[Postoperative nausea and vomiting]

Comparison of endoscope-assisted and microscope-assisted type I tympanoplasty; a systematic review and meta-analysis

OBJECTIVES

To analyze and compare the available data about the outcomes of endoscopic and microscopic type I tympanoplasty.

DATA SOURCES

PubMed, Cochrane library Ovid, Scopus, Google scholar, and ClinicalTrials.

METHODS

We conducted a meta-analysis in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We included comparative studies describing type I tympanoplasty, and comparing surgical outcomes of the endoscope with the microscope in terms of efficacy and safety.

RESULTS

Our systematic search yielded 22 studies meeting the inclusion criteria and eligible for analysis. The pooled graft uptake rates and audiological results of endoscopic and microscopic tympanoplasty demonstrated non-significant differences. In contrast, endoscopic type I tympanoplasty outperforms microscopic tympanoplasty regarding a highly significant decrease not only in pooled mean operative time but also in the pooled complications rate.

CONCLUSIONS

Based on our meta-analysis, the surgical outcomes of endoscope-assisted and microscope-assisted type I tympanoplasty in terms of postoperative hearing outcomes and the graft uptake rate were comparable. On the contrary, operative time and complications rate proved to be significantly reduced with endoscopy compared to microscopy. Hence, the endoscope is as efficient as the microscope in type I tympanoplasty but less invasive, fewer in complications and shorter in operative time.

Reduction in post-operative nausea and vomiting (PONV) by preoperative risk stratification and adherence to a standardized anti emetic prophylaxis protocol in the day-care surgical population

Context

Postoperative nausea (PON) and postoperative vomiting (POV) are the most undesirable morbidity after anaesthesia. There is paucity of data on PONV from the Indian subcontinent.

Aims

We aim to study the prevalence of PON and POV, associated risk factors and the effect of following standardized risk stratification and prophylaxis protocols in the day care patient population.

Settings and Design

This was a prospective cohort study at a tertiary care teaching institute.

Methods and Material

Data from 500 patients undergoing day care surgery over a period of 12 months were analysed. We used the Apfel scoring system for evaluation of risk of post-operative nausea and vomiting (PONV) for each participant. A standard PONV prophylaxis protocol was used intra-operatively.

Statistical analysis used

Data analysis was done using the Mann-Whitney U test, the Chi-square and Fisher's exact test.

Results

The period prevalence of post-operative nausea (PON) and post-operative vomiting (POV) was 2.04% and 2.45%, respectively, in this study. The prevalence of PONV in each risk category was lower than that predicted by the Apfel score due to utilization of a standard anti-emetic prophylactic protocol. We found younger age, previous history of nausea, previous history of vomiting, urological surgeries and alcohol consumption as significant risk factors for postoperative nausea. Longer duration of surgery, previous history of nausea, alcohol consumption and higher BMI were the significant risk factors for postoperative vomiting.

Conclusions

Adherence to preoperative risk stratification and a standard anti-emetic prophylactic protocol can significantly reduce the prevalence of postoperative nausea and vomiting.

[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.

[First experience with outpatient laparoscopic cholecystectomy in Tunisia]

INTRODUCTION

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones. There is some debate as to whether it should be performed in outpatient surgery or in one-day surgery to improve patient safety. This study aimed to evaluate the impact of laparoscopic cholecystectomy performed in outpatient surgery versus one-day surgery on standards such as mortality, serious adverse events and quality of life.

METHODS

We conducted a cross-sectional descriptive study in the Department of General Surgery at the Habib Thameur Hospital over the period May 2009-February 2010. We here report 67 cases of symptomatic vesical lithiasis treated with outpatient laparoscopic cholecystectomy (OLC). ASA III and IV patients, diabetic patients treated with sulfonamides or insulin, severely obese patients, patients over 65 years of age and under 18 years of age, patients with a history of major abdominal surgery, patients with suspected lithiasis of the common bile duct, acute cholecystitis or pancreatitis were excluded from the study. Patients had to reside within 50 km of the hospital and be accompanied by an adult to undergo OLC.

