was -0.247 (favouring ginger; [LL]: -0.455, [UL]: -0.040, p-value: 0.019). Moreover, our results suggest that ginger reduces the incidence of postoperative nausea and vomiting, as well antiemetic drug demand; however, these effects are not statistically significant compared to placebo, which may be explained by underdosing.

CONCLUSIONS

According to our thorough meta-analysis ginger is safe and well tolerated, and decreases the severity of PONV, and may lower the incidence of postoperative nausea and vomiting, which in turn may reduce antiemetic drug demand, suggesting that ginger may be a useful alternative to antiemetic medications to alleviate PONV.

Pethidine dose and female sex as risk factors for nausea after esophagogastroduodenoscopy

Nausea and vomiting after esophagogastroduodenoscopy have not been studied in detail. The aim of this study was to evaluate the risk factors for post-endoscopic nausea. We performed a case-control study at the Toyoshima Endoscopy Clinic. Eighteen patients with post-endoscopic nausea and 190 controls without post-endoscopic nausea were analyzed. We conducted univariate and multivariate logistic regression analyses with respect to patient age; sex; body height; body weight; the use of psychotropic drugs as baseline medications; and the dosing amounts of midazolam, pethidine, flumazenil and naloxone. On univariate analysis, post-endoscopic nausea was significantly related with patient age (odds ratio = 0.946); female sex (odds ratio = 10.85); body weight (odds ratio = 0.975); and the dose per kg body weight of pethidine (odds ratio = 53.03), naloxone (odds ratio = 1.676), and flumazenil (odds ratio = 1.26). On multivariate analysis, the dose per kg body weight of pethidine (odds ratio = 21.67, p = 0.004) and female sex (odds ratio = 13.12, p = 0.047) were the factors independently associated with post-endoscopic nausea. The prevalence of nausea after esophagogastroduodenoscopy was 0.49% (18/3,654). In conclusion, post-endoscopic nausea was associated with the dose of pethidine and female sex.

Effect of oral ginger on prevention of nausea and vomiting after laparoscopic cholecystectomy: a double-blind, randomized, placebo-controlled trial

Background

Postoperative nausea and vomiting (PONV) are among the most frequent complications following laparoscopic cholecystectomy. Recently, some studies have shown ginger, as an herbal medicine, to be effective and safe in PONV prevention; however, there is no evidence of its efficacy in the Iranian population.

Objective

The aim of this study was to determine the effect of oral ginger on PONV prevention after laparoscopic cholecystectomy.

Methods

This double-blind, randomized, placebo-controlled clinical trial was performed on women who were undergoing laparoscopic cholecystectomy in Imam Raza Hospital, Mashhad, Iran between April and November, 2016. Patients were divided randomly into two groups of G) intervention group (n=75, received 2 capsules containing 250 mg ginger) and P) placebo group (n=75, received 2 placebo capsules) one hour before surgery. Nausea severity and vomiting frequency were evaluated at 2, 4, 6, and 12 hours after the operation. Data analysis was done by SPSS version 16.0 software with Chi-square test, Independent-sample-t-test, repeated measure ANOVA and Mann-Whitney U test.

Results

The two groups were homogenous in terms of age, gender and surgery duration. The severity of nausea was lower in the ginger group at the 2, 4, 6, and 12 hours after the operation; however, these differences were statically significant only at 2 (p=0.034) and 12 hours (p=0.043). Although the incidence of vomiting was higher in the placebo group in the 2nd and 12th hours after surgery, the number of vomiting episodes in 2, 4, 6 and 12 hours after surgery was statistically similar in the two groups (p>0.05). The nausea severity was significantly changed during 12 hours of study in both groups (p=0.001), however the nausea severity was always lower in the ginger group (p=0.078).

Conclusion

This study demonstrated that 500mg oral ginger one hour before surgery in women who were undergoing laparoscopic cholecystectomy is effective in decreasing severity of PONV.

Trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2016122222218N2.

Funding

The study was financially supported by Deputy of Research of Mashhad University of Medical Sciences.

Evidence-based review and appraisal of the use of droperidol in the emergency department

Droperidol is a short-acting, potent dopamine D2 antagonist that can pass through the blood–brain barrier. A black box warning was issued for droperidol by the United States Food and Drug Administration in 2001 because of a risk of development of torsades de pointes induced by QT prolongation. Many experts feel that the incidence of arrhythmia is overestimated, and low-dose droperidol is almost always used by anesthesiologists for postoperative nausea and vomiting. In this review, we used evidence-based analysis to appraise high-quality studies with a low risk of bias published after 2001 on the use of droperidol in the emergency department (ED). Droperidol appears not only efficacious but also safe to treat patients with nausea/vomiting, acute psychosis, and migraine in the ED. For these conditions, droperidol may be an option for shared decision-making.

Perioperative Care of Elderly Surgical Outpatients

The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.

Comparison of efficacy of palonosetron-dexamethasone combination with palonosetron or dexamethasone alone for prophylaxis against post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

Background and Aims:

Post-operative nausea and vomiting (PONV) is highly distressing and unpleasant symptom. Dexamethasone and palonosetron are effective antiemetics with minimal side effect profile. This study compares the efficacy of palonosetron or dexamethasone alone and their combination (palonosetron plus dexamethasone) for prevention of PONV after laparoscopic cholecystectomy.

Methods:

This prospective, randomised, double-blind trial was done on 187 adults, American Society of Anesthesiologists Grade I and II patients, aged 18–75 years undergoing laparoscopic cholecystectomy. They were allocated to three groups which were to receive either of the three treatment regimens: dexamethasone 8 mg (Group D, n = 57), palonosetron 0.075 mg (Group P, n = 66) or dexamethasone 8 mg plus palonosetron 0.075 mg (Group PD, n = 64). The primary outcome was incidence of PONV in 24 h and the secondary outcome was a number of rescue antiemetic required. One-way ANOVA test was used to compare the means amongst three groups. To compare the proportions in the groups, Chi-square test/Fisher's exact test/Two proportions Z-test was applied as appropriate.

Results:

Overall incidences of PONV in the study 24 h postoperatively were 23.4% in PD, 27.2% in P group and 56.14% in D group (P < 0.001). Requirement of rescue antiemetic was more in dexamethasone group than other two groups (PD = 1 time, P = 1.38 times and D = 1.5 times).

Conclusion:

Palonosetron alone and palonosetron-dexamethasone combination were equally effective in the prevention of PONV. Dexamethasone alone was least effective amongst the three groups. There is no difference between palonosetron and palonosetron-dexamethasone for PONV prevention.