[Update on PONV-What is new in prophylaxis and treatment of postoperative nausea and vomiting? : Summary of recent consensus recommendations and Cochrane reviews on prophylaxis and treatment of postoperative nausea and vomiting]

The outpatient experience in unicompartmental knee arthroplasty: How to perform safely in the ambulatory surgery center

The number of outpatient unicompartmental knee arthroplasty (UKA) procedures has increased substantially over the last decade. The ambulatory surgery center (ASC) and hospital outpatient department provide a safe, cost-effective alternative with significant cost savings to the healthcare system. Advancements in technology and perioperative management strategies have expanded the number of eligible patients to optimize outcomes with a focus on safety. Therefore, this review will describe the safety, efficacy, economics, and perioperative protocols for performing UKA in an outpatient setting. Patient selection, risk factors, patient education and expectations, anesthesia, pain management strategies, and outcomes will be discussed.

Effects of adding intravenous midazolam to a dual postoperative nausea and vomiting regimen in patients undergoing breast surgery: A pragmatic randomized controlled trial

Background

For high-risk patients, adding a third antiemetic drug to dual postoperative nausea and vomiting (PONV) prophylaxis is controversial. Given the established antiemetic properties of midazolam, this study compared the combination of low-dose dexamethasone-ondansetron and midazolam with high-dose dexamethasone-ondansetron.

Methods

A total of 300 female patients scheduled for breast surgery were recruited and randomly assigned to two groups. The DO group received dexamethasone 8 mg and ondansetron 4 mg, whereas the DOM group received dexamethasone 4 mg, ondansetron 4 mg, and midazolam 0.04 mg/kg. The primary outcome was the incidence of PONV within 24 h. Secondary outcomes were PONV severity, antiemetic requirement, blood glucose levels, satisfaction and sedation scores, time to eye opening and extubation, pain outcome, and sore throat.

Results

Primary outcome analysis included 298 patients. Incidence of PONV within the first 24 h after surgery occurred in 52 of 150 (35%) patients in the DO group and 33 of 148 (22%) patients in the DOM group (adjusted risk ratio, 0.63; 95% confidence interval, 0.45-0.88; P = 0.007). The antiemetic requirement was significantly greater in the DO group compared with the DOM group (P = 0.034). However, a significantly higher sedation level and longer time for eye-opening and extubation were observed in the DOM group (P < 0.05).

Conclusion

Compared to high-dose dexamethasone and ondansetron alone, midazolam combined with low-dose dexamethasone and ondansetron decreased the incidence of PONV in patients undergoing breast surgery; however, it increased the sedation level in the early postoperative period.

Comparison of aprepitant versus ondansetron for prevention of postoperative nausea and vomiting: A systematic review and meta-analysis with trial sequential analysis

Background and Aims

Postoperative nausea and vomiting (PONV) is a common complication after surgery. Preventing PONV in high-risk patients often requires a multimodal approach combining antiemetic drugs with diverse mechanisms. While aprepitant, a neurokinin-1 receptor antagonist, is recognised as highly effective for PONV prevention, uncertainties remain regarding its effectiveness.

Methods

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The analysis assessed the effectiveness of aprepitant (A), aprepitant plus ondansetron (AO) and aprepitant plus dexamethasone and ondansetron (ADO) in preventing PONV compared to ondansetron alone (O) or in combination with dexamethasone (DO).

Results

In the analysis of 12 studies involving 2729 patients, aprepitant demonstrated significant efficacy in preventing PONV compared to ondansetron alone (A versus [vs.] O: PONV incidence 12.5% vs. 28.5%, relative risk [RR] = 0.45, P < 0.001; complete response rate 55.97% vs. 50.35%, RR = 1.13, P = 0.010). The combination of aprepitant with ondansetron (AO) also showed a significantly lower incidence of PONV compared to ondansetron alone (11.3% vs. 26.8%, RR = 0.43, P < 0.001) and a higher complete response rate (38.1% vs. 26.84%, RR = 1.41, P = 0.020). In addition, ADO significantly reduced PONV incidence compared to DO (ADO vs. DO: 13.63% vs. 35.38%, RR = 0.38, P = 0.006).

Conclusion

Aprepitant, whether used alone or in combination with ondansetron or both ondansetron and dexamethasone, consistently outperforms ondansetron in achieving a complete response as it lowers vomiting rates and reduces the need for rescue therapy during the crucial 24-48-h postoperative period.

Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy

PURPOSE OF THE REVIEW

Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality.

RECENT FINDINGS

Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.

[Remimazolam-Update on basic pharmacologic principles and clinical potential]

In recent years the still relatively new short-acting benzodiazepine remimazolam has been approved and clinically implemented in several countries and regions. Remimazolam is also now approved in the EU and the market launch in Germany is expected in the not too distant future. This is therefore a good point in time to summarize the current evidence for various areas of application, including general anesthesia, sedation and intensive care medicine as well as different dosing schemes.

A case-control study on the clinical characteristics of granisetron-related arrhythmias and the development of a predictive nomogram

BACKGROUND

Automatic monitoring and assessment are increasingly employed in drug safety evaluations using hospital information system data. The increasing concern about granisetron-related arrhythmias requires real-world studies to improve our understanding of its safety.

AIM

This study aimed to analyze the incidence, clinical characteristics, and risk factors of granisetron-related arrhythmias in hospitalized patients using real-world data obtained from the Adverse Drug Event Active Surveillance and Assessment System-II (ADE-ASAS-II) and concurrently aimed to develop and validate a nomogram to predict the occurrence of arrhythmias.

METHOD

Retrospective automatic monitoring of inpatients using granisetron was conducted in a Chinese hospital from January 1, 2017, to December 31, 2021, to determine the incidence of arrhythmias using ADE-ASAS- II. Propensity score matching was used to balance confounders and analyze clinical characteristics. Based on risk factors identified through logistic regression analysis, a prediction nomogram was established and internally validated using the Bootstrap method.

RESULTS

Arrhythmias occurred in 178 of 72,508 cases taking granisetron with an incidence of 0.3%. Independent risk factors for granisetron-related arrhythmias included medication duration, comorbid cardiovascular disease, concomitant use of other 5-hydroxytryptamine 3 receptor antagonists, alanine aminotransferase > 40 U/L, and blood urea nitrogen > 7.5 mmol/L. The nomogram demonstrated good differentiation and calibration, with enhanced clinical benefit observed when the risk threshold ranged from 0.10 to 0.82.

CONCLUSION

The nomogram, based on the five identified independent risk factors, may be valuable in predicting the risk of granisetron-related arrhythmias in the administered population, offering significant clinical applications.

Is Postoperative Pain Associated With Nausea and Vomiting Following Orthognathic Surgery?

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse side-effect following orthognathic surgery, with pain potentially contributing as a risk factor.

PURPOSE

The study's purpose was to measure the association between postoperative pain and PONV.

STUDY DESIGN, SETTING, SAMPLE

This prospective cohort study involved patients who underwent bimaxillary surgery at Erciyes University, Oral and Maxillofacial Surgery Hospital. Patients with a history of routine antiemetic use, pregnancy, breastfeeding, morbid obesity, cardiac dysrhythmia, mental retardation, or psychiatric illness were excluded.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The predictor variable was postoperative pain, which was measured using a 100-mm visual analogue scale (VAS). VAS scores were documented at the 30-minute postoperative mark (referred to as VAS1), and the mean of hourly VAS scores over the initial three postoperative hours (denoted as VAS2).

MAIN OUTCOME VARIABLE(S)

The primary outcome was the occurrence of PONV, defined as active vomiting, retching, or nausea leading to vomiting. The secondary outcome was the timing of PONV, categorized as early (within 6 hours), late (6-24 hours), and delayed (beyond 24 hours postoperatively).

COVARIATES

The study's covariates were age, sex, body mass index, Apfel risk scores, surgery duration, history of PONV or motion sickness, and smoking status.

ANALYSES

Descriptive statistics and χ2 tests were used for data analysis, with statistical significance set at P value < .05.

RESULTS

The sample was composed of 86 subjects with a median age of 20 years (range: 18-30 years), of which 37.2% were male. The frequency of PONV was 50%. Postoperative pain, as measured by VAS scores, was significantly higher in the PONV group compared to the non-PONV group. The median VAS1 score was 60.0 (PONV group, range 40-90) versus 50.0 (non-PONV, range 0-90) (P = .041); for VAS2, it was 60.0 (PONV, range 40-80) compared to 40.0 (non-PONV, range 30-60) (P < .001).

CONCLUSIONS AND RELEVANCE

The frequency of PONV observed in patients undergoing bimaxillary surgery is substantial, necessitating the identification and management of risk factors to enhance perioperative care and patient outcomes. By improving PONV management and addressing postoperative pain, health-care providers can enhance the perioperative experience and patient outcomes in bimaxillary surgery.