RESULTS

Seventeen patients were included and then excluded from our study because of the perioperative detection of signs of acute cholecystitis or difficulties in dissection leading to subhepatic drainage using Redon catheter at the end of the intervention. Finally, our study included 50 patients, 7 men and 43 women; the average age was 48 years. Surgery was based on the most common procedures. After leaving the recovery room, patients were conducted in the outpatient sector where they received a liquid diet. The patients were examined before 7 o'clock in the evening and discharge was established on the basis of the possibility of establishing an oral analgesic treatment, patients tolerance to liquid diet, the lack of urinary disorder, patients acceptance for discharge and analgesic and anti-inflammatory treatment if needed. Thirty-nine patients (78%) were discharged from hospital and 11 were kept in hospital. Patients > 45 years of age, anesthesia duration > 70 minutes and post operative fatigue were identified as risk factors for unsuccessful discharge. No readmission was observed. Discharged patients were satisfied with the therapeutic protocol, resulting in excellent and good outcome in the majority of cases (94%).

CONCLUSION

Outpatient laparoscopic cholecystectomy seems to be as safe as day surgery laparoscopic cholecystectomy having low rate of complications and of hospital readmissions in some selected patients and lower surgery costs.

Effects of preoperative administration of ginger (Zingiber officinale Roscoe) on postoperative nausea and vomiting after laparoscopic cholecystectomy

One of the most common postoperative problems is nausea and vomiting. Although using some anesthetic materials has been considered as the mainstay of this phenomenon, the exact factors are not known. Because of several morbidities associated with postoperative nausea and vomiting (PONV), its prevention and treatment has been a challenge for physicians, so several drugs have been recommended for this purpose. Based on the documented antiemetic specificity of ginger, we evaluated and compared the effects of preoperative administration of ginger on PONV with ondansetron administration as the standard medication. The participants included 100 patients with cholelitiasis who were candidate for laparoscopic cholecystectomy. Patients were divided into two groups: group A comprised 50 patients who received 500 mg oral ginger 1 h before surgery, and group B included 50 patients who received 4 mg intravenous ondansetron before completion of surgery. Antiemetic efficacy was assessed by visual analogue scale scores of nausea intensity at 0, 4, 8, 16, and 24 h after surgery and frequency of vomiting during the evaluation period. Although multifactor analysis showed that nausea severity was significantly lower in the ginger group, the data indicated that except 16 h after operation, the differences between two groups in the frequency of vomiting was not significant. In conclusion, though complementary studies are needed to have a strong suggestion, based on this study, we recommend administration of oral ginger 1 h before operation to control the severity of PONV in patients undergoing laparoscopic cholecystectomy.

Comparison of Ramosetron with Palonosetron for Prevention of Postoperative Nausea and Vomiting in Patients Receiving Opioid-Based Intravenous Patient-Controlled Analgesia after Gynecological Laparoscopy

We aimed to compare the effects of ramosetron and palonosetron in the prevention of postoperative nausea and vomiting (PONV) in patients that received opioid-based intravenous patient-controlled analgesia (IV-PCA) after gynecological laparoscopy. We reviewed the electronic medical records of 755 adults. Patients were classified into two groups, ramosetron (group R, n = 589) versus palonosetron (group P, n = 166). Based on their confounding factors, 152 subjects in each group were selected after the implementation of propensity score matching. The overall incidence of PONV at postoperative day (POD) 0 was lower in group R compared to group P (26.9% versus 36.8%; P = 0.043). The severity of nausea was lower in group R than in group P on postoperative day (POD) 0 (P = 0.012). Also, the complete responder proportion of patients was significantly higher in group R compared to that in group P on POD 0 (P = 0.043). In conclusion, ramosetron showed a greater efficacy in the prevention of postoperative nausea at POD 0 compared to palonosetron in patients after gynecological laparoscopy.

Nitrous oxide-based techniques versus nitrous oxide-free techniques for general anaesthesia

BACKGROUND

Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise.

OBJECTIVES

To determine if nitrous oxide-based anaesthesia results in similar outcomes to nitrous oxide-free anaesthesia in adults undergoing surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites (http://clinicaltrials.gov/, http://controlled-trials.com/, and http://www.centerwatch.com).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol-based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the outcome data. We used meta-analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed-effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random-effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

MAIN RESULTS

We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta-analyses showed that nitrous oxide-based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta-analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide-based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low.

