Which clinical anesthesia outcomes are important to avoid? The perspective of patients

Bibliometric Evaluation of the 100 Top-Cited Articles on Anesthesiology

This review is a bibliometric analysis based on anesthesiology, which is a medical specialty that deals with a patient's complete preoperative, intraoperative, and postoperative care. The objective of the review attempts to analyze the bibliometric characteristics of the 100 most top-cited articles on anesthesiology. The meta-data of the study were collected from the Core Collection of Web of Science database. A title search option was employed, and "Anesthesia" and "Anesthesiology" were typed in two different search boxes separated with the Boolean operator ''OR''. Further, the data were sorted by highest citation order; later, "article" was selected from the filter of document type, and all other types of documents were excluded. Finally, downloaded the bibliographic details of the 100 top-cited articles. VOSviewer Software (version 1.6.10 by van Eck and Waltman) was used for bibliometric network analysis for co-authors and keywords. Pearson chi-square test was used for statistical analysis. The 100 top-cited articles were published between the years of 1971 and 2018. These articles gained a maximum of 1006 to a minimum of 276 citations with an average of 384.57 cites/article. Open accessed articles gained a slightly higher ratio of citations, while more than half of the articles were published in the two leading journals of "Anesthesiology" and "Anesthesia and Analgesia". There was no statistically significant difference in both citation analysis among open and closed access journals and Anesthesia vs Non-Anesthesia journals. Thirty-six articles were published in journals not specifically related to Anesthesia. Most of the top-cited articles were contributed by the United States, whereas Surgery and General Anesthesia were the two most occurred keywords.  We conclude that all the top-cited articles in anesthesiology were contributed by authors who belonged to the developed nations and the United States outclassed the rest of the world. This bibliometric analysis would be valuable to practitioners, academics, researchers, and students to understand the dynamics of progress in the field of anesthesiology.

Effect of Oral Care Solution on Sore Throat After I-Gel Laryngeal Mask General Anesthesia: A Randomized Controlled Trial

Background

Sore throat is a common complication after general anesthesia. Oral care solutions have been used to reduce the incidence of oral complications or ventilator-associated pneumonia, but their effect on postoperative sore throat (POST) is unclear. This study aims to investigate whether oral care solution can alleviate POST in patients undergoing i-gel laryngeal mask general anesthesia.

Methods

A total of 120 patients who were scheduled for elective surgery under laryngeal mask general anesthesia were enrolled. The patients were randomly assigned to an experimental group (oral care solution) and a control group (0.9% saline) and gargled for 1 min with 10mL of oral care solution or saline 5 min before anesthesia induction. The primary outcomes were the overall incidence of sore throat within 24 h and incidence at 20 min, 1 h, 6 h, 24 h after removal of i-gel. The secondary outcomes were the severity of sore throat at the four time points and incidence of hoarseness, cough within 24 h after removal of i-gel.

Results

A total of 111 patients were included in the analysis. The overall incidence of sore throat within 24 h in the experimental group was significantly lower than that in the control group, as was the incidence at four time points (P<0.05). The VAS scores at the four time points in the experimental group were significantly lower than those in the control group (P<0.05), and the results of repeated measurement analysis of variance showed that time effect and intergroup effect were statistically significant (P<0.001). No differences were found between the groups in the incidence of hoarseness and cough.

Conclusion

Gargling with oral care solution before anesthesia induction can significantly reduce the incidence and severity of POST in patients undergoing i-gel laryngeal mask general anesthesia.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience

BACKGROUND

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA.

METHODS

In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA.

RESULTS

Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year.

CONCLUSIONS

These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Opioid Free Total Intravenous Anesthesia With Dexmedetomidine-Esketamine-Lidocaine for Patients Undergoing Lumpectomy

Background

The aim of the study was to evaluate the feasibility of the opioid-free anesthesia (OFA) technique with dexmedetomidine, esketamine, and lidocaine among patients diagnosed with benign breast mass and scheduled for lumpectomy.

Methods

We enrolled 80 female patients who were aged from 18 to 60 years, graded with American Society of Anesthesiologists physical status I or II, diagnosed with benign breast mass, and scheduled for lumpectomy. These patients were randomly treated with OFA or opioid-based anesthesia (OBA). Dexmedetomidine-esketamine-lidocaine and sufentanil-remifentanil were administered in OFA and OBA group, respectively. We mainly compared the analgesic efficacy of OFA and OBA technique, as well as intraoperative hemodynamics, the quality of recovery, and satisfaction score of patients.

Results

There was no significant difference between the two groups with regard to visual analogue scale (VAS) score at 2, 12, and 24 h after extubation. However, the time to first rescue analgesic was prolonged in OFA group than that in OFB group (6.18 ± 1.00 min vs. 7.40 ± 0.92 min, P = 0.000). Further, mean arterial pressure and heart rate at T0 (entering operating room), T1 (before anesthesia induction), T2 (immediately after intubation), T3, T4, and T5 (1, 5, and 10 min after surgical incision, respectively) were significantly higher in OFA group than that in OBA group. Incidence of hypotension and bradycardia was lower in OFA group. Consistently, fewer patients in OFA group consumed atropine (8% vs. 32%, P = 0.019) and ephedrine (5% vs. 38%, P = 0.001) compared to OBA group. Furthermore, patients in OFA group had a longer awakening time (7.14 ± 2.63 min vs. 4.54 ± 1.14 min, P = 0.000) and recovery time of orientation (11.76 ± 3.15 min vs. 6.92 ± 1.19 min, P = 0.000). Fewer patients in the OFA group experienced postoperative nausea and vomiting (PONV) (11% vs. 51%, P = 0.000) and consumed ondansetron (5% vs. 35%, P = 0.003) compared to OBA group. And patients in OFA group had a higher satisfaction score than those in OBA group (9 (8 - 9) vs. 7 (7 - 8), P = 0.000).

Conclusion

For patients undergoing lumpectomy, OFA technique with dexmedetomidine-esketamine-lidocaine showed a better postoperative analgesic efficacy, a more stable hemodynamics, and a lower incidence of PONV. However, such advantage of OFA technique should be weighed against a longer awakening time and recovery time of orientation in clinical practice.

The Effectiveness of Ondansetron and Dexamethasone in Preventing Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy

Background The current research compared the effectiveness of dexamethasone with ondansetron in terms of the frequency of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Methodology A comparative cross-sectional study was conducted in the Department of Surgery, Civil Hospital, Karachi, Pakistan, between June 2021 and March 2022. All patients aged between 18 and 70 years who were scheduled for elective laparoscopic cholecystectomy under general anesthesia were included in the study. All women who were on antiemetics or cortisone before surgery pregnant, and had hepatic, or renal malfunction were excluded. Group A included patients who were administered 8 mg of dexamethasone intravenously, and group B included patients who were prescribed 4 mg of ondansetron intravenously. Observation of patients was done for any symptoms such as vomiting, nausea, or the need for any antiemetic medication after the surgery. The number of episodes of vomiting and nausea was recorded in the proforma along with the duration of stay in the hospital. Results A total of 259 patients were examined during the study - 129 (49.8%) in the dexamethasone group (group A) and 130 (50.2%) in the ondansetron group (group B). The mean age of group A was 42.56 ± 11.9 years, with a mean weight of 61.4 ± 8.5 kg. The mean age of group B was 41.19 ± 10.8 years, with a mean weight of 62.56 ± 6.3 kg. Upon assessing the effectiveness of each drug in preventing nausea and vomiting, postoperatively, it was found that both drugs were equally effective in preventing nausea in the majority of the patients (73.85% vs. 65.89%; P = 0.162). However, ondansetron was significantly more effective in preventing vomiting in patients than dexamethasone (91.54% vs. 79.07%; P = 0.004). Conclusions This study concluded that the use of either dexamethasone or ondansetron effectively reduces the incidence of postoperative nausea and vomiting. However, ondansetron was significantly more effective in reducing the incidence of vomiting in patients after laparoscopic cholecystectomy than dexamethasone.

Anesthetic drug shortages in Pakistan: a multicentre nationwide survey

PURPOSE

There is a paucity of literature on anesthetic drug shortages and their impact on patient safety in lower-middle-income countries. We sought to determine the magnitude of the problem, the effect on patient care and safety, and the adverse patient outcomes witnessed by anesthesiologists in Pakistan METHODS: We conducted a nationwide, multicentre, cross-sectional survey of a representative sample of anesthesiologists in Pakistan (January 2021 to June 2021). The survey questionnaire was adapted from the American Society of Anesthesiologists (ASA) survey on drug shortages and was modified based on the national essential medication list 2018 of Pakistan. It was distributed through Google Forms to anesthesiologists practicing in both the private and government sector. The names of hospitals or the identity of anesthesiologists was not required. The questionnaire consisted of 20 items and focused on the anesthesiologists' experience of drug shortages, the availability of drugs, and the impact of drug shortages on their individual practice.

RESULTS

Two hundred and forty-six responses were received. Approximately 50% (122/246) of anesthesia practitioners in Pakistan reported anesthetic drug shortages. Fifty-seven percent of respondents mentioned using an inferior drug that may have significantly affected the delivery of anesthetic care. Four participants mentioned severe morbidity and another four mentioned observing a mortality associated with drug shortage.

