Recent smoking behavior and postoperative nausea and vomiting

Interpretation of the four risk factors for postoperative nausea and vomiting in the Apfel simplified risk score: an analysis of published studies

PURPOSE

The Apfel simplified risk score, developed in 1999, is the most widely used tool for risk stratification of postoperative nausea and vomiting (PONV). It includes four risk factors: female sex, non-smoking status, history of PONV or motion sickness, and use of postoperative opioids. Nevertheless, there is considerable heterogeneity in the definition and application of these risk factors in PONV research. Our aim was to determine how these risk factors are implemented in studies employing the Apfel score.

METHODS

Citations of the index Apfel score paper between 1 September 1999 and 1 September 2019 were identified in the Scopus database. Original full-text reports in English measuring all four risk factors were eligible for inclusion. Data collected included the definition, timing, and collection method of the four risk factors.

RESULTS

Of the identified studies, 255 of the 535 reported all four risk factors, with calculated Apfel risk scores reported in 116 of the 255 (46%) papers. Smoking, PONV, motion sickness, and postoperative opioid use were defined in four (2%), zero (0%), one (0.4%), and seven (3%) papers, respectively. Postoperative opioid use was defined as "anticipated" in 138 (54%) studies and "actual" in 72 (18%) studies and was unclear in 45 (28%) studies.

CONCLUSIONS

Significant variation exists in how the Apfel risk factors are defined and applied in PONV research, particularly with respect to postoperative opioid use. More guidance in the application of this tool may optimize risk estimation and PONV prophylaxis, and potentially improve research quality.

Preoperative Fasting Abbreviation and its Effects on Postoperative Nausea and Vomiting Incidence in Gynecological Surgery Patients

Objective To investigate the effects of preoperative fasting abbreviation with a carbohydrate and protein-enriched solution, on postoperative nausea and vomiting (PONV) incidence in gynecological surgery patients, a population naturally at risk for such unpleasant episodes.

Methods The present prospective double-blind randomized study was performed at The Hospital Municipal e Maternidade Dr. Odelmo Leão Carneiro (HMMOLC, in the Portuguese acronym), in Uberlândia, state of Minas Gerais, Brazil, in partnership with the Gynecology Department of the Universidade Federal de São Paulo (UNIFESP), approved by the Human Research Ethics Committee of UNIFESP and the board of HMMOLC, and included in the Brazil Platform and in the Brazilian Clinical Trial Registry. After signing the consent form, 80 women, who were submitted to gynecological surgery in the period from January to June 2016, were randomized into 2 groups: control group (n = 42) and juice group (n = 38). They received, respectively, 200 mL of inert solution or liquid enriched with carbohydrate and protein 4 hours presurgery. The incidence, frequency and intensity of PONV were studied using the Visual Analogue Scale (VAS), with statistical analysis performed by the software IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp, Armonk, NY, USA).

Results The incidence of nausea and vomiting was lower than in the literature, to this population, with 18.9% (14/74) for the control group and 10.8% (8/74) for the juice group, respectively, with no statistically significant difference between the groups.

Conclusion The incidence of nausea and vomiting was lower than in the literature, but it cannot be said that this is due to the abbreviation of fasting. It can provide greater comfort, with the possibility of PONV prevention in patients at risk for these episodes.

Outcomes and Factors Associated With Reduced Symptoms in Patients With Gastroparesis

BACKGROUND & AIMS

Gastroparesis is a chronic clinical syndrome characterized by delayed gastric emptying. However, little is known about patient outcomes or factors associated with reduction of symptoms.

METHODS

We studied adult patients with gastroparesis (of diabetic or idiopathic type) enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium Gastroparesis Registry, seen every 16 weeks and treated according to the standard of care with prescribed medications or other therapies at 7 tertiary care centers. Characteristics associated with reduced symptoms, based on a decrease of 1 or more in the gastroparesis cardinal symptom index (GCSI) score after 48 weeks of care, were determined from logistic regression models. Data were collected from patients for up to 4 years (median, 2.1 y).

RESULTS

Of 262 patients, 28% had reductions in GCSI scores of 1 or more at 48 weeks. However, there were no significant reductions in GCSI score from weeks 48 through 192. Factors independently associated with reduced symptoms at 48 weeks included male sex, age 50 years and older, initial infectious prodrome, antidepressant use, and 4-hour gastric retention greater than 20%. Factors associated with no reduction in symptoms included overweight or obesity, a history of smoking, use of pain modulators, moderate to severe abdominal pain, a severe gastroesophageal reflex, and moderate to severe depression.