AUTHORS' CONCLUSIONS

Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre-existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review.

Dexamethasone reduces nausea and vomiting but not pain after thyroid surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after thyroidectomy. The aim of this article was to evaluate the efficacy of dexamethasone for prevention of PONV and pain in patients undergoing thyroidectomy.

MATERIAL AND METHODS

We performed this meta-analysis based on the QUORUM (Quality of Reporting of Meta-analyses) guidelines. Our study included randomized controlled trials (RCTs) that compared preoperative single-dose administration of dexamethasone with no dexamethasone in patients undergoing thyroidectomy. The primary outcome was occurrence and severity of PONV, and the secondary outcomes included pain, use of analgesics, and steroid-related complications.

RESULTS

Seven RCTs were included, with a total of 611 patients. A statistically and clinically significant difference in the incidence and severity of PONV was found in favor of dexamethasone (SMD, 0.23; 95% CI, 0.13-0.41; P<0.00001; SMD, 0.53; 95% CI, -1.03 to -0.03; P=0.04). However, there was no significant difference in reduction of pain severity and analgesic consumption in using dexamethasone (SMD, -0.83; 95% CI, -1.85 to 0.18; P=0.14; SMD, -0.19; 95% CI, -0.43 to 0.04; P=0.10). No steroid-related complications were noted.

CONCLUSIONS

A single preoperative administration of dexamethasone reduced the incidence and severity of PONV but not pain severity and analgesic consumption in patients undergoing thyroidectomy. Further studies with a larger sample size are needed to further explore the efficacy of dexamethasone on postoperative pain severity and analgesic consumption.

Spinal-epidural anesthesia versus general anesthesia in the management of percutaneous nephrolithotripsy

OBJECTIVE

To compare the efficacy between combined spinal-epidural block and general anesthesia in patients undergoing percutaneous nephrolithotripsy (PNL).

METHODS

A total of 180 patients undergoing PNL were randomly allocated to receive spinal-epidural anesthesia plus intravenous patient-controlled anesthesia with tramadol or general anesthesia (propofol induction, maintenance with sevoflurane) plus intravenous patient-controlled anesthesia with tramadol (G group). Hemodynamic changes, postanesthesia care unit (PACU) discharge times, times to home readiness, side effects, patient and endoscopist satisfaction, postoperative pain (scored from 0 to 10 on a visual analog scale), and analgesic medication were recorded.

RESULTS

Rates of hypotension (p = 0.06) and bradycardia (p = 0.14) did not differ between the groups. Compared with the G group, duration of PACU and the time to home readiness (p = 0.001 for each) were shorter in the spinal-epidural group. The incidence of nausea was higher in the G group (p = 0.001); vomiting and pruritus rates were similar between groups. No patient had respiratory depression. The spinal-epidural group had better patient satisfaction (p = 0.001) and lower pain scores (p = 0.001). The G group required more diclofenac during the first 48 h (p = 0.001).

CONCLUSIONS

In patients undergoing PNL, spinal-epidural anesthesia and analgesia gave greater patient satisfaction, shorter times for PACU and home readiness, and less postoperative pain. Spinal-epidural anesthesia is an attractive alternative to general anesthesia in these patients.

[Long QT syndrome and anaesthesia]

The long QT syndrome (LQTS) is a rare, congenital or acquired disease, which may lead to fatal cardiac arrhythmias (torsade de pointes, TdP). In all LQTS subtypes, TdPs are caused by disturbances in cardiac ion channels. Diagnosis is made using clinical, anamnestic and electrocardiographic data. Triggers of TdPs are numerous and should be avoided perioperatively. Sufficient sedation and preoperative correction of electrolyte imbalances are essential. Volatile anaesthetics and antagonists of muscle relaxants should be avoided and high doses of local anaesthetics are not recommended to date. Propofol is safe for anaesthesia induction and maintenance. The acute therapy of TdPs with cardiovascular depression should be performed in accordance with the guidelines for advanced cardiac life support and includes cardioversion/defibrillation and magnesium. Torsades de pointes may be associated with bradycardia or tachycardia resulting in specific therapeutic and prophylactic measures.

