The effects of antagonizing residual neuromuscular blockade by neostigmine and glycopyrrolate on nausea and vomiting after ambulatory surgery

[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.

What is the role of neuromuscular blocking drugs in ambulatory anesthesia?

PURPOSE OF REVIEW

During ambulatory anesthesia, muscle relaxants should be used judiciously because of their impact on operating room efficiency and the potential for morbidity and mortality.

RECENT FINDINGS

Short-acting and low doses of medium-acting muscle relaxants are appropriate for the typically short period of anesthesia required in ambulatory settings, but they are not necessarily indicated. Their adverse effects range from annoying to lethal. Even when the effects are relatively benign, delays may reduce efficiency. Direct laryngoscopy and endotracheal intubation can often safely be accomplished with opioids and propofol, or with topical anesthesia. Procedures such as laparoscopic cholecystectomies can safely be performed with anesthesia via a laryngeal mask airway; with other procedures, a regional technique or monitored anesthesia care is satisfactory. New agents may improve upon currently available muscle relaxants in terms of rapid onset, short duration, and minimal adverse effects.

SUMMARY

Anesthetic and surgical needs should dictate the use of muscle relaxants, and alternatives to their use should be considered.

Fast-tracking in outpatient surgery

Fast-tracking in outpatient surgery is a new paradigm that allows for rapid throughput and early discharge, thereby facilitating perioperative efficiency. Compared with the conventional recovery process, bypassing the postanesthesia care unit reduces the time to discharge home. An ideal anesthetic technique for fast-tracking would provide for rapid emergence and the prevention of common postoperative complications such as pain, nausea, and vomiting using a multimodal approach.

Neostigmine 50 microg kg(-1) with glycopyrrolate increases postoperative nausea in women after laparoscopic gynaecological surgery

BACKGROUND

Neostigmine, used for reversal of neuromuscular block, has been implicated in the development of postoperative nausea and vomiting (PONV). The use of mivacurium, which does not require neostigmine reversal due to its metabolism by plasma cholinesterase, has made it possible to study the effect of neostigmine on PONV in a randomised, double-blind, placebo-controlled manner.

METHODS

Ninety healthy women scheduled for laparoscopic gynaecological surgery were randomly allocated to two groups in a double-blind manner. One group was given neostigmine (50 microg kg(-1)) and glycopyrrolate (10 microg kg(-1)) (group NG), the other NaCl i.v. as placebo (group P) at the end of surgery when all the patients were spontaneously reversed to at least 75% of full muscle power. The risk of PONV was reduced by using low doses of opioids and ondansetron prophylaxis. All the patients were monitored and assessed for 24 h with regard to pain, nausea, vomiting and overall satisfaction.

RESULTS

There was a statistically significant difference (P=0.03) in the occurrence of nausea during the first 6 h postoperatively between NG group (30%) and P group (11%), resulting in the more extensive use of antiemetic drugs in the NG group (28%) than in P group (7%) (P=0.01) in this period. There was no difference between the groups in the frequency of vomiting; seven nauseated patients had vomiting, four in group NG, three in group P. Total number of patients with PONV during the observation period of 24 h, usage of antiemetic rescue medication and overall patient satisfaction did not differ significantly between the groups.

CONCLUSION

The results suggest that antagonism of neuromuscular block with a high dose of neostigmine increases postoperative nausea and the use of antiemetic drugs during the first 6 h after administration.