Incidence of nausea and vomiting in outpatients undergoing general anesthesia in relation to selection of intraoperative opioid

Opioid-free general anesthesia: considerations, techniques, and limitations

PURPOSE OF REVIEW

To discuss the role of opioids during general anesthesia and examine their advantages and risks in the context of clinical practice. We define opioid-free anesthesia (OFA) as the absolute avoidance of intraoperative opioids.

RECENT FINDINGS

In most minimally invasive and short-duration procedures, nonopioid analgesics, analgesic adjuvants, and local/regional analgesia can significantly spare the amount of intraoperative opioid needed. OFA should be considered in the context of tailoring to a specific patient and procedure, not as a universal approach. Strategies considered for OFA involve several adjuncts with low therapeutic range, requiring continuous infusions and resources, with potential for delayed recovery or other side effects, including increased short-term and long-term pain. No evidence indicates that OFA leads to decreased long-term opioid-related harms.

SUMMARY

Complete avoidance of intraoperative opioids remains questionable, as it does not necessarily ensure avoidance of postoperative opioids. Multimodal analgesia including local/regional anesthesia may allow OFA for selected, minimally invasive surgeries, but further research is necessary in surgeries with high postoperative opioid requirements. Until there is definitive evidence regarding procedure and patient-specific combinations as well as the dose and duration of administration of adjunct agents, it is imperative to practice opioid-sparing approach in the intraoperative period.

Characteristics of ambulatory spine care visits in the United States, 2009-2016

BACKGROUND

Back pain is a leading reason for seeking care in the United States (US), and is a major cause of morbidity.

OBJECTIVE

To analyze demographic, patient, and visit characteristics of adult ambulatory spine clinic visits in the United States from 2009-2016.

METHODS

Data from the National Ambulatory Medical Care Survey from 2009-2016 were used and were sample weighted.

RESULTS

Most patients presenting for ambulatory spine care were 45-64 years (45%), were most commonly female (56.8%), and private insurance (45%) and Medicare (26%) were most common payors. The percentage of visits for spine care done at a primary care setting was 50.1% in 2009-2010 and 48.3% in 2014-2015. Approximately 15.5% were seen in orthopedic surgery clinics in 2009-2010 and 7.3% in 2015-2016. MRI was utilized in 11.7% in 2009-2010 and 11.0% in 2015-2016. Physical therapy was prescribed in 13.2% and narcotic analgesic medications were prescribed in 36.2% of patients in 2015-2016.

CONCLUSIONS

MRI was used more frequently than guidelines recommended, and physical therapy was less frequently utilized despite evidence. A relatively high use of opiates in treatment of back pain was reported and is concerning. Although back pain represents a substantial public health burden in the United States, the delivery of care is not evidence-based.

Fewer postoperative opioids are associated with decreased duration of stay for children with perforated appendicitis

BACKGROUND

The impact of postoperative opioid use on outcomes for children with perforated appendicitis is unknown.

METHODS

A retrospective cohort study was performed using the Pediatric Health Information System database from 2005 to 2015. Children 2 to 18 years with perforated appendicitis who underwent an appendectomy were identified. Postoperative day analgesic use was categorized as nonopioid analgesia alone, opioids (with or without nonopioid analgesia), or no analgesics. The impact of postoperative opioid use on postoperative duration of stay and 30-day readmission was evaluated using multivariable mixed-effects regression analysis.

RESULTS

Overall, 47,726 children with perforated appendicitis were identified. On postoperative day 1, 17.7% received nonopioid analgesia alone, 77.6% received opioids, and 4.7% received no analgesics. On adjusted analysis, postoperative day 1 opioid use was associated with a 0.75-day (95% confidence interval: 0.54-0.96) increased postoperative duration of stay. Starting opioids after postoperative day 1 was associated with 2.21 days (95% confidence interval: 1.90-2.51) longer postoperative duration of stay. Among children who received opioids on postoperative day 1, continued use of opioids after postoperative day 1 was associated with a 1.88 day (95% confidence interval: 1.77-1.98) longer postoperative duration of stay. Postoperative day 1 opioid use did not significantly affect 30-day readmission.