[Nausea and vomiting in the postoperative phase. Expert- and evidence-based recommendations for prophylaxis and therapy]

There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries. This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics; assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions is mainly dependent on the patient's individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk, generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV. Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The group suggests algorithms where prophylactic interventions are mainly dependent on the patient's risk for PONV. These algorithms should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.

[Outpatient opiate therapy in cancer patients during their last days of life]

BACKGROUND

Pain is one of the symptoms that many tumor patients are especially afraid of in the final phase of their illness. Symptoms can change rapidly, making quick adaptation of the therapy necessary. This poses particular challenges to organizational structures in outpatient treatment if the patients' desire to spend their last days of life in their accustomed surroundings is to be realized.

METHODS

Pain intensity and the associated symptoms in a WHO step III opiate therapy during the last 3 days of life were investigated retrospectively among 601 tumor patients who had received medical care from Home Care Berlin. Differences in gender, age, living conditions/care situation and place of death were evaluated with due consideration for the different pain medications administered and for the different forms and routes of administration.

RESULTS

More than 80% of the patients reported freedom from pain or only moderate pain during the opiate therapy. Care provided by the hospice-at-home medical service Home Care Berlin allowed excellent control of tumor patients' symptoms with only moderate side-effects in their final days of life. Among patients receiving opioids by the transdermal route there were significantly more frequent complaints of pain (p=0.004) and nausea (p=0.001). During the last days of life continuous subcutaneous infusions containing opiates facilitated good analgesia within an acceptable spectrum of side-effects. Most problems with controlling symptoms in outpatients were encountered in younger patients.

CONCLUSION

Morphine emerged as the drug of first choice in this investigation, because it can be given parenterally and also because of its price. The use of subcutaneous and intravenous administration systems such as PCA pumps requires trained nursing services and regular house visits by physicians experienced in palliative medicine.

[Perioperative patient management. Evaluation of subjective stress and demands of patients undergoing elective gynaecological surgery]

BACKGROUND

The aim of this investigation was to assess the extent of stress and demands in patients during preparation for general anesthesia for elective surgical procedures.

PATIENTS AND METHODS

A total of 52 female patients scheduled for elective gynecological surgery under general anesthesia were included in this prospective study. The extent and time course of actual demands describing perceived emotional stress was assessed at close intervals using the German version of the Questionnaire for Actual Demands (KAB). Pre-operative and postoperative anxiety was assessed using part one of Spielberger's state-trait-anxiety inventory (STAI-X1). This was compared to hemodynamic (heart rate und blood pressure) and endocrinal stress parameters [cortisol concentration in serum and saliva, prolactin and dehydroepiandrosteronesulfate (DHEA-S) in serum]. Postoperatively, all patients were asked to rate the quality of care during preparation for general anesthesia.

RESULTS

The extent of patients' demands and stress during preparation for general anesthesia could be quantified by the short questionnaire for the actual demands (KAB). So-called objective stress parameters like hemodynamic and endocrinal data alone did not correlate with perceived stress. However, the subjective information correlated with the nature of the underlying diagnosis. The postoperative assessment of quality of care during preparation for general anesthesia did not correlate with the course of actual demands and stress.

CONCLUSION

In future studies assessing the perioperative management of patients and quality of care, standardized testing questionnaires should be preferred, instead of vegetative parameters alone, to reliably evaluate perioperative demands and stress in surgical patients.

Elektive Kolonresektionen in Deutschland

BACKGROUND

Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany.

METHODS

In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection.

RESULTS

The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia.

CONCLUSION

In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

There is no dose-escalation response to dexamethasone (0.0625-1.0 mg/kg) in pediatric tonsillectomy or adenotonsillectomy patients for preventing vomiting, reducing pain, shortening time to first liquid intake, or the incidence of voice change

BACKGROUND

Tonsillectomy is associated with postoperative nausea and vomiting (PONV) if no prophylaxis is administered. Previous studies have shown that a single dose of dexamethasone decreases the incidence of PONV. The most effective dose of dexamethasone to affect clinical outcome is yet to be defined.