CONCLUSION

Anesthetic drug shortages are common in anesthetic practice in Pakistan and they appear to affect patient care and outcomes.

Acupuncture-assisted anaesthesia for catheter ablation of atrial fibrillation to reduce the consumption of morphine hydrochloride and postoperative nausea and vomiting (PONV): study protocol for a randomised controlled trial

BACKGROUND

Patients often experience postoperative nausea and vomiting (PONV) after catheter ablation of atrial fibrillation (AF) because of the use of opioids for anaesthesia and analgesia during the procedure. Some clinical trials have demonstrated that acupuncture-assisted anaesthesia (AAA) reduces opioid consumption and prevents PONV. Although several studies have been conducted on AAA, its safety and efficacy in AF catheter ablation remain unclear due to small sample sizes and a paucity of methodologically rigorous designs. Therefore, this trial was designed to evaluate the safety and efficacy of AAA in reducing PONV and morphine hydrochloride consumption during catheter ablation.

METHODS

This single-centre, patient-blinded, randomised, non-penetrating sham-controlled trial will be conducted in China. A total of 100 patients will be randomly assigned to the AAA and conventional anaesthesia (CA) groups in a ratio of 1:1. The patients will receive AAA or CA plus sham acupuncture during catheter ablation and will be followed up for 30 days. The primary outcomes include the total amount of morphine hydrochloride consumed during catheter ablation and PONV within the first 24 hours after the procedure. The secondary outcomes include pain, nausea and vomiting, anxiety, patient's ability to cope during catheter ablation, AF recurrence and quality of life, as assessed using the numeric rating scale. Adverse events will be recorded and their influence will be analysed at the end of the trial.

DISCUSSION

This study will help in evaluating the safety and efficacy of AAA applied for AF catheter ablation in reducing opioid doses during the procedure and the occurrence of PONV.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine. The results of the study will be published in peer-reviewed journals and presented at conferences if possible.

TRIAL REGISTRATION NUMBER

ChiCTR 2100042646; Chinese Clinical Trial Registry.

The effect of newly designed dual-channel elastomeric pump for intravenous patient-controlled analgesia after total laparoscopic hysterectomy: a randomized, double-blind, prospective study

BACKGROUND

A newly designed intravenous patient-controlled analgesia (PCA) device with a dual-channel elastomeric infusion pump has been recently introduced. One channel is a continuous line with a constant flow rate basal infusion, while the other channel has an adjustable flow rate and bolus function and is labeled as a selector-bolus channel. This study compared dual and single-channel intravenous PCA in terms of clinical effect and quality of recovery.

METHODS

Eighty-four patients undergoing total laparoscopic hysterectomy were randomly allocated to a 1-channel group (n = 41) or a 2-channel group (n = 43). Only the selector-bolus channel was utilized, but the continuous channel was not utilized in the 1-channel group, but both channels were utilized in the 2-channel group. In the 1-channel group, 16 μg/kg of fentanyl, 2 mg/kg of ketorolac, and 12 mg of ondansetron with normal saline were administered to the selector-bolus channel and normal saline only in the continuous channel for blinding. In the 2-channel group, 16 μg/kg of fentanyl was administered to the selector-bolus channel, and ketorolac (2 mg/kg) and ondansetron (12 mg) were administered via the continuous channel. The quality of recovery was evaluated preoperatively and 24 h postoperatively using the Quality of Recovery-40 (QoR-40). Cumulative PCA consumption, postoperative pain rated using the numeric rating scale (NRS; during rest/cough), and postoperative nausea were evaluated 6, 12, 24, 36, and 48 h after surgery. Incidence of vomiting and use of antiemetics and rescue analgesics was measured.

RESULTS

The 24-h postoperative QoR-40 score was higher in the 2-channel group than in the 1-channel group (P=0.031). The incidence of nausea at 12 h and 36 h was significantly higher in the 1-channel group (P=0.043 and 0.040, respectively), and antiemetic use was more frequent in the 1-channel group (P=0.049). Patient satisfaction was higher in the 2-channel group (P=0.036). No significant differences were observed in pain scores during resting/cough or cumulative PCA consumption.

CONCLUSIONS

The 2-channel PCA showed better patient satisfaction with higher QoR-40 during the recovery compared with the 1-channel PCA. Better satisfaction was associated with lower nausea and reduced rescue antiemetics by maintaining the infusion of adjuvant analgesic agents and antiemetic agents constantly by utilizing dual channels.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov , NCT04082039 on 9 September 2019.

A Retrospective Health Economic Analysis of a Stable Hypochlorous Acid Preserved Wound Cleanser Versus 0.9% Saline Solution as Instillation for Negative-Pressure Wound Therapy in Severe and Infected Wounds

Introduction Negative-pressure wound therapy (NPWT) with instillation and dwell time is an accepted adjunct therapy for infected wounds. A study was conducted to assess whether the use of hypochlorous acid preserved wound cleanser (HAPWOC) (Vashe, Urgo Medical North America, Fort Worth, TX, USA) as the irrigant would reduce the cost of care in comparison to 0.9% saline (NaCl). Method A comparative, observational, retrospective analysis assessed 27 serious and infected wounds in 24 patients. The lesions were of different and complex etiologies, including necrotizing fasciitis and stage IV diabetic foot ulcers. NPWT was used as part of the overall multimodal treatment regimen. The only variance in the treatment protocol was the use of saline (N=8) or HAPWOC (N=19) as the irrigant. Results When compared to NaCl, wounds treated with HAPWOC trended toward fewer operating room (OR) visits versus NaCl (3.3 versus 4.1) and a shorter length of hospital stay (LOS) (24.3 days versus 37.9 days). The Orlando Health Transparency guide shows the cost of OR debridement as $2,525. Thus, debridement for HAPWOC-treated wounds ($8,332) costs $2,020 (24%) less than for NaCl-treated wounds ($10,352). Using the 2016 Kaiser Health data (average daily hospital cost, excludingall interventions: $2,052), the cost of HAPWOC and NaCl instill translates to $49,864 and $77,771, respectively, a difference of $27,906 (56%) more for NaCl treatment. The Agency for Healthcare Research and Quality (AHRQ) 2012 data indicate an average daily cost of hospital stay, including all interventions, of $10,400. Thus, HAPWOC treatment cost translates to $252,720 versus NaCl-related costs of $394,160; in these calculations, using NaCl costs $141.440 (+56%) more per patient than HAPWOC. Conclusion The use of NPWT with HAPWOC versus NaCl as instillation in NPWT reduces the number of visits to the operating room and LOS. This has a significant impact on lowering the cost of care when HAPWOC is used.

Rapid detection of single nucleotide polymorphisms using the MinION nanopore sequencer: a feasibility study for perioperative precision medicine

Introduction

Precision medicine is a phrase used to describe personalized medical care tailored to specific patients based on their clinical presentation and genetic makeup. However, despite the fact that several single nucleotide polymorphisms (SNPs) have been reported to be associated with increased susceptibility to particular anesthetic agents and the occurrence of perioperative complications, genomic profiling and thus precision medicine has not been widely applied in perioperative management.

Methods

We validated six SNP loci known to affect perioperative outcomes in Japanese patients using genomic DNA from saliva specimens and nanopore sequencing of each SNP loci to facilitate allele frequency calculations and then compared the nanopore results to those produced using the conventional dideoxy sequencing method.

Results

Nanopore sequencing reads clustered into the expected genotypes in both homozygous and heterozygous cases. In addition, the nanopore sequencing results were consistent with those obtained using conventional dideoxy sequencing and the workflow provided reliable allele frequency estimation, with a total analysis time of less than 4 h.

Conclusion

Thus, our results suggest that nanopore sequencing is a promising and versatile tool for SNP genotyping, allowing for rapid and feasible risk prediction of perioperative outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40981-022-00506-7.

Efficacy of type-I and type-II pectoral nerve blocks (PECS I and II) in patients undergoing mastectomy: a prospective randomised clinical trial

INTRODUCTION

The benefits of type I/II pectoral nerve blocks (PECS I/II), which can be dose dependent, have been examined in different studies. Nonetheless, few randomised trials have been performed in South America. The present randomised trial examined the efficacy of PECS I/II with a higher dose of the local anaesthetic to manage perioperative pain after mastectomy in Brazil.

MATERIAL AND METHODS

This was a randomised, parallel, single-centre, and single-blind trial. Eighty participants undergoing elective mastectomy were randomised (1 : 1) to receive PECS I/II plus ultrasound-guided ropivacaine (0.5%) or standard general anaesthesia. The primary outcome was pain intensity at rest 24 hours after surgery, assessed with a numerical rating scale. Haemodynamic outcomes, consumption of opioids, anaesthe-tics and antiemetics, and post-anaesthetic recovery times were also recorded.