CONCLUSION

Early and continued postoperative opioid use is associated with prolonged postoperative duration of stay in children undergoing appendectomy for perforated appendicitis. Minimizing opioid use, even on postoperative day 2, may result in a decreased postoperative duration of stay.

Experience of Immediate Ambulation and Early Discharge After Tumescent Anesthesia and Propofol Infusion in Cosmetic Breast Augmentation

INTRODUCTION

Current cosmetic breast augmentation relies on general anesthesia that normally requires 40 min to total recovery. With experience, the surgical procedure can be completed expediently in 20 min under tumescent anesthesia and propofol full sedation to achieve immediate postoperative ambulation and home discharge readiness, and thus improve patient satisfaction and reduce cost. We retrospectively examined the outcomes of the protocol.

MATERIALS AND METHODS

Per protocol, 1200 female patients underwent simple cosmetic breast augmentation accomplished with tumescent anesthesia, immediate mobilization, and early home discharge readiness after surgery. The following records were analyzed: vital sign stability during mobilization in the first 30 cases (primary goal), duration of surgery and anesthesia, frequency of intraoperative opioid use, frequency of ambulation needing assistance, Verbal Analog Scores and incidences of pain, orthostatic intolerance events, incidences of postoperative nausea and vomiting or anti-emetic use, and complications at follow-up visits (secondary goal).

RESULTS

Hemodynamics during immediate postoperative mobilization demonstrated no statistically significant fluctuations and/or orthostatic intolerance requiring interventions. The mean duration of surgery was 20.4 ± 4.1 min. The mean duration of anesthesia was 25.2 ± 6.8 min. All patients tolerated immediate postoperative ambulation well. Adverse postoperative events were scarce. Only 9.1% reported postoperative pain, and 5.7% reported postoperative nausea and vomiting. One percent had transit post-ambulation dizziness needing supine positioning for less than 3 min. The average time to meet home-readiness criteria was 4.7 min, and there was no incidence of hematoma, infection, or complaints at follow-ups.

CONCLUSIONS

For simple cosmetic breast augmentation, instead of general anesthesia and 40 min of recovery time, a tumescent anesthetic technique can be used for immediate postoperative ambulation and a 4.7-min home discharge readiness without a decrease in anesthesia quality and safety.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of intraoperative single bolus fentanyl administration and remifentanil infusion on postoperative nausea and vomiting

BACKGROUND

Although the use of postoperative opioids is a well-known risk factor for postoperative nausea and vomiting (PONV), few studies have been performed on the effects of intraoperative opioids on PONV. We examined the effects of a single bolus administration of fentanyl during anesthesia induction and the intraoperative infusion of remifentanil on PONV.

METHODS

Two hundred and fifty women, aged 20 to 65 years and scheduled for thyroidectomy, were allocated to a control group (Group C), a single bolus administration of fentanyl 2 µg/kg during anesthesia induction (Group F), or 2 ng/ ml of effect-site concentration-controlled intraoperative infusion of remifentanil (Group R) groups. Anesthesia was maintained with sevoflurane and 50% N2O. The incidence and severity of PONV and use of rescue antiemetics were recorded at 2, 6, and 24 h postoperatively.

RESULTS

Group F showed higher incidences of nausea (60/82, 73% vs. 38/77, 49%; P = 0.008), vomiting (40/82, 49% vs. 23/77 30%; P = 0.041) and the use of rescue antiemetics (47/82, 57% vs. 29/77, 38%; P = 0.044) compared with Group C at postoperative 24 h. However, there were no significant differences in the incidence of PONV between Groups C and R. The overall incidences of PONV for postoperative 24 h were 49%, 73%, and 59% in Groups C, F, and R, respectively (P = 0.008).

CONCLUSIONS

A single bolus administration of fentanyl 2 µg/kg during anesthesia induction increases the incidence of PONV, but intraoperative remifentanil infusion with 2 ng/ml effect-site concentration did not affect the incidence of PONV.

