Indication for surgery and the risk of postoperative nausea and vomiting after craniotomy: a case-control study

Intraoperative Brainstem Auditory Evoked Potentials and Postoperative Nausea and Vomiting After Microvascular Decompression

BACKGROUND

We performed this study to investigate the effect of intraoperative brainstem auditory evoked potential (IBAEP) changes on the development of postoperative nausea and vomiting (PONV) after microvascular decompression (MVD) for neurovascular cross compression.

METHODS

A total of 373 consecutive cases were treated with MVD. The use of rescue antiemetics after surgery was used as an objective indicator of PONV. IBAEP monitoring was routinely performed in all.

RESULTS

The use of rescue antiemetics was significantly associated with female sex (OR = 3.427; 95% CI, 2.077-5.654; P < 0.001), PCA use (OR = 3.333; 95% CI, 1.861-5.104; P < 0.001), and operation time (OR = 1.017; 95% CI, 1.008-1.026; P < 0.001). A Wave V peak delay of more than 1.0 milliseconds showed a significant relation with the use of rescue antiemetics (OR = 1.787; 95% CI, 1.114-2.867; P = 0.016) and a strong significant relation with the use of rescue antiemetics more than 5 times (OR = 2.426; 95% CI, 1.372-4.290; P = 0.002).

CONCLUSIONS

A wave V peak delay of more than 1.0 milliseconds might have value as a predictor of PONV after MVD. More detailed neurophysiological studies will identify the exact pathophysiology underlying PONV after MVD.

5-Hydroxytryptamine and postoperative nausea and vomiting after microvascular decompression surgery

BACKGROUND

The incidence of postoperative nausea and vomiting (PONV) after microvascular decompression (MVD) surgery is high; however, its underlying mechanisms remain unknown. Serum 5-hydroxytryptamine (5-HT) levels are elevated in patients with PONV. However, the relationship between 5-HT and patients experiencing PONV after MVD surgery is still unknown. Therefore, we hypothesized that 5-HT levels are associated with PONV after MVD surgery.

METHODS

This prospective study included 85 patients with hemifacial spasm who received MVD surgery. Blood samples were collected preoperatively, postoperatively, and on postoperative day 1, and cerebrospinal fluid samples were collected intraoperatively. 5-HT levels were detected by enzyme-linked immunosorbent assay (ELISA). The incidence and severity of PONV were evaluated at 2, 6, and 24 h after MVD surgery.

RESULTS

In the multivariate regression analysis, PONV within 24 h after MVD surgery was associated with elevated cerebrospinal fluid 5-HT levels [odds ratio (OR) = 1.21, 95% confidence interval (CI): 1.01-1.45, p = 0.044], and reduction of intraocular pressure [OR = 11.54, 95% CI: 1.43-92.84, p = 0.022]. Receiver operating characteristic curve analysis revealed an area under the curve of 0.873 (95% CI: 0.77-0.98, p < 0.001).

CONCLUSION

Our study found that the cerebrospinal fluid 5-HT levels is an independent risk factor for PONV within 24 h after MVD surgery.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Postoperative Nausea and Vomiting After Craniotomy: An Evidence-based Review of General Considerations, Risk Factors, and Management

One of the most common and distressing symptoms after craniotomy is postoperative nausea and vomiting (PONV). PONV could generate delayed postanesthesia care and hospitalization discharge, lower patient satisfaction, and an increase in overall hospitalization costs. The incidence of reported PONV after craniotomy is 22% to 70% without prophylaxis, and a multimodal regimen of medication has been recommended. We conducted a comprehensive literature review of the clinical evidence related to PONV prevention and management after craniotomy. All clinical trials in adult populations relevant to PONV after craniotomy available in English language and indexed in PubMed, Google Scholar and Cochrane Library databases from January 1997 up to September 2018 were retrieved using a combination of free-text words related to PONV in craniotomy. After screening manuscripts identified in the initial search, 23 clinical trials investigating systemic pharmacological intervention versus placebo or active control in patients undergoing craniotomy under general anesthesia met the criteria for inclusion in this comprehensive narrative review. The pathophysiology and mechanisms of PONV after craniotomy could be multifactorial in etiology. Therefore, based on current evidence, PONV management after craniotomy should focus on perioperative patient assessment, surgical, and anesthesia-related risk factors and the selection of systemic pharmacological considerations to reduce its incidence and complications. A multimodal regimen of medication targeting different chemoreceptors in the vomiting center is recommended. Ondansetron and dexamethasone, or their combination, are the most frequently used and effective agents. Further randomized clinical trials comparing different regimens that significantly reduce the incidence of PONV in craniotomy would provide relevant evidence-based data for PONV management in this patient population.