RESULTS

Sixty participants (75%) completed the study. The mean age was 54 years, with 57% of participants undergoing mastectomy and 43% undergoing quadrantectomy. Median pain intensity (interquartile range) at rest (24 h postoperatively) was lower in the PECS I/II group compared to the control group: 0 (0-1.75) vs. 1 (1-2), P = 0.021. A smaller number of patients in the PECS I/II group required intraoperative fentanyl (23.3% vs. 83.3%; P < 0.001) and postoperative tramadol (20.0 vs. 76.7%; P < 0.001). Mean doses of fentanyl and tramadol were about 4-5 times lower in the PECS I/II group (P < 0.001). PECS I/II significantly reduced sevoflurane consumption during surgery (P = 0.01). No difference was observed regarding adverse effects.

CONCLUSIONS

PECS I/II blockade with high-dose local anaesthetic is efficacious and safe, resulting in lower levels of perioperative pain after mastectomy compared to standard general anaesthesia.

The Generalizability of Patients' Preferences and Concerns regarding Anesthesia Care for Cesarean Delivery: A Prospective Survey

Background

False assumptions regarding the generalizability of patients' expectations and preferences across different demographic groups may contribute in part to the increased prevalence of negative peripartum outcomes seen among women of color. The intention of this study was to determine preferences and concerns regarding anesthesia care during cesarean delivery in a largely African-American population and to compare them to those obtained in a prior study conducted in a demographically distinct population.

Methods

Women presenting for scheduled cesarean delivery or induction of labor completed a preoperative survey requesting demographic information and the opportunity to rank ten common potential anesthetic outcomes in relation to each other from most to least desirable. Participants were also asked about their biggest fear concerning their anesthetic and their preferences and expectations regarding degree of wakefulness, pain, and other adverse events. Those who underwent cesarean delivery were administered a briefer postoperative survey. We tabulated preference rankings and then compared demographic and outcome data to that obtained in a previous study with a demographically dissimilar population.

Results

A total of 73 women completed the preoperative survey, and 64 took the postoperative survey. Pain during and after cesarean delivery was ranked as least desirable outcomes and fear of paralysis was respondents' principal concern with neuraxial anesthesia. Postoperative concerns were similar to preoperative concerns and did not correlate with the frequency with which specific adverse outcomes occurred. These results were consistent with those from the previous study despite the women in this study being more likely to be younger, unmarried, African-American, and less educated than those in the previous investigation.

Conclusions

Patient preference rankings and concerns were remarkably similar to those previously demonstrated despite a number of demographic differences between the two populations, suggesting generalizability of these preferences to a broader obstetric population.

Factors Associated with Postoperative Nausea and Vomiting after Breast Cancer Surgery with Inhalation Anesthesia

BACKGROUND

The incidence and risk factors of postoperative nausea and vomiting (PONV) and early PONV (ePONV) were evaluated in patients who underwent breast surgery with volatile anesthesia.

METHODS

In this retrospective study, multivariate logistic regression was used to determine incidence and identify risk factors for PONV.

RESULTS

Among 928 patients, 166 (18%) and 220 (24%) had ePONV and PONV, respectively. In multivariate analysis, anesthesia duration and use of desflurane were independent risk factors for ePONV. For PONV, anesthesia duration and Apfel score were independent risk factors.

CONCLUSIONS

Our results indicate that desflurane was the main cause of ePONV. However, during the delayed phase, a higher Apfel score was the strongest predictor. In the early and delayed phases, long anesthesia duration was associated with high risk of PONV. Thus, prolonged anesthesia and desflurane use should be avoided for patients at high risk of PONV, particularly those with high Apfel scores.

Development and internal validation of an algorithm to predict intraoperative risk of inadvertent hypothermia based on preoperative data

Intraoperative hypothermia increases perioperative morbidity and identifying patients at risk preoperatively is challenging. The aim of this study was to develop and internally validate prediction models for intraoperative hypothermia occurring despite active warming and to implement the algorithm in an online risk estimation tool. The final dataset included 36,371 surgery cases between September 2013 and May 2019 at the Vienna General Hospital. The primary outcome was minimum temperature measured during surgery. Preoperative data, initial vital signs measured before induction of anesthesia, and known comorbidities recorded in the preanesthetic clinic (PAC) were available, and the final predictors were selected by forward selection and backward elimination. Three models with different levels of information were developed and their predictive performance for minimum temperature below 36 °C and 35.5 °C was assessed using discrimination and calibration. Moderate hypothermia (below 35.5 °C) was observed in 18.2% of cases. The algorithm to predict inadvertent intraoperative hypothermia performed well with concordance statistics of 0.71 (36 °C) and 0.70 (35.5 °C) for the model including data from the preanesthetic clinic. All models were well-calibrated for 36 °C and 35.5 °C. Finally, a web-based implementation of the algorithm was programmed to facilitate the calculation of the probabilistic prediction of a patient's core temperature to fall below 35.5 °C during surgery. The results indicate that inadvertent intraoperative hypothermia still occurs frequently despite active warming. Additional thermoregulatory measures may be needed to increase the rate of perioperative normothermia. The developed prediction models can support clinical decision-makers in identifying the patients at risk for intraoperative hypothermia and help optimize allocation of additional thermoregulatory interventions.

Penehyclidine for prevention of postoperative nausea and vomiting following bimaxillary orthognathic surgery: a randomized, double-blind, controlled trial

PURPOSE

To investigate the efficacy and safety of low-dose bolus plus continuous infusion of penehyclidine in preventing postoperative nausea and vomiting (PONV) following bimaxillary surgery.

METHODS

Three hundred fifty-four patients were randomly allocated into three groups. In the Control group, placebo (normal saline) was injected before anesthesia and infused over 48 h after surgery; in the Bolus group, 0.5 mg penehyclidine was injected before anesthesia, whereas placebo was infused after surgery; in the Infusion group, 0.25 mg penehyclidine were injected before anesthesia, another 0.25 mg penehyclidine was infused after surgery. The primary endpoint was the incidence of PONV within 72 h.

RESULTS

A total of 353 patients were included in intention-to-treat analysis. The PONV incidence was 61.0% (72/118) in the Control group, 40.2% (47/117) in the Bolus group, and 28.0% (33/118) in the Infusion group. The incidence was significantly lower in the Bolus group than in the Control group (RR 0.66; 95% CI 0.51-0.86; adjusted P = 0.003) and in the Infusion group than in the Control group (RR 0.46; 95% CI 0.33-0.63; adjusted P < 0.001); the difference between the Infusion and Bolus groups was not statistically significant (RR 0.70; 95% CI 0.48-1.00; adjusted P = 0.144). Emergence agitation occurred more frequently in the Bolus group than in the Control group (36.8% [43/117] vs. 21.2% [25/118], adjusted P = 0.027), but did not differ significantly between the Infusion and Control groups.

CONCLUSIONS

A low-dose bolus plus continuous infusion of penehyclidine was effective in preventing PONV without increasing emergence agitation.

TRIAL REGISTRATION

Clinicaltrials.gov. Identifier: NCT04454866.

Is Prevention of Postoperative Vomiting Surgery Dependent? A Retrospective Cohort Study of Total Knee Arthroplasty

The study of postoperative nausea and vomiting (PONV) has been ongoing since the early days of general anesthesia. The search for risk factors of PONV and the development of new agents to treat PONV are the two main strategies to combat the adverse side effects of general anesthesia. Female sex, non-smoking status, a history of PONV/motion sickness, and postoperative opioid use are the four independent risk factors for PONV derived after a series of prospective studies, evidence-based systematic reviews, and meta-analyses. The two frequently asked questions that arise ask whether risk factors apply to different clinical settings and whether prevention measures of PONV can be surgery dependent. We conducted a comprehensive review of 665 patients who underwent primary total knee arthroplasty (TKA) between January and December 2019. As nausea is subjective and its measurement is not standardized, postoperative vomiting (POV) was used as a study endpoint. The exclusion criteria were desflurane anesthesia, spinal anesthesia, anesthesia without bispectral index monitoring, and day surgery. Three well-recognized risk factors, consisting of body weight, sevoflurane consumption, and postoperative opioid consumption, were not considered as independent risk factors of POV, while female sex, preoperative adductor canal block (ACB), and dexamethasone were identified as being so in this study. The risk of POV in the female sex was 2.49 times that in the male sex; however, when dexamethasone was used, this risk was reduced by >40% compared with no antiemetic use, and by >50% when patients received preoperative ACB compared with those without the block. The clinical characteristics of our TKA patients—female dominance, old age, and their fairly constant body weights that were distinct from those of other surgical patients—suggested that age may play a crucial role in determining the relative contributions of the different risk factors of POV. We concluded that risk factors of POV are dependent on clinical settings. Based on these results, it is reasonable to speculate that a surgery-dependent plan for the prevention of POV is feasible for patients in similar clinical settings.

Efficacy of perioperative intravenous dexmedetomidine administration for the prevention of postoperative sore throat: a meta-analysis

Objective

Postoperative sore throat (POST) is an undesirable intubation-related complication after surgery. Several studies have investigated the efficacy of perioperative intravenous dexmedetomidine administration for the prevention of POST, but the results have been inconsistent. We aimed to summarize all existing evidence and draw a more precise conclusion to guide future clinical work.

Methods

PubMed, Cochrane Library, EMBASE and China National Knowledge Infrastructure databases were comprehensively searched for all randomized controlled trials published before 1 February 2021 that investigated the efficacy of dexmedetomidine for the prevention of POST.