Operation-specific risk of postoperative nausea: a cross-sectional study comparing 72 procedures

OBJECTIVES

Determination of the procedure-specific, risk-adjusted probability of nausea.

DESIGN

Cross-sectional analysis of clinical and patient-reported outcome data. We used a logistic regression model with type of operation, age, sex, preoperative opioids, antiemetic prophylaxis, regional anaesthesia, and perioperative opioids as predictors of postoperative nausea.

SETTING

Data from 152 German and Austrian hospitals collected in the Quality Improvement in Postoperative Pain Treatment (QUIPS) registry from 2013 to 2022. Participants completed a validated outcome questionnaire on the first postoperative day. Operations were categorised into groups of at least 100 cases.

PARTICIPANTS

We included 78 231 of the 293 947 participants from the QUIPS registry. They were 18 years or older, willing and able to participate and could be assigned to exactly one operation group.

MAIN OUTCOME MEASURES

Adjusted absolute risk of nausea on the first postoperative day for 72 types of operation.

RESULTS

The adjusted absolute risk of nausea ranged from 6.2% to 36.2% depending on the type of operation. The highest risks were found for laparoscopic bariatric operations (36.2%), open hysterectomy (30.4%), enterostoma relocation (29.8%), open radical prostatectomy (28.8%), laparoscopic colon resection (28.6%) and open sigmoidectomy (28%). In a logistic regression model, male sex (OR: 0.39, 95% CI 0.37 to 0.41, p<0.0001), perioperative nausea and vomiting prophylaxis (0.73, 0.7 to 0.76, p<0.0001), intraoperative regional anaesthesia (0.88, 0.83 to 0.93, p<0.0001) and preoperative opioids for chronic pain (0.74, 0.68 to 0.81, p<0.0001) reduced the risk of nausea. Perioperative opioid use increased the OR up to 2.38 (2.17 to 2.61, p<0.0001).

CONCLUSIONS

The risk of postoperative nausea varies considerably between surgical procedures. Patients undergoing certain types of operation should receive special attention and targeted prevention strategies. Adding these findings to known predictive tools may raise awareness of the still unacceptably high incidence of nausea in certain patient groups. This may help to further reduce the prevalence of nausea.

TRIAL REGISTRATION NUMBER

DRKS00006153; German Clinical Trials Register; https://drks.de/search/de/trial/DRKS00006153.

Postoperative Nausea and Vomiting following Endoscopic Sinus Surgery under the Guidance of Adequacy of Anesthesia or Pupillometry with Intravenous Propofol/Remifentanil

Postoperative nausea and vomiting (PONV) constitutes an adverse event after endoscopic sinus surgery (ESS) under general anesthesia (GA) with intravenous opioids, such as remifentanil (RMF). Monitoring the nociception/antinociception balance using the surgical pleth index (SPI) or pupillary dilatation reflex (PRD) helps guide intravenous RMF infusion. We aimed to investigate whether their employment could help reduce the incidence of PONV in patients undergoing ESS. The data of 30 patients from the GA group, 31 from the SPI group, and 28 from the PRD group were analyzed. The initial RMF infusion rate of 0.25 µg/kg body weight/minute was increased by 50% when the SPI, PRD, or Boezaart Bleeding Scale (BBS) were elevated by >15, >5%, or >2 points, respectively, until they normalized. PONV was present in 7/89 patients (7.9%): 2/31 patients (6.5%) of the SPI group, 1/30 patients (3.3%) of the GA group, and 4/28 patients (14.3%) of the PRD group. Neither PRD nor SPI guidance for RMF administration reduced the incidence of PONV compared to standard practice. Further studies are required in order to investigate the possibility of PONV eradication in patients undergoing ESS under GA when it is possibly combined with paracetamol/metamizole preventive analgesia, as well as those using antiemetic prophylaxis based on the Apfel Score and premedication with midazolam.

A nomogram to predict postoperative nausea and vomiting in the ward following laparoscopic bariatric surgery

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common and distressing complication of laparoscopic bariatric surgery (LBS). However, there is a lack of effective integrated prediction models for preventing and treating PONV in patients after LBS.