Addition of ultralow dose naloxone to postoperative morphine PCA: unchanged analgesia and opioid requirement but decreased incidence of opioid side effects

Ultralow doses of naloxone (0.001-0.1 microg/kg) produce analgesia in animal models. However, no clinical study has evaluated the combination of ultralow dose naloxone and morphine using patient-controlled analgesia (PCA). This randomized, double blind controlled study sought to determine if the combination of ultralow dose naloxone and morphine in PCA solutions affects opioid requirements, analgesia, and side effects. Two-hundred and sixty-five patients (18-65 years old) undergoing operations were randomized to receive PCA morphine 1 mg/ml (n=129) or PCA morphine 1 mg/ml plus naloxone 0.6 microg/ml (n=136). We evaluated the numbers of supplemental rescue doses, the cumulative dose of each PCA solution, pain intensity, pain relief, and opioid side effects during the first 24 h after surgery. We found that opioid requirements did not differ significantly between groups. The morphine+naloxone group on average required 0.07 mg more morphine (95% CI -1.1 to 1.3) during the 24 h than the morphine group. Pain intensity levels were also similar in both groups. The morphine+naloxone group had 0.06 units lower (95% CI -0.5 to 0.4) pain intensity levels than the morphine group. The morphine+naloxone group had a lower incidence of nausea and pruritus than the morphine group (P=0.01 for both symptoms). However, the incidence of vomiting, time to tolerate fluids, sedation, and urinary retention were similar between groups (all P values >0.1). The combination of ultralow dose naloxone and morphine in PCA does not affect analgesia or opioid requirements, but it decreases the incidence of nausea and pruritus.

The combination of low dose of naloxone and morphine in PCA does not decrease opioid requirements in the postoperative period

The continuous infusion of low doses of naloxone has been reported to decrease postoperative opioid requirements and opioid side effects. However, there is no study that evaluates the effectiveness of the combination of a low dose of naloxone and morphine using patient-controlled analgesia (PCA). This prospective, randomized double-blind controlled study sought to determine if the combination of a low dose of naloxone and morphine in a PCA solution decreases postoperative opioid requirements and pain intensity. One hundred sixty-six patients (18-65 years old) undergoing operations of less than 3 h duration with an American Society of Anesthesiologist physical status I or II were randomized to receive PCA morphine 1 mg/cc plus normal saline or PCA morphine 1 mg/cc plus naloxone 6 microg/cc. Initial PCA settings were 0.5 cc per demand with a lockout time of 10 min. The numbers of 2.5 cc supplemental rescue doses and the cumulative dose of each solution were recorded in the first 24 h after the surgical procedure. Pain intensity and opioid side effects were evaluated every 10 min in the post-anesthesia care unit and every 4 h afterwards. Patient satisfaction was assessed at the end of the 24 h of observation. The morphine+naloxone group had more treatment failures (P=0.0001), higher opioid requirements (P=0.0097), greater pain intensity (P=0.04), less pain relief (P=0.004), and less satisfaction (P=0.01) than the morphine group. The incidence of side effects was similar in both groups (P=0.3). Contrary to previous reports, adding low doses of naloxone to a morphine PCA solution increases opioid requirements and pain.

A randomized controlled trial of fentanyl for abortion pain

OBJECTIVE

Our aim was to find out whether intravenous fentanyl was effective in reducing the pain of first-trimester abortion.

STUDY DESIGN

This randomized controlled trial included 825 women attending a nonhospital abortion facility. Some women chose standard care. Women who did not choose standard care were randomly assigned to receive either 50 to 100 microg of fentanyl, a placebo, or no intervention. With SAS software and a mixed effects analysis of variance model with covariates, we compared mean pain scores of the fentanyl and placebo groups to detect a difference of at least 1 point on an 11-point pain scale.

RESULTS

The mean pain score of the fentanyl group was 1.0 point less than that of the placebo group (95% confidence interval, 3.7-4.3) and 0.9 point less than that of the observational group (95% confidence interval, 4.7-5.1). This pain reduction was statistically significant, but the women who were studied wanted a 2-point reduction from fentanyl.

CONCLUSION

Fentanyl, when compared with the placebo, reduced abortion pain by 1.0 point on an 11-point scale. This reduction was of questionable clinical significance and was less than desired by the women included in the study.