Results

Nine studies involving 400 patients were included in our meta-analysis. Compared with the control groups (i.e., saline and anesthetic drugs), perioperative intravenous use of dexmedetomidine significantly reduced the incidence of POST [risk ratio (RR): 0.56; 95% confidence interval (CI): 0.40–0.77; I² = 0%) and coughing on the tube during extubation (RR: 0.58; 95% CI: 0.41–0.82; I² = 0%). Additionally, patients in the dexmedetomidine group were more likely to develop bradycardia (RR: 2.46; 95% CI: 1.28–4.71; I² = 0%) and hypotension (RR: 3.26; 95% CI: 1.14–9.33; I² = 0%) during the administration of dexmedetomidine than those in the control group.

Conclusion

Perioperative intravenous administration of dexmedetomidine has a positive effect on the prevention of POST.

Risk Factors of Postoperative Vomiting in the Eye of "Real-World Evidence"-Modifiable and Clinical Setting-Dependent Risk Factors in Surgical Trauma Patients

Numerous studies on postoperative nausea and vomiting (PONV) have been carried out since the early days of contemporary surgery. The incidence of PONV has been greatly reduced in recent years and new drugs for PONV keep evolving in the market; however, a substantial number of patients are still under the threat of PONV. Female gender, non-smokers, a history of PONV/motion sickness, and postoperative opioid use are four well-recognized risk factors of PONV. Many potential risk factors reported in previous studies were not consistently presented as predictors for PONV. Two questions then arise; are risk factors clinical setting dependent and are risk factors modifiable? We attempted to answer the questions through a comprehensive review of perioperative records of surgical patients from the Trauma Department of our hospital. As nausea is subjective and no standard is applicable for its measurement, postoperative vomiting (POV) was used as an endpoint in this study. To the best of our knowledge, this is the first study to address the POV issue in surgical trauma patients. A total of 855 patients were enrolled in this study after excluding age below 20 years old, total intravenous anesthesia, desflurane anesthesia, or records with missing data. Our results showed that female gender (OR 4.89) is the strongest predicting factor, followed by a less potent predicting factor—more intraoperative opioid consumption (OR 1.07)—which favor more POV. More intraoperative crystalloid supply (OR 0.71) and a higher body weight (OR 0.9) favor less POV. Other potential risk factors did not reach statistical significance in this study as independent risk factors. Our results also showed that when the intraoperative crystalloid infusion rate is greater than 4 mL/kg/h (OR 0.20), it favors a lower rate of POV; when intraoperative opioid consumption is greater than 12 mg morphine equivalents, MME (OR 1.87), it favors a higher rate of POV. We concluded that dominance of any independent risk factor over other risk factors depends on how individual factors interact with the clinical setting. Some risk factors could be modified, and a cut-off value could be derived to facilitate a better plan for POV prevention.

Disability-free survival after major cardiac surgery: a population-based retrospective cohort study

BACKGROUND

Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery.

METHODS

We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models.

RESULTS

The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 μmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability.

INTERPRETATION

The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.

Cognitive status of patients judged fit for discharge from the post-anaesthesia care unit after general anaesthesia: a randomized comparison between desflurane and propofol

Background

The Aldrete’s score is used to determine when a patient can safely leave the Post-Anaesthesia Care Unit (PACU) and be transferred to the surgical ward. The Aldrete score is based on the evaluation of vital signs and consciousness. Cognitive functions according to the anaesthetic strategy at the time the patient is judged fit for discharge from the PACU (Aldrete’s score ≥ 9) have not been previously studied. The aim of this trial was to assess the cognitive status of inpatients emerging either from desflurane or propofol anaesthesia, at the time of PACU discharge (Aldrete score ≥ 9).

Methods

Sixty adult patients scheduled for hip or knee arthroplasty under general anaesthesia were randomly allocated to receive either desflurane or propofol anaesthesia. Patients were evaluated the day before surgery using Digit Symbol Substitution Test (DSST), Stroop Color Test and Verbal Learning Test. After surgery, the Aldrete score was checked every 5 min until reaching a score ≥ 9. At this time, the same battery of cognitive tests was applied. Each test was evaluated separately. Cognitive status was reported using a combined Z score pooling together the results of all 3 cognitive tests.

Results

Among the 3 tests, only DSST was significantly reduced at Aldrete Score ≥ 9 in the Desflurane group. Combined Z-scores at Aldrete Score ≥ 9 were (in medians [interquartils]): − 0.2 [− 1.2;+ 0.6] and − 0.4 [− 1.1;+ 0.4] for desflurane and propofol groups respectively (P = 0.62). Cognitive dysfunction at Aldrete score ≥ 9 was observed in 3 patients in the Propofol group and in 2 patients in the Desflurane group) (P = 0.93).

Conclusion

No difference was observed in cognitive status at Aldrete score ≥ 9 between desflurane and propofol anaesthesia. Although approximately 10% of patients still had cognitive dysfunctions, an Aldrete score ≥ 9 was associated with satisfactory cognitive function recovery in the majority of the patients after lower limb arthroplasty surgery under general anaesthesia.

Trial registration

Clinical Trials identifier NTC02036736.

Influence of two-handed jaw thrust during tracheal intubation on postoperative sore throat: a prospective randomised study

Objective

General anaesthesia with tracheal intubation results in sore throat. We evaluated the influence of the two-handed jaw thrust on postoperative sore throat in patients who require tracheal intubation.

Methods

In this prospective, double-blind, single-centre, parallel-arm, and randomised trial, 92 patients who were scheduled for general anaesthesia for total hip arthroplasty were allocated to one of two groups. In the jaw thrust group (n = 46), the two-handed jaw thrust manoeuvre was applied at intubation. In the control group (n = 46), conventional intubation with sham jaw thrust was performed. Incidences of airway morbidities including sore throat, hoarseness, and cough at 2, 4, and 24 hours postoperatively were compared.

Results

During the postoperative 24 hours, the incidence of sore throat (8 [17%] vs. 20 [44%]) and hoarseness were lower in the jaw thrust group (8 [17%] vs. 18 [39%]) compared with the control group. The incidence of cough during the postoperative 24 hours was similar between the groups.

Conclusions

The jaw thrust manoeuvre significantly reduced sore throat and hoarseness in patients after general anaesthesia using tracheal intubation.

Clinical trial registration: NCT 03568279.

Defining success in regional anaesthesia

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

Improving Provision of Preanesthetic Information Through Use of the Digital Conversational Agent "MyAnesth": Prospective Observational Trial

Background

Due to time limitations, the preanesthetic consultation (PAC) is not the best time for patients to integrate information specific to their perioperative care pathway.

Objective

The main objectives of this study were to evaluate the effectiveness of a digital companion on patients' knowledge of anesthesia and their satisfaction after real-life implementation.

Methods

We conducted a prospective, monocentric, comparative study using a before-and-after design. In phase 1, a 9-item self-reported anesthesia knowledge test (Delphi method) was administered to patients before and after their PAC (control group: PAC group). In phase 2, the study was repeated immediately after the implementation of a digital conversational agent, MyAnesth (@+PAC group). Patients’ satisfaction and their representations for anesthesia were also assessed using a Likert scale and the Abric method of hierarchized evocation.

Results

A total of 600 tests were distributed; 205 patients and 98 patients were included in the PAC group and @+PAC group, respectively. Demographic characteristics and mean scores on the 9-point preinformation test (PAC group: 4.2 points, 95% CI 3.9-4.4; @+PAC: 4.3 points, 95% CI 4-4.7; P=.37) were similar in the two groups. The mean score after receiving information was better in the @+PAC group than in the PAC group (6.1 points, 95% CI 5.8-6.4 points versus 5.2 points, 95% CI 5.0-5.4 points, respectively; P<.001), with an added value of 0.7 points (95% CI 0.3-1.1; P<.001). Among the respondents in the @+PAC group, 82% found the information to be clear and appropriate, and 74% found it easily accessible. Before receiving information, the central core of patients’ representations for anesthesia was focused on the fear of being put to sleep and thereafter on caregiver skills and comfort.

Conclusions

The implementation of our digital conversational agent in addition to the PAC improved patients' knowledge about their perioperative care pathway. This innovative audiovisual support seemed clear, adapted, easily accessible, and reassuring. Future studies should focus on adapting both the content and delivery of a digital conversational agent for the PAC in order to maximize its benefit to patients.

Propofol-based total intravenous anesthesia decreases the incidence of postoperative nausea and vomiting without affecting flap survival in free flap breast reconstruction

Background

Postoperative nausea and vomiting (PONV) may cause undesirable effects after microsurgical breast reconstruction. Although total intravenous anesthesia (TIVA) with propofol has been demonstrated to be effective in reducing PONV, it has not been assessed in autologous free flap breast reconstruction. The purpose of this study was to investigate the antiemetic prophylaxis effect and safety of TIVA in microvascular breast reconstruction.