METHODS

Based on a randomized controlled trial conducted between November 1, 2021, and May 13, 2022, we included 334 participants who underwent LBS according to the inclusion criteria. The database was divided randomly into training and validation cohorts in a ratio of 7:3. Least absolute shrinkage and selection operator plus multivariable logistic regression were used to identify independent predictors and construct a nomogram. The performance of the nomogram was assessed and validated by the area under the receiver operating characteristic curve (AUC), the concordance index (C-index), calibration plots, and a decision curve analysis (DCA). We also explored specific risk factors for PONV in patients with diabetes.

RESULTS

The subjects were divided randomly into training (n = 234) and validation (n = 100) cohorts. Age, history of diabetes, type of surgery, and sugammadex use were incorporated to construct a nomogram prediction model. In the training cohort, the AUC and the optimism-corrected C-index were 0.850 [95% confidence interval (CI) 0.801-0.899] and 0.848, while in the validation cohort they were 0.847 (95% CI 0.768-0.925) and 0.844, respectively. The calibration plots showed good agreement between the predicted and actual observations. The DCA results demonstrated that the nomogram was clinically useful. The type of surgery, sugammadex use, and insulin level at 120 min were predictors of PONV in patients with diabetes with an AUC of 0.802 (95% CI 0.705-0.898).

CONCLUSIONS

We developed and validated a prediction model for PONV in patients after LBS. A risk factor analysis of PONV in patients with diabetes provides clinicians with a more precise prophylactic protocol.

Efficacy and safety of intraperitoneal dexamethasone on postoperative nausea and vomiting following laparoscopy: study protocol for a systematic review and meta-analysis

INTRODUCTION

Intraperitoneal dexamethasone has been reported to be effective to reduce the incidence of postoperative nausea and vomiting (PONV). Therefore, this meta-analysis will analyse the efficacy and safety of intraperitoneal dexamethasone on PONV following laparoscopy.

METHODS AND ANALYSIS

Electronic databases (eg, Cochrane Library, PubMed, Excerpta Medica Database, Web of Science, National Institute of Informatics, Oriental Medicine Advanced Searching Integrated System and China National Knowledge Infrastructure) and clinical trial registries will be systematically searched from their inception to 1 October 2022. After the study and data collection processes, we will identify randomised controlled trials that reported details of intraperitoneal dexamethasone on PONV following laparoscopy to conduct a meta-analysis. We will perform the study process and data collection separately. The collected data will be statistically analysed using Review Manager 5.4 software. The risk of bias will be assessed using the Cochrane risk-of-bias tool 2. The Grading of Recommendations Assessment, Development and Evaluation certainty assessment, and a trial sequential analysis will be conducted to ensure the accuracy of this meta-analysis.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required since this study is a systematic review and meta-analysis. The findings of this meta-analysis will be submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42022362924.

Research trends of acupuncture therapy on postoperative nausea and vomiting from 2011 to 2023: A bibliometric analysis

BACKGROUND

The utilization of acupuncture as a therapeutic intervention for the management of postoperative nausea and vomiting has experienced a notable increase in its popularity, and the purpose of this analysis is to provide a comprehensive understanding of the level of concern within the academic discipline and the main contributors and their partnership, as well as to identify research focal points and trends.

METHODS

A comprehensive search was carried out to identify relevant articles on the topic of acupuncture therapy for PONV in the Web of Science and China National Knowledge Internet. The search spanned from January 1, 2011, to June 6, 2023. The annual publications were count to see the degree of scholarly attention devoted to the discipline and how it has changed over time. A statistical analysis of article distribution across various journals was conducted to serve a rough indicator for assessing the quality of articles. And a bibliometric analysis was conducted using the software CiteSpace to visually analyze various aspects of the literature. Analyze authors, institutions and countries to identify the main contributors and their collaborative relationship; and analyze keywords and references to explore research hotspots and trends.

RESULTS

This study examined a comprehensive collection of 819 articles focused on acupuncture therapy for PONV, demonstrating a varying upward trend in the quantity of publications. Notably, the most productive author and institution were identified as Zheng Man and Guangzhou University of Traditional Chinese Medicine, respectively. While China had the highest number of publications, the United States held a greater prominence in this specific field. Collaboration among contributors was found to be weak. High-frequency keywords in the publications included "transcutaneous electrical acupoint stimulation," "electroacupuncture," "pain," and so forth. The literature with the highest citation count pertained to "Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting," while the article with the highest centrality was "Consensus Guidelines for the Management of Postoperative Nausea and Vomiting." Several large clusters obtained from the references are also included "postoperative pain," "transcutaneous electrical acupoint stimulation". Nothing pertaining to mechanism study was found in the analysis results.