Improving recovery after microvascular decompression surgery for hemifacial spasm: experience from 530 cases with enhanced recovery after surgery (ERAS) protocol

OBJECTIVE

To assess the efficacy of microvascular decompression (MVD) for hemifacial spasm with an enhanced recovery after surgery (ERAS) protocol.

METHODS

984 hemifacial spasm patients who underwent MVD from Jan 2017 to Dec 2017 were analyzed. They were divided into the conventional treatment group (control; n = 453) and the later ERAS group (n = 531). The multimodal ERAS protocol consists of 23 perioperative elements. Time to feeding, mobilization, and urinary catheter removal, wound pain, postoperative nausea and vomiting (PONV), and total, preoperative, and perioperative hospital length of stay (LOS), along with outcomes and complications, were analyzed.

RESULTS

The patients in both groups had similar clinical characteristics. Patients in the ERAS group had significantly higher rates of early feeding (469 [88.5%], ERAS, vs. 183 [40.6%], control; p < 0.05), early mobilization (497 [93.7%], ERAS, vs. 215 [47.7%], control; p < 0.05), and early removal of urinary catheter (458 [86.4%], ERAS, vs. 175 [38.8%], control; p < 0.05). The ERAS group also had a significantly lower incidence of wound pain (135 [25.5%], ERAS, vs. 348 [77.2%], control) and PONV (173 [32.6%], ERAS, vs. 251 (55.7%), control) (p < 0.05) and significantly shorter preoperative (0.9 ± 0.3 d, ERAS, vs. 2.3 ± 0.6 d, control), postoperative (4.1 ± 0.4 d, ERAS, vs. 5.8 ± 0.7 d, control), and total LOS (5.2 ± 0.3 d, ERAS, vs. 8.8 ± 0.6 d, control) (p < 0.05). There was no significant difference in outcomes or surgical complication rates between two groups.

CONCLUSIONS

Implementation of the ERAS protocol for patients undergoing MVD procedures for the treatment of HFS improved the quality of perioperative care without an increase in adverse events.

Successful implementation of an enhanced recovery after surgery (ERAS) protocol reduces nausea and vomiting after infratentorial craniotomy for tumour resection: a randomized controlled trial

BACKGROUND

Infratentorial craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). Enhanced Recovery After Surgery (ERAS) protocols have been shown in multiple surgical disciplines to improve outcomes, including reduced PONV. However, very few studies have described the application of ERAS to infratentorial craniotomy. The aim of this study was to examine whether our ERAS protocol for infratentorial craniotomy could improve PONV.

METHODS

We implemented an evidence-based, multimodal ERAS protocol for patients undergoing infratentorial craniotomy. A total of 105 patients who underwent infratentorial craniotomy were randomized into either the ERAS group (n = 50) or the control group (n = 55). Primary outcomes were the incidence of vomiting, nausea score, and use of rescue antiemetic during the first 72 h after surgery. Secondary outcomes included postoperative anxiety level, sleep quality, and complications.

RESULTS

Over the entire 72 h post-craniotomy observation period, the cumulative incidence of vomiting was significantly lower in the ERAS group than in the control group. Meanwhile, the incidence of vomiting was significantly lower in the ERAS group on postoperative days (PODs) 2 and 3. Notably, the proportion of patients with mild nausea (VAS 0-4) was higher in the ERAS group as compared to the control group on PODs 2 or 3. Additionally, the postoperative anxiety level and quality of sleep were significantly better in the ERAS group.

CONCLUSION

Successful implementation of our ERAS protocol in infratentorial craniotomy patients could attenuate postoperative anxiety, improve sleep quality, and reduce the incidence of PONV, without increasing the rate of postoperative complications.

TRIAL REGISTRATION

ChiCTR-INR-16009662, 27 Oct 2016, Clinical study on the development and efficacy evaluation of Enhanced Recovery After Surgery (ERAS) in Neurosurgery.

[Postoperative nausea and vomiting in neurosurgery: the approaches are varied but the problem remains unsolved]

Postoperative nausea and vomiting (PONV) can induce brain displacement and herniation, especially in patients with cerebral edema.

