The effects of systolic arterial blood pressure variations on postoperative nausea and vomiting

Journal of Clinical Monitoring and Computing 2019 end of year summary: monitoring tissue oxygenation and perfusion and its autoregulation

Tissue perfusion monitoring is increasingly being employed clinically in a non-invasive fashion. In this end-of-year summary of the Journal of Clinical Monitoring and Computing, we take a closer look at the papers published recently on this subject in the journal. Most of these papers focus on monitoring cerebral perfusion (and associated hemodynamics), using either transcranial doppler measurements or near-infrared spectroscopy. Given the importance of cerebral autoregulation in the analyses performed in most of the studies discussed here, this end-of-year summary also includes a short description of cerebral hemodynamic physiology and its autoregulation. Finally, we review articles on somatic tissue oxygenation and its possible association with outcome.

Effects of menstrual cycle on nausea and vomiting after general anesthesia

PURPOSE

To investigate the impact of menstrual cycle on patients undergoing gynecological endoscopic surgery.

PATIENTS AND METHODS

220 patients scheduled for gynecological endoscopic surgery under general anesthesia were selected. The patients were divided into three groups based on 3 phases of menstrual cycle which are the follicular phase (Group F), ovulatory phase (Group O) or luteal phase (Group L). It is based on their duration of menstruation and the last day of menstrual bleeding from the date of surgery. Primary outcomes were the incidences of early and late postoperative nausea and vomiting (PONV) in the three patient groups. Preoperative venous blood was taken to determine the estrogen and progesterone levels of the patients.

RESULTS

A total of 207 patients were enrolled. The incidence of early PONV was highest in group O (22.22% vs 43.33% vs 17.86%, P < 0.01). Multivariate logistic regression showed that menstrual cycle (P < 0.01) and sufentanil dosage (P < 0.05) were independent risk factors for early PONV, menstrual cycle (P = 0.03) and intraoperative hypotension (P = 0.03) were independent risk factors for late PONV. After the propensity matching, the incidences of early and late PONV in group O were both higher than that in other two groups (19.23% vs 44.68% vs 16.90%, P < 0.01; 53.80% vs 72.34% vs 45.07%, P = 0.01).

CONCLUSION

The incidence of PONV after gynecological endoscopic surgery was different in patients with different menstrual cycles, with the highest incidence in ovulation.

Dynamic predictive model for postoperative nausea and vomiting for intravenous fentanyl patient-controlled analgesia

Postoperative nausea and vomiting is the most common side-effect of opioid-based intravenous patient-controlled analgesia. Apfel's simplified risk score is popular but it has some limitations. We developed and validated a dynamic predictive model for nausea or vomiting up to 48 postoperative hours, available as an online web application. Fentanyl was used by 22,144 adult patients for analgesia after non-cardiac surgery under general anaesthesia: we randomly divided them into development (80%) and validation (20%) cohorts, repeated 100 times. We used linear discriminant analysis to select variables for multivariate logistic regression. The incidences of postoperative nausea or vomiting were: 0-48 h, 5691/22,144 (26%); 0-6 h, 2749/22,144 (12%); 6-12 h, 2687/22,144 (12%); 12-18 h, 2624/22,144 (12%); 18-24 h, 1884/22,144 (9%); and 24-48 h, 1082/22,144 (5%). The median (95%CI) area under the receiver operating characteristic curve was 0.72 (0.71-0.73) up to 48 postoperative hours compared with 0.65 (0.64-0.66) for the Apfel model, p < 0.001. The equivalent areas for 0-6 h, 6-12 h, 12-18 h, 18-24 h and 24-48 h were: 0.70 (0.69-0.72); 0.71 (0.69-0.73); 0.69 (0.68-0.71); 0.70 (0.67-0.72); and 0.69 (0.66-0.71), respectively. Our web application allows clinicians to calculate incidences of nausea and vomiting in patients receiving intravenous fentanyl for patient-controlled analgesia.

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.

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.

Muscular tissue oxygen saturation during robotic hysterectomy and postoperative nausea and vomiting: exploring the potential therapeutic thresholds

The relationship between muscular tissue oxygen saturation (SmtO₂) during surgery and postoperative nausea and vomiting (PONV) remains to be determined. Patients undergoing robotic hysterectomy participated in this prospective cohort study. SmtO₂ of the brachioradialis muscle in the forearm was continuously monitored during surgery. Thresholds based on relative changes or absolute values were systematically assigned. The relationship between thresholds and PONV was investigated based on threshold analysis (i.e., exceeding or not exceeding a threshold), area under the curve analysis (i.e., the size of the area enclosed by the SmtO₂ trace and threshold), and multivariable analysis by accounting for recognized PONV risk factors. PONV occurred in 35 of 106 patients (33%). Based on the multivariable analysis, the SmtO₂ threshold of 20% above baseline correlated with less PONV (OR 0.39; 95% CI 0.16-0.93; p = 0.034), and the following values correlated with more PONV: 5% below baseline (OR 2.37; 95% CI 1.26-4.45; p = 0.007), 20% below baseline (OR 16.08; 95% CI 3.05-84.73; p = 0.001), < 70% (OR 2.86; 95% CI 1.17-6.99; p = 0.021) and < 60% (OR 6.55; 95% CI 1.11-38.53; p = 0.038). Our study suggests that a potential therapeutic goal for PONV prophylaxis may be to maintain SmtO₂ at > 70% and above baseline.