METHODS

One-hundred-twenty-five children were enrolled in a double-blind, prospective, randomized, dose-escalating study of dexamethasone: 0.0625, 0.125, 0.25, 0.5, or 1 mg/kg, maximum dose 24 mg. Nonparametric ANOVA was used to analyze the incidence of vomiting by treatment group for 0 to < or =5 h, >5 to 24 h. The Cox Proportional Likelihood Ratio Test was used to compare the time of first vomit and time to first pain medication across treatment groups.

RESULTS

There was no difference in the incidence of vomiting for the five escalating doses of dexamethasone in the time period. There were no differences in secondary outcomes (analgesic requirements, time to first liquid, and change in voice) across treatment groups.

CONCLUSION

We conclude that the lowest dose of dexamethasone (0.0625 mg/kg) was as effective as the highest dose of dexamethasone (1.0 mg/kg) for preventing PONV or reducing the incidence of other secondary outcomes following tonsillectomy or adenotonsillectomy. There is no justification for the use of high-dose dexamethasone for the prevention of PONV in this cohort of children.

Ondansetron, metoclopramid, dexamethason, and their combinations compared for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

A prospective randomized study was performed to assess the value of some individual risk factors for postoperative nausea and vomiting (PONV), and to compare the efficacy of ondansetron, metoclopramide, dexamethason, and combinations of these antiemetics in preventing PONV in patients after laparoscopic cholecystectomy.

METHODS

The study enrolled 210 patients (157 women and 53 men) scheduled for laparoscopic cholecystectomy. The patients were randomly divided into seven groups. In groups 1 to 6, antiemetic drugs were administered. Group 7, the control group, received no antiemetic. For all the patients, individual risk factors for the incidence of nausea also were analyzed. Both nausea and vomiting were assessed separately 1, 4, 8, and 12 h after the procedure.

RESULTS

Postoperative nausea and vomiting were significantly less frequent in menopausal women and more frequent in patients with a history of motion sickness. A comparison of mean values for the incidence of nausea and vomiting in groups 1 to 6 with the same values in group 7 showed that the mean PONV incidences were highest in groups 3 and 7, and the difference was significant.

CONCLUSIONS

Administration of antiemetic drugs significantly decreases the incidence of PONV in patients after laparoscopic cholecystectomy. The best decreases were achieved when ondansetron and dexamethason were applied together.

„Schlaf-Wach-Schlaf“-Technik zur CS Wachkraniotomie

Awake craniotomy in tumor and epilepsy surgery or for the implantation of electrodes for deep brain stimulation requires specific anesthesiological strategies. Propofol allows for quick emergence and has little effect on the respiratory function of the usually spontaneously breathing patient. Pain control may be instituted by hemiscalp block for trepanation or local infiltration for deep brain electrode implantation. In addition, low dose remifentanil is recommended for trepanation (i.e. tumor or epilepsy surgery). The airway may be secured by an ordinary Magill tube placed transnasally with its tip underneath the epiglottis. To protect the patient against vomiting an adequate antiemetic prophylaxis is required.

The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis

OBJECTIVE

The aim of this study was to specifically determine the impact of a fixed dose of ginger administration, compared with placebo, on the 24-hour postoperative nausea and vomiting.

STUDY DESIGN

The design was a systematic review and metaanalysis of trials revealed by searches. Randomized controlled trials comparing ginger with placebo to prevent postoperative nausea and vomiting and postoperative vomiting from Medline, IPA, CINAHL, Cochrane CENTRAL, HealthStar, Current Contents, bibliographies of retrieved articles, contact of authors, and experts in the field. Two reviewers selected studies for inclusion and independently extracted data.

RESULTS

Five randomized trials including a total of 363 patients were pooled for analysis of preventing postoperative nausea and vomiting and postoperative vomiting. The summary relative risks of ginger for postoperative nausea and vomiting and postoperative vomiting were 0.69 (95% confidence interval 0.54 to 0.89) and 0.61 (95% confidence interval 0.45 to 0.84), respectively. Only one side effect, abdominal discomfort, was reported.

CONCLUSIONS

This meta-analysis demonstrates that a fixed dose at least 1 g of ginger is more effective than placebo for the prevention of postoperative nausea and vomiting and postoperative vomiting. Use of ginger is an effective means for reducing postoperative nausea and vomiting.