OBJECTIVE

To evaluate the urgency of the problem associated with postoperative nausea and vomiting in current clinical practice (with modern approaches being used for its prevention) and to reveal the risk factors of PONV that are typically encountered in neurosurgical patients.

MATERIAL AND METHODS

A prospective observational study involved 240 patients who had undergone elective surgeries at the N.N. Burdenko National Scientific and Practical Center for Neurosurgery between July and November 2017. The data were collected from the questionnaires filled out by the patients during the first 48 h after the surgery and from patients' medical records.

RESULTS

The overall rate of PONV was 39.6%. Thirty-six out of 53 (68%) patients developed PONV after the posterior fossa surgeries. The risk of PONV in this group was significantly higher (p<0.05) compared to the rate of PONV after interventions at a different location. The rate of PONV after treatment of extracranial pathology was ~10.5%; for a different location, it was as high as 32-37%. Intraoperative dexamethasone was used in 156 (65%) patients; in this group, the rate of PONV was 39.9%. Patients received ondansetron at a dose of 8 mg for a preventive purpose at the end of the surgery. A total of 162 patients were given the drug; 59 (36.4%) of them developed POTV during 48 h post-administration. Seventy-eight patients did not receive ondansetron. Thirty-six of them (46.2%) (p>0.05) developed POTV. The rate of POTV assessed during the first 8 h after surgery was 22.8% in patients who had received ondansetron and 37.2% in those who had not received it (p<0.05). Patients who had not intraoperatively received a combination of these drugs developed POTV in 55 (45%) cases (p>0.05).

CONCLUSION

The problem associated in POTV remains topical in neurosurgery. The current approaches are not absolutely effective for prevention of POTV, whose rate ranges between 10.5 and 68% depending on surgery location. Further studies focused on administration of NK-1 receptor antagonists and electrical stimulation of the median nerve are needed to enhance the effectiveness of POTV prevention.

Effects of Intraoperative Dexamethasone and Ondansetron on Postoperative Nausea and Vomiting in Microvascular Decompression Surgery: A Randomized Controlled Study

Background

Postoperative nausea and vomiting (PONV) is a common problem and may lead to catastrophic complications, especially in neurosurgical cases. The aim of this study was to evaluate the effects of dexamethasone and ondansetron for preventing PONV in patients who underwent microvascular decompression (MVD) surgery.

Methods

A prospective, double-blinded, randomized control trial was conducted with 54 patients who underwent MVD. Patients were allocated into two groups. The study group (Gr. D) received intraoperative dexamethasone 4 mg iv and ondansetron 4 mg iv, whereas the control group (Gr. N) received placebo (0.9% normal saline 1 ml iv and 0.9% normal saline 2 ml iv). The incidence and severity of PONV were observed at 1, 2, 4, and 24 hr postsurgery.

Results

At 1, 2, 4, and 24 hr postsurgery, Gr. D had a lower incidence (7.4%, 11.1%, 29.6%, and 66.7%) and lower severity of PONV than Gr. N (18.5%, 29.6%, 37.0%, and 81.5% at 1, 2, 4, and 24 hr; p > 0.05). The requirement for antiemetic drugs was not significantly different between the groups (p > 0.05).

Conclusion

Administration of dexamethasone and ondansetron 4 mg seemed to decrease the incidence of PONV in the first 24 hours but not significantly. Therefore, further studies are to be carried out by escalating either dexamethasone dose or the dose of ondansetron or both.

Update on anesthesia for craniotomy

PURPOSE OF REVIEW

In this review, we present an update on the relationship between anesthesia and intraoperative hemodynamic complications, early postanesthesia recovery, postoperative pain and postoperative nausea and vomiting after craniotomy. We also review latest advances in education and research in neuroanesthesia for brain surgery.

RECENT FINDINGS

Insights from clinical reports published from January 2012 to April 2013 on anesthesia for craniotomy will be summarized. Recent findings address the need for a tight intraoperative hemodynamic monitoring - that should include aggressive prevention of arterial hypotension and cardiac arrhythmias - and a careful management of fluids and electrolytes balance. Data on the relationship between anesthesia (selection of anesthetics used intraoperatively) and early recovery demonstrate a limited benefit when ultra-short acting drugs (as remifentanil vs fentanyl) are used. Evidence on postoperative pain and postoperative nausea and vomiting contribute to define how to better prevent and treat these complications. Latest guidelines on training and research in neuroanesthesia define unique end points in this subspecialty.