CONCLUSIONS

Over a median follow-up period of 2.1 years, 28% of patients treated for gastroparesis at centers of expertise had reductions in GCSI scores of 1 or greater, regardless of diabetes. These findings indicate the chronic nature of gastroparesis. We identified factors associated with reduced symptoms that might be used to guide treatment. ClinicalTrials.gov no: NCT00398801.

Anaesthesia for patient with chronic obstructive pulmonary disease

The chronic obstructive pulmonary disease has become a disease of public health importance. Among the various risk factors, smoking remains the main culprit. In addition to airway obstruction, the presence of intrinsic positive end expiratory pressure, respiratory muscle dysfunction contributes to the symptoms of the patient. Perioperative management of these patients includes identification of modifiable risk factors and their optimisation. Use of regional anaesthesia alone or in combination with general anaesthesia improves pulmonary functions and reduces the incidence of post-operative pulmonary complications.

Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi-center study

BACKGROUND

The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery.

METHODS

The 355 allocated patients were followed during recovery and the first day at home.

RESULTS

Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS>3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes.

CONCLUSION

We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment.

Etoricoxib for pain management during thyroid surgery–a prospective, placebo-controlled study

Objective

To assess the efficacy of etoricoxib in pain treatment during thyroid surgery.

Design

Double-blind, placebo-controlled, randomized trial.

Setting

A secondary-level central hospital in Finland.

Patients

Sixty-nine consecutive patients (59 women) aged 18 to 70 years who underwent thyroid surgery.

Interventions

Patients were randomized to receive etoricoxib 120 mg (n = 34) or placebo (n = 35) by mouth 60 minutes before surgery. After surgery oxycodone 2 mg administered intravenously was provided for rescue analgesia.

Main Outcome Measures

Oxycodone consumption during the first 6 (primary) and the 7 to 24 hours (secondary) after surgery.

Results

During the first 6 hours, all patients in the placebo group and 31 of 34 patients in the etoricoxib group were given oxycodone for rescue analgesia ( P = 0.072). In the 7 to 24 postsurgical hours, 25 of 35 patients in the placebo group versus 16 of 34 patients in the etoricoxib group needed rescue analgesics (mean difference 24%, 95% CI −1 to 47%, P = 0.039).

Conclusion

Etoricoxib 120 mg reduced pain in the 7 to 24 postsurgical time period but did not have opioid-sparing effect during the first 6 hours after surgery.

Tobacco dependence in surgical patients

PURPOSE OF REVIEW

Many patients who smoke cigarettes require anesthesia and surgery. Their smoking can have profound consequences for perioperative management. Efforts to help them quit will be rewarded by both improved immediate postoperative outcomes and the long-term health benefits after surgery. This review will introduce basic concepts important to perioperative tobacco control and cover recent advances in the field.

RECENT FINDINGS

Evidence continues to accumulate regarding how smoking increases perioperative risk, especially of wound-related complications. There is also new information regarding how abstinence from smoking reduces risk, including how the timing of preoperative abstinence affects outcome. Methods to help surgical patients continue to be developed, taking advantage of surgery as a teachable moment for intervention. There is a need to develop methods practical in the surgical setting. Several pharmacological tools to help surgical patients quit smoking are available, including a new partial acetylcholine receptor agonist.

SUMMARY

The fact that the perioperative period represents an excellent opportunity to help surgical patients quit smoking is becoming increasingly apparent. Although these efforts, and the evidence base to support them, are still at an early stage of development, seizing this opportunity will benefit both the short and long-term health of our patients who smoke.

Tobacco control for anesthesiologists

Anesthesiologists daily witness the consequences of tobacco use, the most common preventable cause of death. Smoking-related diseases such as atherosclerosis and chronic obstructive pulmonary disease increase anesthetic risk, and even smokers without overt disease are at increased risk for morbidity such as pulmonary and wound-related complications. Evidence suggests that stopping smoking will reduce the frequency of these complications. Nicotine and the other constituents of cigarette smoke, such as carbon monoxide, have important physiologic effects that may affect perioperative management. In addition, it is now apparent that the scheduling of elective surgery represents an excellent opportunity for smokers to quit in the long term. This review serves as an introduction to tobacco control for anesthesiologists, first examining issues of importance to perioperative management. It then discusses how anesthesiologists and other perioperative physicians can help address tobacco use, both at an individual level with their patients, and by contributing to the implementation of effective public health strategies in their countries. Anesthesiologists can play a key role in helping their patients quit smoking. Effective tobacco control measures applied to surgical patients will not only improve immediate perioperative outcomes but also long-term health.