Postoperative nausea and vomiting: risk factors, prediction tools, and algorithms

Postoperative Complications

Surgery under anesthesia poses a significant stress to the body, and postoperative complications occur in up to 20% of cases. An understanding of postoperative complications, including assessment of patients at risk, risk mitigation, early recognition, and evidence-based treatment, is essential to provide high-value health care. Common postoperative complications reviewed in this article include fever, cerebrovascular accident, nausea and vomiting, ileus, and urinary retention, including discussion of pathophysiology, prevention, and treatment.

Transcutaneous Pericardium 6 Acupoint Electrical Stimulation Provides Comparable Antiemetic Effect to Granisetron When Combined With Dexamethasone in Patients Undergoing Breast Cancer Surgery

INTRODUCTION

Perioperative transcutaneous pericardium 6 (P6) electrical stimulation is effective for prevention of postoperative nausea and vomiting (PONV). The patients undergoing breast cancer surgery have a high PONV prevalence; however, the effectiveness of P6 stimulation in this surgical population has not been investigated.

MATERIALS AND METHODS

A total of 198 patients undergoing mastectomy under general anesthesia were enrolled. They were randomly assigned to the one of three treatments: P6 stimulation + dexamethasone (group PD, n = 66), granisetron + dexamethasone (group GD, n = 66), and dexamethasone alone (group DM, n = 66). The primary endpoint was the incidence of postoperative vomiting (POV) within postoperative 48h. The secondary endpoints included the use of rescue antiemetic, severity of POV, and the incidence of postoperative nausea and other adverse events.

RESULTS

The incidence of POV in group PD (9.1%) was similar to group GD (10.6%, P = 0.770), but significantly lower than that in the group DM (28.8%, P = 0.004) within postoperative 48 h. And, the incidence of postoperative nausea was similar between group PD and group GD but lower than that in group DM. The use of rescue antiemetics had no statistical differences among the three groups. The median (interquartile range) scores of POV severity were higher in group GD [6.0 (5.0, 7.0)] than in group DM [4.0 (3.0, 6.0), P = 0.012] within postoperative 48 h, but similar to group PD [5.5 (4.0, 6.3), P = 0.208].

CONCLUSIONS

Combined with dexamethasone, P6 stimulation has similar effectiveness for PONV prophylaxis with 5- hydroxytryptamine 3 antagonist granisetron but lower cost of antiemetic use. Moreover, both groups had a lower incidence of PONV and higher satisfaction than dexamethasone alone in patients undergoing breast cancer surgery.

Construction of a nursing assessment framework for patients in anaesthesia recovery period: A modified Delphi study

AIM

To construct a nursing assessment framework for patients in anaesthesia recovery period.

DESIGN

A three-round modified Delphi method was employed to capture the consensus of 22 panellists.

METHODS

The initial items in the nursing assessment framework for patients in anaesthesia recovery period were developed based on the mini-clinical evaluation exercise (mini-CEX). A panel of 22 experts participated in this study. The panellists have more than 10 years of experience in either clinical anaesthesia, or post-anesthesia nursing, or operating room nursing, or surgical intensive nursing. Between March and April 2023, the panellists evaluated and recommended revisions to the initial framework.

RESULTS

This study resulted in the development of a nursing assessment framework for patients in anaesthesia recovery period. The initial version of the framework consisted of six dimensions with 27 items. Six items were modified after the first round of consultation. After the second round, five modifications and four deletions were made based on expert opinion. The third round resulted in a convergence of expert opinion. The framework, which consists of 24 items across five dimensions, was refined. The five dimensions are as follows: History-taking, Physical assessment, Clinical judgement, Organizational efficiency and Humanistic concern.

CONCLUSION

The nursing assessment framework for patients in anaesthesia recovery period was reached consensus between the 22 experts' opinions.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The assessment framework constructed in this study could be used for the process evaluation of post-anesthesia nursing. The framework may guide perianesthesia nurses in the timely and effective assessment of patients during this critical phase of care. It may be used for perianesthesia nursing education or to evaluate nurses' assessment skills.

REPORTING METHOD

The study is reported in accordance with the Guidance on Conducting and Reporting DElphi Studies (CREDES) recommendations.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

[Opioid-free anesthesia : Wrong track or meaningful exit from the era of opioid-based analgesia?]

The limitations and disadvantages of opioids in anesthesia are very well known but the advantages combined with a lack of effective alternatives even now still prevents refraining from using opioids as part of an adequate pain therapy. For decades, pain research has had the declared goal of replacing opioids with new substances which have no serious side effects; however, currently this goal seems to be a long way off. Due to the media coverage of the "opioid crisis" in North America, the use of opioids for pain management is also increasingly being questioned by the patients. Measures to contain this crisis are only slowly taking effect in view of the increasing number of deaths, which is why the triggers are still being sought. The perioperative administration of opioids is not only a possible gateway to addiction and abuse but it can also cause outcome-relevant complications, such as respiratory depression, postoperative nausea and vomiting and an increase in postoperative pain. Therefore, these considerations gave rise to the idea of an opioid-free anesthesia (OFA), i.e., opioids are not administered as part of anesthesia to carry out surgical procedures. Although this idea may make sense at first glance, a rapid introduction of this concept appears to be risky as it entails significant changes for the entire anesthesiological management. Based on relatively robust data from clinical studies, this concept can now be evaluated and discussed not only emotionally but also objectively. This review article presents arguments for or against the complete avoidance of intraoperative or even perioperative opioids. The current conditions in Germany are primarily taken into account, so that the perioperative pain therapy is transferable to the established standards. The results from current clinical studies on the implementation of an opioid-free anesthesia are summarized and discussed.