SUMMARY

Neuroanesthesia for craniotomy should be aimed to ensure intraoperative loss of consciousness (unless awake craniotomy is the selected anesthesiological approach), pain control and an uneventful postoperative recovery, but should also be addressed to manipulate physiological variables including cerebral blood flow and to obtain optimal surgical exposure.

Comparison of the antiemetic effect of ramosetron with ondansetron in patients undergoing microvascular decompression with retromastoid craniotomy: a preliminary report

BACKGROUND

Microvascular decompression with retromastoid craniotomy carries an especially high risk of postoperative nausea and vomiting. In this study, we compare the antiemetic efficacy of ramosetron and ondansetron in patients undergoing microvascular decompression with retromastoid craniotomy.

METHODS

Using balanced anesthesia with sevoflurane and remifentanil infusion, ondansetron 8 mg (group O, n = 31) or ramosetron 0.3 mg (group R, n = 31) was administered at the dural closure. The incidence and severity of postoperative nausea and vomiting, required rescue medications and the incidence of side effects were measured at post-anesthetic care unit, 6, 24 and 48 hours postoperatively. Independent t-tests and the chi-square test or Fisher's exact test were used for statistical analyses.

RESULTS

There were no differences in the demographic data between groups, except for a slightly longer anesthetic duration of group R (P = 0.01). The overall postoperative 48 hour incidences of nausea and vomiting were 93.6 and 61.3% (group O), and 87.1 and 51.6% (group R), respectively. Patients in group R showed a less severe degree of nausea (P = 0.02) and a lower incidence of dizziness (P = 0.04) between 6 and 24 hours.

CONCLUSIONS

The preventive efficacy of ramosetron when used for postoperative nausea and vomiting was similar to that of ondansetron up to 48 hours after surgery in patients undergoing microvascular decompression with retromastoid craniotomy. A larger randomized controlled trial is needed to confirm our findings.

Critical care nursing in acute postoperative neurosurgical patients

The nursing discipline is vital throughout patients' hospital progression. One of the most critical moments in the hospital stay is the postoperative period. Neurosurgical patients require a high level of nursing care and vigilance and additional postoperative monitoring in intensive care units designed specifically for this demographic. In the postoperative setting, patient care must be transferred from anesthesia to nursing in a manner that is continuous and safe. This article focuses on neurosurgical patients in the postoperative period, the assessment of these patients, and critical care nursing, with emphasis on common issues and interventions for this dynamic patient population.

Neuroanesthesiology update

We review topics pertinent to the perioperative care of patients with neurological disorders. Our review addresses topics not only in the anesthesiology literature, but also in basic neurosciences, critical care medicine, neurology, neurosurgery, radiology, and internal medicine literature. We include literature published or available online up through December 8, 2013. As our review is not able to include all manuscripts, we focus on recurring themes and unique and pivotal investigations. We address the broad topics of general neuroanesthesia, stroke, traumatic brain injury, anesthetic neurotoxicity, neuroprotection, pharmacology, physiology, and nervous system monitoring.

Is microvascular decompression surgery a high risk for postoperative nausea and vomiting in patients undergoing craniotomy?

PURPOSE

Patients undergoing microvascular decompression surgery often experience postoperative nausea and vomiting (PONV). However, there is little information about the incidence of PONV after microvascular decompression. We hypothesized that microvascular decompression is an especially high-risk procedure for PONV in patients undergoing neurosurgery, and investigated risk factors related to PONV after neurosurgery.

METHODS

All patients who underwent craniotomy in our institution during a period of 2 years were investigated retrospectively. Medical charts were reviewed to identify PONV during the 24-h postoperative period and related risk factors. Multivariate logistic regression analysis was conducted to elucidate the impact of microvascular decompression on PONV after craniotomy.

RESULTS

Among 556 craniotomy cases, 350 patients met the inclusion criteria. Multivariate logistic regression analysis showed that microvascular decompression was an independent risk factor for PONV after craniotomy (odds ratio 5.38, 3.02-9.60), in addition to female gender, non-smoker status, amount of intraoperative fentanyl administered, and cerebrovascular surgery.

CONCLUSION

In this retrospective study, microvascular decompression surgery was an especially high-risk factor for PONV in patients undergoing craniotomy. It may be necessary to adopt a combination of prophylactic methods to reduce the incidence of PONV after microvascular decompression.