PONV: a problem of inhalational anaesthesia?

Even nowadays every third or fourth patient suffers from postoperative nausea and vomiting (PONV) after general anaesthesia with volatile anaesthetics. There is now strong evidence that volatile anaesthetics are emetogenic and that there are no meaningful differences between halothane, enflurane, isoflurane, sevoflurane, and desflurane in this respect. However, when propofol is substituted for volatile anaesthetics the risk for PONV is reduced by only about one fifth, indicating that there are other even more important causes for PONV following general anaesthesia. A main causative factor might be the use of perioperative opioids, but their impact--relative to other factors including volatile anaesthetics--has never been quantified. Patient-specific risk factors have also been shown to be clinically relevant; they are therefore included in the calculation of simplified risk scores that allow prediction of a patient's risk independent of the type of surgery. Although controversial, the well-known different incidences following certain types of surgery are most likely caused by patient-specific and anaesthesia-related risk factors. There is a common consensus that prophylaxis with anti-emetic strategies is rarely justified when the risk of PONV is low, while it is warranted in case of imminent medical risk associated with vomiting or in a patient with a high risk for PONV. A recently published large multicentre trial of factorial design, IMPACT, has demonstrated that various anti-emetic strategies are associated with a very similar and constant relative reduction rate of about 25-30% and that the main predictor for the efficacy of prophylaxis is the patient's risk for PONV. Interestingly, all anti-emetics (dexamethasone, droperidol and ondansetron) work independently, so that their combined benefit can be derived directly from the single effects. The effectiveness of the anti-emetics was also independent of a variety of risk factors, including volatile anaesthetics. This means that any anti-emetic prophylaxis for PONV induced by volatile anaesthetics is equally effective. Of course, the most logical approach for prevention would be the omission of volatile anaesthetics and nitrous oxide using a total intravenous anaesthesia with propofol. However, since volatile anaesthetics are probably not the most important risk factors, it might be even better--if appropriate--to avoid general anaesthesia by using a regional, opioid-free anaesthesia if PONV is a serious problem.

Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under spinal anaesthesia: a randomized study of ondansetron prophylaxis

BACKGROUND AND OBJECTIVE

Patients undergoing total abdominal hysterectomy under general anaesthesia have a high risk of developing postoperative nausea and vomiting (PONV). The aim of this study was to evaluate the incidence of PONV in patients undergoing total abdominal hysterectomy under spinal anaesthesia with intravenous patient-controlled analgesia (PCA) using morphine and to compare its incidence with and without antiemetic prophylaxis.

METHODS

Thirty-four patients undergoing total abdominal hysterectomy under spinal anaesthesia with i.v. PCA morphine postoperatively were divided into two groups. The first (n = 17) received ondansetron prophylaxis near the end of surgery while the second (n = 17) received no prophylaxis. Morphine consumption, emetic episodes (on a 3-point scale), patient satisfaction (visual analogue score), sedation and pruritus were evaluated 2, 4, 6, 9, 12, 18 and 24h postoperatively.

RESULTS

Patient characteristics, postoperative morphine consumption (43.3 +/- 7.6 vs. 40.3 +/- 12.3 mg) and peristaltic recovery time (16.9 +/- 5 vs. 18.4 +/- 5.2 h) were similar in both groups. Overall nausea and vomiting were significantly lower in the ondansetron prophylaxis group than in the group without prophylaxis (52.9% vs. 88.2%, P < 0.05). Though nausea alone was higher in the prophylaxis group (41.2% vs. 29.4%), nausea with vomiting was significantly lower in the prophylaxis group (11.8% vs. 58.8%, P < 0.01). Patients' satisfaction scores were higher in the ondansetron group at all times and the difference was significant (P < 0.05) 4 h postoperatively.

CONCLUSIONS

The incidence of PONV in patients undergoing total abdominal hysterectomy under spinal anaesthesia with i.v. PCA morphine is very high (88.2%). Antiemetic prophylaxis with ondansetron is highly recommended in this patients group resulting in a lower incidence of nausea and vomiting, and significantly improves patient' satisfaction and life quality in the early postoperative period.