CONCLUSION

The utilization of acupuncture for the treatment of postoperative nausea and vomiting has been gaining increasing recognition, although there remains room for improvement in the quality of research conducted in this area. Chinese authors and institutions have emerged as significant contributors to this field, while the United States has demonstrated greater proficiency in fostering collaborative efforts. It is imperative to enhance collaboration among these contributors. The current focal points of acupuncture for PONV encompass pain management, electroacupuncture, auricular acupuncture, and transcutaneous electrical acupoint stimulation. Additionally, TEA and enhanced recovery after surgery have been identified as the forefronts of research in this particular domain. In addition, there is still much room for research in the aspect of mechanism and insurance coverage. This study provides an in-depth perspective on acupuncture for PONV, which offers reference material for clinicians with rational choice of therapeutic scheme, educators with hot topics, and researchers with valuable research directions.

Is PONV still a problem in pediatric surgery: a prospective study of what children tell us

Background

Postoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies.

Methods

A prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey.

Results

On the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8-19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9-11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1-1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5-4.4) and diclofenac (OR 2.0, 95% CI: 1. 3-3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9-4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7-11.6).

Conclusions

The main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome.

The preventive effect of dexmedetomidine on anesthesia complications in strabismus surgery: a systematic review and meta-analysis

OBJECTIVE

Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated with strabismus surgery, including postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex. However, its effectiveness and side effects of the present studies are different. The sample sizes of the present studies on the prevention of complications of dexmedetomidine are small. Therefore, this study evaluates the efficacy of dexmedetomidine in preventing anesthesia-related complications in strabismus surgery through a systematic review and meta-analysis.

METHODS

Literature was retrieved from 10 commonly used databases and randomized controlled trials published up to May 2022 were sought. The included studies compared the intervention effects of dexmedetomidine versus placebo on anesthesia-related complications in surgery. The occurrence rates of postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex in patients undergoing strabismus surgery were evaluated. Statistical analyses and forest plots were generated using Review Manager and STATA software. Binary outcomes were measured using relative risk (RR) with a 95% confidence interval for each outcome. The Cochrane risk of bias tool was used to assess the bias and risk in the studies that met the inclusion criteria.

RESULTS

A total of 13 articles were ultimately included in the analysis, comprising 1,018 patients who underwent strabismus surgery. The dexmedetomidine group, compared to the placebo group, demonstrated significant reductions in the incidence of postoperative delirium (RR = 0.73, P = 0.001), severe postoperative delirium (RR = 0.45, P = 0.005), postoperative nausea and vomiting (RR = 0.48, P < 0.0001), and the need for supplemental analgesia postoperatively (RR = 0.60, P = 0.004). Additionally, subgroup analysis revealed that intravenous administration of dexmedetomidine significantly reduced the incidence of oculocardiac reflex (RR = 0.50, P = 0.001). In contrast, intranasal administration of dexmedetomidine did not have a significant effect on the incidence of oculocardiac reflex (RR = 1.22, P = 0.15). There was a significant difference between the subgroups (P = 0.0005, I2 = 91.7%).

CONCLUSION

Among patients undergoing strabismus surgery, the use of dexmedetomidine can alleviate postoperative delirium and reduce the incidence of postoperative nausea and vomiting, as well as postoperative pain. Moreover, intravenous administration of dexmedetomidine can lower the occurrence rate of the oculocardiac reflex.

Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery

PURPOSE

The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer.

DESIGN

This study used a prospective, cross-sectional, observational design.

METHODS

The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales.

FINDINGS

Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery.

CONCLUSIONS

Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.

Pain treatment and prophylaxis on pain

PURPOSE OF REVIEW

Also in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment.

RECENT FINDINGS

Postoperative pain should be addressed both pre, intra- and postoperatively. The management should be with a multimodal nonopioid-based procedure specific guideline for the routine cases. In 10-20% of cases, there will be a need to adjust and supplement the basic guideline with extra analgesic measures. This may be because there are contraindications for a drug in the guideline, the procedure is more extensive than usual or the patient has extra risk factors for strong postoperative pain. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis. Opioids should be with nondepot formulations, titrated to effect in the postoperative care unit and eventually continued only when needed for a few days at maximum.

SUMMARY

Multimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.