Factors contributing to a prolonged stay after ambulatory surgery

We identified predictors for prolonged postoperative stay after ambulatory surgery using multiple logistic regression models. We collected perioperative data for 16,411 ambulatory surgical patients. A log-transformed time to discharge variable was modeled by multiple linear regression, including patient-, anesthesia-, and surgery-specific variables. The impact of hypothetical elimination of perioperative adverse events on mean length of stay was also estimated. Separate analyses were performed among patients who received general anesthesia (GA) and monitored anesthesia care (MAC). Patients receiving GA stayed 50 min longer than patients receiving MAC. Patients receiving GA and undergoing strabismus, transurethral, or otorhinolaryngological/dental procedures had the longest postoperative stay. Among patients receiving GA, smokers had a 4% shorter stay compared with nonsmokers; among patients receiving MAC, those with congestive heart failure (CHF) had a 11% longer stay compared with patients without CHF. Postoperative nausea and vomiting, dizziness, excessive pain, and cardiovascular events predicted 22%-79% increases in postoperative stay. The hypothetical elimination of all adverse events resulted in a 9.6% decrease in mean length of stay among patients receiving GA, but in only a 3.8% decrease among patients receiving MAC. The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and cardiovascular events. Patients with CHF and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving GA.

IMPLICATIONS

The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.

Quality of emergence from anesthesia and incidence of vomiting with remifentanil in a pediatric population

We conducted a randomized trial to compare the incidence of vomiting and the quality of emergence from anesthesia associated with the use of remifentanil versus a nonopiate. It was expected that remifentanil would provide smoother emergence from anesthesia with a comparably low rate of vomiting. The study sample consisted of 115 pediatric patients undergoing dental restoration and extraction who were randomly assigned to the nonopiate or remifentanil groups based on their hospital admission numbers. The nonopiate patients received sufficient desflurane to prevent movement, typically 7%-9%. The remifentanil group received remifentanil 0.2 microg x kg(-1) x min(-1) and enough desflurane to prevent movement, typically 3.2%-3.6%. A trained postanesthesia care unit nurse, blinded to the anesthetic technique, assessed the quality of emergence and incidence of vomiting. Sixty-three patients received remifentanil and 52 received the nonopiate. The groups were not significantly different in either quality of emergence or incidence of vomiting. Remifentanil provided results comparable to a nonopiate with no increase in emesis.

IMPLICATIONS

A randomized, controlled clinical trial of 115 patients undergoing dental restoration indicated that an anesthetic technique using remifentanil provided quality of emergence comparable to and no greater incidence of vomiting than a nonopiate technique.

Postoperative pain control in ambulatory surgery

Optimizing postoperative pain control is the key to further advancement in the field of ambulatory anesthesia. The current situation in postoperative pain management indicates room for improvement, especially in the area of patient education and the development of individualized discharge analgesic packages. Multimodal analgesia provides superior analgesia with a lower side-effect profile. Preoperative administration of analgesia would decrease the intraoperative analgesic requirement, which may lead to a smooth and rapid recovery. Finally, new, portable analgesic delivery systems are under investigation and may prove to be the method of choice for future postoperative pain, management in ambulatory anesthesia.

Factors influencing stay in the postanesthesia care unit: a prospective analysis

STUDY OBJECTIVE

To identify indicators of prolonged length of stay (LOS) in the postanesthesia care unit (PACU) and to test the following hypotheses: (1) that patient age, pain medication administration at the time of PACU admission, length of surgery, and cardiovascular, pulmonary, and pain responses postoperatively predict prolonged PACU LOS and (2) that cardiovascular and pulmonary symptoms preoperatively predict cardiovascular and pulmonary symptoms postoperatively.

DESIGN

Prospective, observational analysis.

SETTING

PACU of a university teaching hospital.

PATIENTS

1,067 patients scheduled for surgery with general anesthesia between February and September 1996, 18 years of age or older.

MEASUREMENT AND MAIN RESULTS

11.2% of the variation in prolonged PACU LOS can be predicted by age, pain medication at the time of PACU admission, and postoperative cardiovascular, pulmonary, and pain symptoms. A significant number of patients who did not report a prior history experienced postoperative cardiovascular and pulmonary symptoms.

CONCLUSION

Patient history and postoperative symptoms predict only a small percentage of prolonged PACU stays. Organizational factors may be a more important predictor of prolonged PACU stay. Additionally, assessment of cardiovascular and pulmonary history needs refinement to improve prediction of patient responses postoperatively.