Incidence of orthostatic hypotension and cardiovascular response to postoperative early mobilization in patients undergoing cardiothoracic and abdominal surgery

BACKGROUND

In cardiothoracic and abdominal surgery, postoperative complications remain major clinical problems. Early mobilization has been widely practiced and is an important component in preventing complications, including orthostatic hypotension (OH) during postoperative management. We investigated cardiovascular response during early mobilization and the incidence of OH after cardiothoracic and abdominal surgery.

METHODS

In this prospective observational study, we consecutively analyzed data from 495 patients who underwent elective cardiothoracic and abdominal surgery. We examined the incidence of OH, and the independent risk factors associated with OH during early mobilization after major surgery. Multivariate logistic regression was performed using various characteristics of patients to identify OH-related independent factors.

RESULTS

OH was observed in 191 (39%) of 495 patients. The incidence of OH in cardiac, thoracic, and abdominal groups was 39 (33%) of 119, 95 (46%) of 208, and 57 (34%) of 168 patients, respectively. Male sex (OR 1.538; p = 0.03) and epidural anesthesia (OR 2.906; p < 0.001) were independently associated with OH on multivariate analysis.

CONCLUSIONS

These results demonstrate that approximately 40% patients experience OH during early mobilization after cardiothoracic and abdominal surgery. Sex was identified as an independent factor for OH during early mobilization after all three types of surgeries, while epidural anesthesia was only identified after thoracic surgery. Therefore, the frequent occurrence of OH during postoperative early mobilization should be recognized.

TRIAL REGISTRATION

University hospital Medical Information Network Center (UMIN-CTR) number UMIN000018632 . (Registered on 1st October, 2008).

Effect of intraoperative intravenous crystalloid infusion on post-operative nausea and vomiting after diagnostic gynaecological laparoscopy: Comparison of 30 ml/kg and 10 ml/kg and to report the effect of the menstrual cycle on the incidence of post-operative nausea and vomiting

Aim:

Primary To compare effect of 30 ml/kg and 10 ml/kg crystalloid infusion on post-operative nausea and vomiting after diagnostic gynaecological laparoscopy. Secondary To correlate incidence of post-operative nausea and vomiting associated with different phases of menstrual cycle.

Study Design:

This prospective, randomized, double blinded study was conducted in 200 patients [Group I - 10 ml.kg^-1 crystalloid infusion (n = 100) and Group II - 30 ml.kg^-1 crystalloid infusion (n = 100)] of ASA grades I/II, of either sex in the age group 20-40 years undergoing ambulatory gynaecological laparoscopic surgery. Both groups were compared with respect to post-operative nausea vomiting, hemodynamic parameters and incidence of post-operative nausea and vomiting associated with different phases of menstrual cycle.

Statistical Analysis:

Data for categorical variables and continuous variables are presented as proportions and percentages and mean ± SD, respectively. For normally distributed continuous data, the Student t test was used to compare different groups. Categorical data were tested with the Fisher exact test. Pearson or Spearman correlation coefficients for data normally distributed and not normally distributed, respectively, were used to evaluate the relation between 2 variables. P values < 0.05 were considered statistically significant.

Results:

In the first 4 h after anaesthesia, the cumulative incidence of nausea and vomiting in Group I was 66% as compared to 40% in Group II (P value = 0.036, *S). Anti-emetic use was less in the group II as compared to Group I (13% vs. 20%, P = 0.04). Female patients in the menstrual phase experienced nausea and vomiting in 89.48% of cases as compared to 58.33% and 24.24% during proliferative and secretory phases of menstrual cycle, respectively.

The sensory channel of presentation alters subjective ratings and autonomic responses toward disgusting stimuli-Blood pressure, heart rate and skin conductance in response to visual, auditory, haptic and olfactory presented disgusting stimuli

Disgust causes specific reaction patterns, observable in mimic responses and body reactions. Most research on disgust deals with visual stimuli. However, pictures may cause another disgust experience than sounds, odors, or tactile stimuli. Therefore, disgust experience evoked by four different sensory channels was compared. A total of 119 participants received 3 different disgusting and one control stimulus, each presented through the visual, auditory, tactile, and olfactory channel. Ratings of evoked disgust as well as responses of the autonomic nervous system (heart rate, skin conductance level, systolic blood pressure) were recorded and the effect of stimulus labeling and of repeated presentation was analyzed. Ratings suggested that disgust could be evoked through all senses; they were highest for visual stimuli. However, autonomic reaction toward disgusting stimuli differed according to the channel of presentation. In contrast to the other, olfactory disgust stimuli provoked a strong decrease of systolic blood pressure. Additionally, labeling enhanced disgust ratings and autonomic reaction for olfactory and tactile, but not for visual and auditory stimuli. Repeated presentation indicated that participant's disgust rating diminishes to all but olfactory disgust stimuli. Taken together we argue that the sensory channel through which a disgust reaction is evoked matters.