Methods

Eighty-three patients undergoing microsurgical breast reconstruction with propofol (31 patients) or sevoflurane (52 patients) were retrospectively reviewed. The incidence of PONV was assessed at 2, 6, and 24 hours after surgery. Mean arterial blood pressure (MAP) was compared at T₁ (after flap elevation but before transfer), T₂ (15 minutes after revascularization), and T₃ (at the end of surgery).

Results

The incidence of nausea was significantly reduced in the TIVA group over 0 to 2 hours period (P=0.017), and over 2 to 6 hours period (P=0.033). The incidence of vomiting was significantly reduced in the TIVA group over 0 to 2 hours period (P=0.006), and over 2 to 6 hours period (P=0.005). MAP was higher in the TIVA group at T₁ (P=0.018), T₂ (P=0.005), and T₃ (P=0.007). The incidence of flap failure was similar between the two groups (P=0.373).

Conclusions

Compared with sevoflurane maintaining anesthesia, propofol-based TIVA improves PONV with less fluctuation of MAP, and did not affect flap survival.

Comparison of the Effects of Sugammadex, Neostigmine, and Pyridostigmine on Postoperative Nausea and Vomiting: A Propensity Matched Study of Five Hospitals

Thus far, few studies have compared the effects of sugammadex and cholinesterase inhibitors on postoperative nausea and vomiting (PONV), and the results have been controversial. Here, we compared the effects of sugammadex, neostigmine, and pyridostigmine on PONV by means of a five hospital analysis with propensity score matching. We analyzed adults aged ≥ 18 years who underwent general anesthesia between January 2014 and December 2019. Following propensity score matching, 7793 patients were included in each of the neostigmine and sugammadex matched patient groups (absolute standardized difference (ASD), 0.01–0.07), and 10,197 patients were included in each of the pyridostigmine and sugammadex matched patient groups (ASD, 0.01–0.02), while 19,377 patients were included in each of the pyridostigmine and neostigmine matched patient groups. (ASD, 0.01–0.19). The odds of PONV were low in the sugammadex group (odds ratio, 0.65; 95% confidence interval, 0.59–0.72; p < 0.0001) and pyridostigmine group (odds ratio, 0.22; 95% confidence interval, 0.20–0.24; p < 0.0001) compared to the neostigmine group, while there was no difference between sugammadex and pyridostigmine (odds ratio, 0.95; 95% confidence interval, 0.86–1.04; p = 0.281). Therefore, sugammadex and pyridostigmine may lower the incidence of PONV compared to neostigmine in patients undergoing general anesthesia.

A Comparative Study Between Ondansetron and Gabapentin for Prevention of Postoperative Nausea and Vomiting Following Maxillofacial Surgery

Background and Aim

Gabapentin is an antiepileptic drug with antiemetic properties. We evaluated prophylactic oral gabapentin as compared with ondansetron for postoperative nausea and vomiting (PONV) in patients undergoing maxillo facial surgery.

Settings and Design

A double-blind, randomized study in a teaching hospital.

Materials and Methods

Seventy patients of ASA physical status I and II, scheduled to undergo maxillofacial surgery, were randomly assigned into two groups to receive 300 mg gabapentin or 8 mg ondansetron 1 h before surgery. Standard anaesthesia technique was used in all patients. Students' t test for difference of means between two groups was used for continuous variables. Chi square or Fisher's exact test was used for comparing proportion between two groups. Kaplan-Meier survival analysis was performed to compare the time to event observed between ondansetron and gabapentin groups. Log-rank test was performed to detect statistical significance of time to events between two groups.

Results

There was no significant difference in incidence of PONV between two groups within 2 h postoperatively. No incidence of PONV was observed in gabapentin group within 2-24 h as compared to ondansetron group in which PONV was observed in five cases.

Conclusion

Gabapentin effectively suppresses PONV in maxillo facial surgery.

Dexmedetomidine nebulisation attenuates post-operative sore throat in patients undergoing thyroidectomy: A randomised, double-blind, comparative study with nebulised ketamine

Background and Aims:

Endotracheal intubation is the predominant cause of airway mucosal injury, resulting in post-operative sore throat (POST), with an incidence of 20-74%, which brings immense anguish to patients. This study was conducted to evaluate and compare the efficacy of nebulised dexmedetomidine and ketamine in decreasing POST in patients undergoing thyroidectomy.

Methods:

Patients were randomly allocated into two groups of 50 each; Group 1 received ketamine 50mg (1mL) with 4mL saline nebulisation, while Group 2 received dexmedetomidine 50μg (1mL) with 4mL saline nebulisation for 15 min. GA was administered 15 min after completing nebulisation. POST monitoring was done at 0,2,4,6,12 and 24h after extubation. POST was graded on a four-point scale (0-3). The statistical analysis were performed using Statistical Package for Social Sciences (SPSS) software version 17.0. Fisher Exact-t-test, Chi square test, Student t-test, Paired t test and repeated measure analysis of variance (ANOVA) were used for analysis.

Results:

The overall incidence of POST in this study was 17%: POST was experienced by seven patients (14.3%) in ketamine and 10 patients (20.4%) in dexmedetomidine group (P = 0.424). There was no statistically significant difference in the incidence of POST between the two groups at 0,2,4,6,12 and 24h post-operatively. Severity of sore throat was also significantly lower in both groups at all time points. A statistically significant increase in heart rate, systolic and diastolic blood pressure was noted in ketamine group, post nebulisation.

Conclusion:

Pre-operative dexmedetomidine nebulisation can be utilised as a safe and ideal alternative to ketamine nebulisation in attenuating POST, with less haemodynamic derangement.

Side Effects to Systemic Glucocorticoid Therapy in Dogs Under Primary Veterinary Care in the UK

Objectives: Systemic glucocorticoids are widely used in companion animals. This study aimed to estimate the frequency, describe the characteristics and to evaluate risk factors for common side effects to systemic glucocorticoid therapy in dogs under primary veterinary care in the UK.

Methods: A cohort study using VetCompass™ data from 455,557 dogs under primary veterinary care during 2013 estimated the frequency of side effects to systemic glucocorticoid therapy occurring within 31 days of therapy. Risk factors for the most common side effects, polyuria and polydipsia (PUPD), were evaluated using multivariable logistic regression modeling (P < 0.05).

Results: During 2013, 28,472 study dogs received systemic glucocorticoids (6.2%, 95% CI 6.2–6.3). Review of the records of 3,000 randomly selected treated dogs identified 148 (4.9%, 95% CI 4.2–5.7%) dogs with at least one side effect recorded within 31 days of therapy. The most frequent side effects were polydipsia (39.2% of total presenting signs), polyuria (28.4%), vomiting (16.2%) and diarrhea (14.9%), dogs receiving only oral systemic glucocorticoids (odds ratio, OR: 3.72) and dogs receiving both oral and injectable systemic glucocorticoid (OR: 10.71) had increased odds of PUPD compared with dogs receiving only injectable systemic glucocorticoid. Focusing on the active substance used, treatment with prednisolone tablets only (OR: 3.53) and treatment with both prednisolone tablets and injectable dexamethasone sodium phosphate (OR: 7.62) showed increased odds of PUPD compared to treatment with injectable dexamethasone sodium phosphate only.

Brief: These results can assist veterinarians to optimize therapeutic selection for reduced side effect, to inform owners on common side effects, and help protect the welfare of pets and their owners.

Epidural Naloxone Attenuates Fentanyl Induced PONV in Patients Undergoing Lower Limb Orthopaedic Surgeries. a Prospective Randomized Double-Blind Comparative Study

Background and aim

Epidural administration of opioids with local anaesthetics is a popular choice for perioperative pain relief. But opioid induced side effects limit their use for postoperative analgesia. Hence, this study was designed to evaluate the effectiveness of epidural naloxone, an opioid receptor antagonist, in reducing PONV in patients receiving epidural fentanyl.

Methods

After obtaining the Institutional Ethics Committee approval and written informed consent, 46 patients, between 18–80 years, of either sex, with ASA physical status 1–3, undergoing lower limb orthopaedic surgeries were enlisted for this prospective, randomized, double blind comparative study. Subjects were allocated to one of the two groups and received epidurally, either fentanyl with bupivacaine (Group C, n = 23) or fentanyl with bupivacaine and naloxone 2 mcg (Group N, n = 25), for reducing postoperative pain. PONV score and Wong Bakers Scale (WBS) for pain score were recorded at 6, 12 and 18hrs, postoperatively.

Results

All patients were comparable with respect to age, gender, ASA PS, height, body weight as well as duration of surgery. A statistically significant decrease in PONV score was observed in Group N at 6 and 12 hours, postoperatively. The patients who required rescue antiemetic were also significantly lower in Group N at 6 and 12 hours. The mean WBS score for pain also showed significant reduction in Group N at 6 hours, postoperatively.

Conclusion

Concomitant use of low dose epidural naloxone and fentanyl is effective in attenuating PONV, besides enhancing analgesia in the earlypostoperative period.