Comparison of three different prophylactic treatments for postoperative nausea and vomiting after total joint arthroplasty under general anesthesia: a randomized clinical trial

BACKGROUND

Postoperative nausea and vomiting (PONV) after total joint arthroplasty is common and associated with delayed recovery. This study was performed to evaluate the efficacy of three different prophylactic regimens for PONV after total joint arthroplasty under general anesthesia.

METHODS

Patients undergoing primary total hip or knee arthroplasty were randomized to Group A (ondansetron), Group B (10 mg dexamethasone plus ondansetron and mosapride), or Group C (three doses of 10 mg dexamethasone plus ondansetron and mosapride). The primary outcome was the total incidence of PONV during postoperative 48 h. The secondary outcomes were complete response, rescue antiemetic treatment, opioid consumption, time until first defecation, postoperative appetite score, satisfaction score, length of hospital stay, blood glucose level, and complications.

RESULTS

Patients in Group C experienced a lower incidence of total PONV (29.3%, p = 0.001) and a higher incidence of complete response (70.7%, p = 0.001) than did patients in Group A (51.9%, 48.2%, respectively). Patients in Group C also experienced a lower incidence of severe PONV (4.3%) than patients in Group A (25.9%, p<0.001) and B (20.4%, p<0.001). Moreover, less rescue antiemetic treatment (1.4 ± 0.5 mg Metoclopramide) and postoperative opioid consumption (1.8 ± 0.3 mg Oxycodone, 6.0 ± 1.0 mg Pethidine) was needed in Group C. Additionally, a shorter time until first defecation, shorter length of stay, and better postoperative appetite scores and satisfaction scores were detected in patients in Group C. A slight increase in the fasting blood glucose level was observed in Group C, and the complications were comparable among the groups.

CONCLUSION

Combined use of ondansetron, mosapride and three doses of dexamethasone can provide better antiemetic effectiveness, postoperative appetite, bowel function recovery, and pain relief than a single dose or ondansetron only.

TRIAL REGISTRATION INFORMATION

The protocol was registered at the Chinese Clinical Trial Registry (ChiCTR1800015896, April 27, 2018).

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review

BACKGROUND

Postoperative nausea and vomiting (PONV) affects patient satisfaction, health care costs, and hospital stay by complicating the postoperative recovery period after adolescent idiopathic scoliosis (AIS) spinal fusion surgery. Our goal was to identify recommendations for optimal management of PONV in AIS patients undergoing posterior spinal fusion (PSF).

METHODS

We performed a systematic review in June 2022, searching the PubMed and Embase electronic databases using search terms "(Adolescent idiopathic scoliosis) AND (Postoperative) AND (Nausea) AND (Vomiting)." Three authors reviewed the 402 abstracts identified from January 1991 to June 2022. Studies that included adolescents or young adults (<21 years) with AIS undergoing PSF were selected for full-text review by consensus. We identified 34 studies reporting on incidence of PONV. Only 6 studies examined PONV as the primary outcome, whereas remaining were reported PONV as a secondary outcome. Journal of Bone and Joint Surgery Grades of recommendation were assigned to potential interventions or clinical practice influencing incidence of PONV with respect to operative period (preoperative, intraoperative, and postoperative period) on the basis that potential guidelines/interventions for PONV can be targeted at those periods.

RESULTS

A total of 11 factors were graded, 5 of which were related to intervention and 6 were clinical practice-related. Eight factors could be classified into the operative period-1 in the intraoperative period and 7 in the postoperative period, whereas the remaining 3 recommendations had overlapping periods. The majority of grades of recommendations given were inconclusive or conflicting. The statement that neuraxial and postoperative systemic-only opioid therapy have a similar incidence of PONV was supported by good (Grade A) evidence. There was fair (Grade B) and poor evidence (Grade C) to avoid opioid antagonists and nonopioid local analgesia using wound catheters as PONV-reducing measures.

CONCLUSION

Although outcomes after spinal fusion for AIS have been studied extensively, the literature on PONV outcomes is scarce and incomplete. PONV is most commonly included as a secondary outcome in studies related to pain management. This study is the first to specifically identify evidence and recommendations for interventions or clinical practice that influence PONV in AIS patients undergoing PSF. Most interventions and clinical practices have conflicting or limited data to support them, whereas others have low-level evidence as to whether the intervention/clinical practice influences the incidence of PONV. We have identified the need for expanded research using PONV as a primary outcome in patients with AIS undergoing spinal fusion surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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