Effect of Body Mass Index on Postoperative Nausea and Vomiting: Propensity Analysis

The impact of body mass index (BMI) on postoperative nausea and vomiting (PONV) is controversial, and few studies have focused on their relationship. We investigated the effects of BMI on PONV, taking into account other PONV risk factors. We analyzed adults over the age of 18 years who received general anesthesia between 2015 and 2019, using propensity score matching. Before propensity score matching, odds ratios (ORs) for PONV were lower for overweight (OR, 0.91; 95% confidence interval (CI), 0.87–0.96; p < 0.0001) or obese patients (OR, 0.77; 95% CI, 0.71–0.84; p < 0.0001) than for normal-BMI patients. After matching, the ORs for PONV of overweight (OR, 0.89; 95% CI, 0.80–0.98; p = 0.016) and obese patients (OR, 0.71; 95% CI, 0.63–0.79; p < 0.0001) were low. However, the ORs of underweight patients did not differ from those of normal-BMI patients, irrespective of matching. Therefore, the incidence of PONV may be lower among adults with a higher-than-normal BMI.

Effect of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation: a randomized control trial

Background

Dexmedetomidine, an alpha-2 agonist, has been used for attenuation of hemodynamic response to laryngoscopy but not through the nebulized route. We evaluated the effects of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation and examined the intraoperative anesthetic-analgesic requirements and recovery outcomes.

Methods

Overall, 120 American Society of Anesthesiologists I & II adult patients (of either gender) undergoing elective surgeries and requiring tracheal intubation, were randomized to receive nebulized dexmedetomidine (1 µg/kg in 3–4 ml of 0.9% saline) or 0.9% saline (3–4 ml), 30 min before anesthesia induction. Heart rate (HR) and non-invasive systolic blood pressure (SBP) were monitored for 10 min following laryngoscopy.

Results

After laryngoscopy, linear mixed effect modelling showed significantly lower trend of increase in HR in the dexmedetomidine group versus saline (P = 0.012); however, there was no difference in the SBP changes between the two groups (P = 0.904). Induction dose of propofol (P < 0.001), intraoperative fentanyl consumption (P = 0.007), and isoflurane requirements (P = 0.013) were significantly lower in the dexmedetomidine group. There was no difference in the 2 h incidence of postoperative nausea and vomiting (PONV) (P = 0.612) or sore-throat (P = 0.741).

Conclusions

Nebulized dexmedetomidine at 1 µg/kg attenuated the increase in HR but not SBP following laryngoscopy and reduced the intraoperative anesthetic and analgesic consumption. There was no effect on early PONV, sore-throat, or increase in incidence of adverse effects. Nebulized dexmedetomidine may represent a favorable alternative to the intravenous route in short duration surgeries.

An Electronic Medical Record-Derived Individualized Performance Metric to Measure Risk-Adjusted Adherence with Perioperative Prophylactic Bundles for Health Care Disparity Research and Implementation Science

BACKGROUND

Health care disparity persists despite vigorous countermeasures. Clinician performance is paramount for equitable care processes and outcomes. However, precise and valid individual performance measures remain elusive.

OBJECTIVES

We sought to develop a generalizable, rigorous, risk-adjusted metric for individual clinician performance (MIP) derived directly from the electronic medical record (EMR) to provide visual, personalized feedback.

METHODS

We conceptualized MIP as risk responsiveness, i.e., administering an increasing number of interventions contingent on patient risk. We embedded MIP in a hierarchical statistical model, reflecting contemporary nested health care delivery. We tested MIP by investigating the adherence with prophylactic bundles to reduce the risk of postoperative nausea and vomiting (PONV), retrieving PONV risk factors and prophylactic antiemetic interventions from the EMR. We explored the impact of social determinants of health on MIP.

RESULTS

We extracted data from the EMR on 25,980 elective anesthesia cases performed at Penn State Milton S. Hershey Medical Center between June 3, 2018 and March 31, 2019. Limiting the data by anesthesia Current Procedural Terminology code and to complete cases with PONV risk and antiemetic interventions, we evaluated the performance of 83 anesthesia clinicians on 2,211 anesthesia cases. Our metric demonstrated considerable variance between clinicians in the adherence to risk-adjusted utilization of antiemetic interventions. Risk seemed to drive utilization only in few clinicians. We demonstrated the impact of social determinants of health on MIP, illustrating its utility for health science and disparity research.

CONCLUSION

The strength of our novel measure of individual clinician performance is its generalizability, as well as its intuitive graphical representation of risk-adjusted individual performance. However, accuracy, precision and validity, stability over time, sensitivity to system perturbations, and acceptance among clinicians remain to be evaluated.

Topical application of ketamine to prevent postoperative sore throat in adults: A systematic review and meta-analysis

BACKGROUND

Postoperative sore throat is a leading undesirable postoperative outcome. Ketamine is an N-methyl-d-aspartate receptor antagonist and its topical application is used for chronic pain and oral/throat indications. We conducted a systematic review to assess the efficacy of preoperative, topical ketamine application for preventing postoperative sore throat.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL through September 23, 2019 for randomized controlled trials in which at least one intervention was topical ketamine to prevent postoperative sore throat in adults undergoing endotracheal intubation. The primary outcome was the incidence of sore throat at 24 hours postoperatively. The comparators were non-analgesic controls (placebo, no treatment, or usual care) or active agents. We pooled the data using a random-effects model.

RESULTS

We included 41 randomized controlled trials involving 3784 participants. Topical ketamine was associated with reduced incidence of sore throat at 24 hours postoperatively compared to non-analgesic methods (risk ratio, 0.45; 95% CI, 0.37-0.54; P < .001). We found significant publication bias, but the results remained unchanged with a trim-and-fill analysis. Trial sequential analysis (TSA) suggested that the efficacy of topical ketamine was adequate (TSA-adjusted 95% CI, 0.33-0.56). The GRADE quality for this evidence was moderate. Topical ketamine was inferior to a combination of nebulized ketamine and clonidine in preventing postoperative sore throat.

CONCLUSIONS

Preoperative, topical ketamine application may be more effective than non-analgesic methods in preventing postoperative sore throat. The number of studies did not suffice to determine the place of topical ketamine among agents to prevent postoperative sore throat.

Preoperative anxiety in adults - a cross-sectional study on specific fears and risk factors

BACKGROUND

Preoperative anxiety comprising anesthesia and surgery related anxiety is common and perceived by many patients as the worst aspect of the surgical episode. The aim of this study was to identify independent predictors of these three anxieties dimensions and to quantify the relevance of specific fears particularly associated with anesthesia.

METHODS

This study was part of a cross-sectional survey in patients scheduled to undergo elective surgery. Anxiety levels were measured with the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Modified numeric rating scales (mNRS, range 0-10) were used to assess the severity of eight selected specific fears which were predominantly analyzed descriptively. Multivariate stepwise linear regression was applied to determine independent predictors of all three anxiety dimensions (APAIS anxiety subscales).

RESULTS

3087 of the 3200 enrolled patients were analyzed. Mean (SD) total preoperative anxiety (APAIS-A-T, range 4-20) was 9.9 (3.6). High anxiety (APAIS-A-T > 10) was reported by 40.5% of subjects. Mean (SD) levels of concern regarding the eight studied specific fears ranged from 3.9 (3.08) concerning "Anesthesiologist error" to 2.4 (2.29) concerning "Fatigue and drowsiness" with an average of 3.2 (2.84) concerning all specific fears. Ranking of all specific fears according to mean mNRS scores was almost identical in patients with high versus those with low anxiety. Among nine independent predictors of anxiety, only 3 variables (female gender, negative and positive anesthetic experience) independently predicted all three APAIS anxiety subscales. Other variables had a selective impact on one or two APAIS anxiety subscales only. Female gender had the strongest impact on all three APAIS anxiety subscales. Adjusted r² values of the three models were all below 13%.

CONCLUSIONS

The high variability of importance assigned to all specific fears suggests an individualized approach is advisable when support of anxious patients is intended. Considering independent predictors of anxiety to estimate each patient's anxiety level is of limited use given the very low predictive capacity of all three models. The clinical benefit of dividing patients into those with high and low anxiety is questionable.

TRIAL REGISTRATION

German Registry of Clinical Trials (DRKS00016725), retrospectively registered.

A Comprehensive Patient and Public Involvement Program Evaluating Perception of Cannabis-Derived Medicinal Products in the Treatment of Acute Postoperative Pain, Nausea, and Vomiting Using a Qualitative Thematic Framework

Introduction: Cannabis-derived medicinal products (CDMPs) have antiemetic properties and in combination with opioids have synergistic analgesic effects in part signaling through the delta and kappa opioid receptors. The objective of this patient and public involvement program was to determine perception of perioperative CDMPs in our local population to inform design of a clinical trial. Methods: A qualitative evaluation was conducted utilizing a focus group, semistructured interviews and a community event. Analysis was conducted through the framework methodology. Verbatim transcriptions were coded categorically into analytical frameworks for thematic analysis. Emergent themes and associated degree of consensus/dissent were determined. The participant cohort was composed of a group of patients and relatives representative of the target population (M:F=1:1, age range 33-85). Results: Most common coding categories in thematic analysis framework included side-effect profile, trial schedule of events, and safety. Consensus was that potential benefits of CDMPs were attractive compared with the known risk profile of opioid use. Decrease in opioid dependence was agreed to be an appropriate clinical end-point for a randomized controlled clinical trial and there was concurrence of positive opinion of a therapeutic schedule of 5 days. Negative CDMP perceptions included addiction, dysphoria, and adverse effects in psychiatric subpopulations. Sublingual or oral administration was the most acceptable route of administration, with some expressing that inhalation delegitimizes therapeutic properties. Conclusions: The perception of postoperative CDMP therapy was overwhelmingly positive in this West London population. The data from this thematic analysis will inform protocol development of clinical trials to determine analgesic and antiemetic efficacy of CDMPs.

Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis

INTRODUCTION

Excessive prescribing after surgery has contributed to a public health crisis of opioid addiction and overdose in North America. However, the value of prescribing opioids to manage postoperative pain after surgical discharge remains unclear. We propose a systematic review and meta-analysis to assess the extent to which opioid analgesia impact postoperative pain intensity and adverse events in comparison to opioid-free analgesia in patients discharged after surgery.

METHODS AND ANALYSIS

Major electronic databases (MEDLINE, Embase, Cochrane Library, Scopus, AMED, BIOSIS, CINAHL and PsycINFO) will be searched for multi-dose randomised-trials examining the comparative effectiveness of opioid versus opioid-free analgesia after surgical discharge. Studies published from January 1990 to July 2019 will be targeted, with no language restrictions. The search will be re-run before manuscript submission to include most recent literature. We will consider studies involving patients undergoing minor and major surgery. Teams of reviewers will, independently and in duplicate, assess eligibility, extract data and evaluate risk of bias. Our main outcomes of interest are pain intensity and postoperative vomiting. Study results will be pooled using random effects models. When trials report outcomes for a common domain (eg, pain intensity) using different scales, we will convert effect sizes to a common standard metric (eg, Visual Analogue Scale). Minimally important clinical differences reported in previous literature will be considered when interpreting results. Subgroup analyses defined a priori will be conducted to explore heterogeneity. Risk of bias will be assessed according to the Cochrane Collaboration's Risk of Bias Tool 2.0. The quality of evidence for all outcomes will be evaluated using the GRADE rating system.

ETHICS AND DISSEMINATION

Ethical approval is not required since this is a systematic review of published studies. Our results will be published in a peer-reviewed journal and presented at relevant conferences. Further knowledge dissemination will be sought via public and patient organisations focussed on pain and opioid-related harms.

The Effect of a Transdermal Scopolamine Patch on Postoperative Nausea and Vomiting after Retromastoid Craniectomy with Microvascular Decompression: A Preliminary Single Center, Double-Blind, Randomized Controlled Trial

Background: We performed this prospective double-blind randomized controlled trial to identify the effect of a preoperative prophylactic transdermal scopolamine (TDS) patch on postoperative nausea and vomiting (PONV) after retromastoid craniectomy with microvascular decompression (RMC-MVD). Methods: We recruited 38 patients undergoing RMC-MVD and randomized them into two groups: the TDS group (n = 19, application of the TDS patch) and placebo group (n = 19, application of a sham patch). Nausea (as a self-reported 100-mm visual analog scale (VAS) score; range, 0 (no nausea) to 10 (worst nausea)), vomiting, and the use of antiemetics were the primary endpoints. Results: There was no significant difference in terms of the incidence of PONV (73.7% in the TDS group and 78.9% in the placebo group; p = 1.00) between the groups. However, the mean nausea VAS score was significantly different at arrival to the general ward (0.93 ± 1.71 in the TDS group vs. 2.52 ± 2.85 in the placebo group; p = 0.046), and throughout the study period (0.03 ± 0.07 in the TDS group vs. 0.44 ± 0.71 in the placebo group; p = 0.029). Rescue antiemetics were more frequently used in the placebo group than in the TDS group (9 (47.4%) vs. 2 (10.5%), respectively; p = 0.029). The mean number of antiemetics used throughout the study period was significantly higher in the placebo group than in the TDS group (1.37 ± 2.19 vs. 0.16 ± 0.50, respectively; p = 0.029). Conclusions: The preoperative prophylactic use of a TDS patch was safe and effective in the management of PONV after RMC-MVD in terms of the severity of PONV and the use of rescue antiemetics.

Comparison of Ondansetron and Granisetron Effects for Prevention of Nausea and Vomiting Following Strabismus Surgery

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complaint after strabismus surgery that leads to unpleasantness, increased hospitalisation time and increased costs. In severe cases, it can lead to dehydration, electrolyte disturbances, aspiration, pneumonia, and even sutures opening.

AIM

This study was conducted to compare the effects of both ondansetron and granisetron on the reduction of PONV after strabismus surgery.

METHODS

This randomised, and the double-blind clinical study was conducted on patients with ASA I and II undergoing strabismus surgery with age over 3 years old in Shafa Hospital, Kerman University of Medical Sciences during 2017 under general anaesthesia. Patients with inclusion criteria were randomly assigned to one of three groups including Ondansetron (A), Granisetron (B) and control group (C). Matching cases and controls on drugs were fully completed. Furthermore, 100 μg/kg of Ondansetron was intravenously injected, followed by injection of 40 μg/kg Granisetron for another intervention group. All patients underwent the same anaesthetic procedure and intravenous injection of drugs during anaesthesia induction. The severity of nausea and vomiting in recovery, 6 and 18 hours after the operation were verified according to the Verbal Rating Scale (VRS). Our data were analysed by Chi-square, ANOVA and TUKEY tests via SPSS version 18.

RESULTS

There was no significant difference between the three groups in terms of age and sex. The incidence of postoperative nausea in recovery among three groups of A, B and C was determined to be 15, 7.5 and 37.5%, respectively. No significant difference was found between the two groups A and B (P = 0.68), although there was a significant difference between these two groups and group C (P < 0.05). The incidence of nausea at 6 hours after surgery in groups A, B and C was recorded as 40, 15 and 65% respectively, indicating that the incidence of nausea in group B was significantly lower than the other two groups, while showed a significant difference with group A (P = 0.039) and group C (P < 0.05). Also, the incident of nausea between groups was not statistically significant 18 hours after surgery (P < 0.05). Additionally, no significant difference was found in different groups in terms of vomiting incidence in recovery, 6 and 18 hours after surgery (P < 0.05).

CONCLUSION

Our study suggests that Granisetron is more effective in preventing PONV during 6 hours after the surgery in comparison with Ondansetron which makes it a favourable alternative for preventing PONV.

Sub-hypnotic dose of propofol as antiemetic prophylaxis attenuates intrathecal morphine-induced postoperative nausea and vomiting, and pruritus in parturient undergoing cesarean section - a randomized control trial

Background

Postoperative Nausea and Vomiting (PONV) is a dreadful and uncomfortable experience that significantly detracts patients’ quality of life after surgery. This study aimed to examine the antiemetic effect of a single sub-hypnotic dose of propofol as prophylaxis for PONV.

Method

In this prospective, double-blind, randomized control trial, 345 parturients presented for elective cesarean section at the Obstetric unit of Tamale Teaching Hospital were recruited. Each recruited parturient was randomly assigned to one of three groups; Propofol group (n = 115) represented those who received propofol 0.5 mg/kg, Metoclopramide group (n = 115) represented those who received metoclopramide 10 mg and, Control group (n = 115) represented those who received 0.9% saline. Spinal anesthesia with 0.5% hyperbaric bupivacaine 7.5–10 mg, and intrathecal morphine 0.2 mg was employed for the anesthesia.

Results

The data indicate that 108 (93.9%) parturients from the control group, 10 (8.7%) from the propofol group and 8 (7.0%) from the metoclopramide group experienced some incidence of PONV. There was no significant difference in the incidence of PONV (nausea, vomiting, and none) between the propofol and the metoclopramide groups (P = 0.99; 0.31; and 0.35 respectively). Parturients who received antiemetic agents were 105 (97.2%), 1 (10.0%) and 3 (37.5%) from the control, propofol and metoclopramide groups respectively. The data indicated that 98 (85.2%) parturients from the control, 3 (2.6%) from propofol group, and 100 (87.0%) from the metoclopramide group experienced some levels of pruritus. There was a significant difference in the incidence of pruritus (mild, moderate, and no pruritus) between the metoclopramide and propofol groups (P <  0.01; P <  0.01; and P <  0.01 respectively).

Conclusion

A sub-hypnotic dose of propofol is effective as metoclopramide in the prevention of PONV in parturient undergoing cesarean section under spinal anesthesia with intrathecal morphine. Sub-hypnotic dose of propofol significantly reduces the incidence of postoperative pruritus following intrathecal morphine use.

Trial registration

Current control trial, registered at ISRCTN trial registry: ISRCTN15475205. Date registered: 03/04/2019. Retrospectively registered.

Effect of fentanyl on nausea and vomiting in cesarean section under spinal anesthesia: a randomized controlled study

Objective

Although opioids may induce nausea and vomiting, they possess sedative effects and can reduce intraoperative nausea and vomiting (IONV). This study assessed the effect of adding fentanyl to midazolam on sedation levels and IONV during cesarean section under spinal anesthesia.

Methods

Eighty parturients scheduled for elective cesarean section were enrolled in the study. Following fetal delivery, patients were administered 0.05 mg/kg of midazolam plus 0.03 mL/kg of normal saline (M group) or 0.05 mg/kg of midazolam plus 1.5 μg/kg of fentanyl (MF group). The primary outcome was the incidence of IONV. The secondary outcomes were incidence of postoperative nausea and vomiting (PONV), intraoperative sedation level, and five-point patient satisfaction score (PSS).

Results

The IONV incidence was significantly lower in the MF group compared with the M group (5% [2/40] vs. 25% [10/40]). The PONV incidence did not differ significantly between the groups. The intraoperative sedation level tended to be deeper in the MF group. The 5-point PSS was significantly higher in the MF group. There was a strong correlation between the sedation level and IONV incidence.

Conclusions

Adding fentanyl to midazolam is effective for sedation and to prevent IONV in women who are undergoing cesarean section under spinal anesthesia.

Assessment of Dog Owner Concern Regarding Peri-operative Nausea and Vomiting and Willingness to Pay for Anti-emetic Treatment

Objective: The objective of this study was to assess dog owners' concern regarding peri-operative nausea and vomiting, and their willingness to pay for treatment.

Design: Descriptive survey.

Sample: A survey was administered to 104 dog owning clients with non-emergent surgical (52) or non-surgical (52) appointments at a University teaching hospital.

Procedure: Descriptive statistics were calculated. A Mann-Whitney U test was used to detect differences between clients expecting their pet to undergo elective general anesthesia and those that did not. A Spearman's Rank Co-efficient was used to correlate predictive data.

Results: Ninety-seven (93%) dog owners had at least some worry regarding their dog experiencing nausea associated with opioid analgesics and anesthesia, with 39/104 (37.5%) moderately to very worried. Forty-one owners (39%) would definitely and 59/104 (56.7%) would likely choose treatment to decrease or prevent signs of nausea. Ninety-four owners (90.4%) had at least some worry regarding vomiting, and 48/104 (46%) indicated they were moderately to very worried. Fifty-three owners (51.4%) would definitely and 49/103 (47.6%) would likely choose treatment to prevent vomiting. The median and mean amount owners were willing to pay was 50 and 76.47 USD, respectively. Ninety-five (91.3%) were likely or very likely to opt for treatment if required to arrive 1 h earlier for their appointment. There was no correlation between age, income, or owner's PONV experience with likelihood of choosing treatment but there was a significant positive correlation with the owner's level of education.

Conclusion: Canine owners are concerned with their pets experiencing nausea and vomiting in relation to opioid analgesics and anesthesia and are willing to pay and stay the required time for effective treatment.

Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery

Background

Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery.

Methods

Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts.

Results

Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies.

Conclusion

There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.

Scheduled injection of ramosetron for prevention of nausea and vomiting following single-port access total laparoscopic hysterectomy: a prospective randomized study

Objective

The purpose of this study was to evaluate the effectiveness of scheduled ramosetron injections for controlling postoperative nausea and vomiting (PONV) after single-port access total laparoscopic hysterectomy (SPA-TLH).

Methods

Ninety patients who underwent SPA-TLH at the Korean National Health Insurance Service Ilsan Hospital between June 2013 and July 2014 were enrolled in this prospective, randomized, double-blinded, placebo-controlled study. The patients were divided into 2 groups as follows: the ramosetron group (0.3 mg intravenously [IV]; n=45) and the placebo group (normal saline IV; n=45). Both groups received their respective injections 12 and 24 hours post surgery. The incidence and severity of PONV (numerical rating scale, 0–10), and the use of rescue antiemetics post surgery were evaluated.

Results

Demographic and perioperative statistically significant differences were not observed between the 2 groups. The incidence of PONV in the ramosetron and placebo groups was 46.7% and 51.1%, respectively (P=0.51). We found significant differences in the severity of PONV between the 24- to 48-hour postoperative periods in both groups (ramosetron group, P=0.04 and placebo group, P=0.03). The use of rescue antiemetics was significantly lower in the ramosetron group than in the placebo group (P=0.02).

Conclusion

After general anesthesia, scheduled injections of ramosetron 12 and 24 hours after SPA-TLH reduced the severity of PONV and the use of rescue antiemetics. Administration of ramosetron can be considered not only immediately after SPA-TLH but also during the first 24-hour recovery period.

Trial Registration

ClinicalTrials.gov Identifier: NCT 02011659

Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens

BACKGROUND

Enhanced recovery protocols (ERP) provide optimal perioperative care for surgical patients. Postoperative nausea and vomiting (PONV) is common after colorectal surgery (CRS). We aim to compare the efficacy of aprepitant to a cost-effective alternative, perphenazine, as components of triple antiemetic prophylaxis in ERP patients.

METHODS

Patients who underwent ERP CRS at a single institution from July 2015 to July 2017 were evaluated retrospectively. Only subjects who received aprepitant (Group 1) or perphenazine (Group 2) preoperatively for PONV prophylaxis were included. Patient characteristics, simplified Apfel PONV scores, perioperative medications, and PONV incidence were compared between the groups. PONV was defined as the need for rescue antiemetics on postoperative days (POD) 0-5.

RESULTS

Five hundred ninety-seven patients underwent CRS of which 498 met the inclusion criteria. Two hundred thirty-one (46.4%) received aprepitant and 267 (53.6%) received perphenazine. The incidence of early PONV (POD 0-1) was comparable between the two groups: 44.2% in Group 1 and 44.6% in Group 2 (P = 0.926). Late PONV (POD 2-5) occurred less often in Group 1 than Group 2, respectively (35.9% vs. 45.7%, P = 0.027). After matching the groups for preoperative, procedural, and anesthesia characteristics (164 pairs), no difference in early or late PONV could be demonstrated between the groups.

CONCLUSIONS

The incidence of PONV remains high despite most patients receiving three prophylactic antiemetic medications. Perphenazine can be considered a cost-effective alternative to oral aprepitant for prophylaxis of PONV in patients undergoing CRS within an ERP.

Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication following general anaesthesia. It may be associated with patient dissatisfaction, increased costs of treatment, and unintended admission to hospital.Supplemental intravenous crystalloid administration in the perioperative period may be a simple intervention to prevent PONV.

OBJECTIVES

To assess whether supplemental intravenous crystalloid administration prevents PONV in patients undergoing surgical procedures under general anaesthesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE (1946 to August 2018), Embase (1947 to August 2018), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL; 1971 to August 2018). We searched clinical trials registers for ongoing or unpublished completed studies (August 2018), handsearched three major journals (British Journal of Anaesthesia, European Journal of Anaesthesiology, and Anesthesiology; August 2018), and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials of participants older than six months undergoing surgical procedures under general anaesthesia and given supplemental perioperative intravenous crystalloids, defined as a volume larger than that received by a comparator group, to prevent PONV.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures described by Cochrane.

MAIN RESULTS

We included 41 studies (4224 participants). Participants underwent ambulatory or short length of stay surgical procedures, and were predominantly American Society of Anesthesiology (ASA) class I or II. There is one study awaiting classification and three ongoing studies. All studies took place in surgical centres, and were conducted in geographically diverse settings. Risk of bias was generally unclear across all domains.Supplemental intravenous crystalloid administration probably reduces the cumulative risk of postoperative nausea (PON) (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.51 to 0.75; 18 studies; 1766 participants; moderate-certainty evidence). When the postoperative period was divided into early (first six hours postoperatively) and late (at the time point closest to or including 24 hours postoperatively) time points, the intervention reduced the risk of early PON (RR 0.67, 95% CI 0.58 to 0.78; 20 studies; 2310 participants; moderate-certainty evidence) and late PON (RR 0.47, 95% CI 0.32 to 0.69; 17 studies; 1682 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the risk of postoperative vomiting (POV) (RR 0.50, 95% CI 0.40 to 0.63; 20 studies; 1970 participants; moderate-certainty evidence). The intervention specifically reduced both early POV (RR 0.56, 95% CI 0.41 to 0.76; 19 studies; 1998 participants; moderate-certainty evidence) and late POV (RR 0.48, 95% CI 0.29 to 0.79; 15 studies; 1403 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the need for pharmacologic treatment of PONV (RR 0.62, 95% CI 0.51 to 0.76; 23 studies; 2416 participants; moderate-certainty evidence).The effect of supplemental intravenous crystalloid administration on the risk of unplanned postoperative admission to hospital is unclear (RR 1.05, 95% CI 0.77 to 1.43; 3 studies; 235 participants; low-certainty evidence).No studies reported serious adverse events that may occur following supplemental perioperative intravenous crystalloid administration (i.e. admission to high-dependency unit, postoperative cardiac or respiratory complication, or death).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that supplemental perioperative intravenous crystalloid administration reduces PON and POV, in ASA class I to II patients receiving general anaesthesia for ambulatory or short length of stay surgical procedures. The intervention probably also reduces the risk of pharmacologic treatment for PONV. The effect of the intervention on the risk of unintended postoperative admission to hospital is unclear. The risk of serious adverse events resulting from supplemental perioperative intravenous crystalloid administration is unknown as no studies reported this outcome. The one study awaiting classification may alter the conclusions of the review once assessed.