Risk factors of postoperative nausea and vomiting after total hip arthroplasty or total knee arthroplasty: a retrospective study

Influence of higher body mass index on postoperative nausea and vomiting in patients following thoracic surgery for lung cancer: a propensity score-matched cohort study

This study aimed to quantify the association between body mass index (BMI) and postoperative nausea and vomiting (PONV) within the initial 48 h following thoracic surgery for lung cancer. We then explored whether changes in serum inflammatory factor concentrations were related to BMI during the early postoperative period. We conducted a propensity score-matched (PSM), retrospective cohort study at a specialized tertiary medical center. A total of 194 patients aged 18-80 years who underwent thoracic surgery for lung cancer at Shanghai Pulmonary Hospital between January and June 2021 were enrolled. The primary outcome was the incidence of PONV during the first 48 h after surgery. Nausea, vomiting or retching at different time periods, severe pain, and concentrations of perioperative serum inflammatory factors including CRP, IL-6, IL-12, and IFN-γ were also assessed. Patients in the high BMI group (BMI ≥ 25 kg/m2) had a lower incidence of PONV than those in the normal BMI group (18.5-25 kg/m2) within the first 48 h after surgery (22 vs. 50%, p = 0.004). The incidence of nausea was lower at 0-12 h (14.5 vs. 37.1%, p = 0.004) and 12-24 h (8.1 vs. 22.6%, p = 0.025) in the high BMI group after surgery, and the incidence of vomiting was lower at 0-12 h (12.9 vs. 30.6%, p = 0.017) in higher BMI after surgery. We found no significant difference in the incidence of severe pain [severe static pain (p = 0.697) and severe dynamic pain (p = 0.158)]. Moreover, higher concentrations of IL-12 (2.24 ± 2.67 pg/ml vs. 1.48 ± 1.14 pg/ml, p = 0.048) and IFN-γ [1.55 (1.00) pg/ml vs. 1.30 (0.89) pg/ml, p = 0.041] were observed in patients with normal BMI on the first day after surgery. Given this finding, patients with a normal BMI should receive more attention for the prevention of PONV than those with a high BMI following thoracic surgery for lung cancer.Trial registration: http://www.chictr.org.cn and ChiCTR2100052380 (24/10/2021).

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery

The enhanced recovery after surgery (ERAS) protocols are a comprehensive therapeutic approach that prioritizes the well-being of patients. It encompasses several aspects such as providing sufficient nutritional support, effectively managing pain, ensuring appropriate fluid management and hydration, and promoting early mobilization after surgery. The advent of ERAS theory has led to a shift in focus within modern ERAS protocols. At present, ERAS protocols emphasize perioperative therapeutic strategies employed by surgeons and anesthesiologists, as well as place increased importance on preoperative patient education, interdisciplinary collaboration, and the enhancement of patient satisfaction and clinical outcomes. This editorial highlights the application of ERAS protocols in the current context of total joint replacement surgery.

The effect of lemon inhalation aromatherapy on pain, nausea, as well as vomiting and neurovascular assessment in patients for lower extremity fracture surgery: a randomized trial

BACKGROUND

Complementary and integrative medicine may be effective for postoperative outcomes. This study aimed to determine the effect of lemon inhalation aromatherapy on pain, nausea, and vomiting and neurovascular assessment in patients for lower extremity fracture surgery.

METHODS

This is a randomized clinical trial study. Ninety patients who had undergone lower extremity fracture surgery were randomly assigned to the intervention (lemon aromatherapy) and control groups. Lemon aromatherapy was started in the morning of the surgery and extended at two-hour intervals until the end of the surgery, in the recovery room, and 16 h after surgery. Numerical pain and nausea and vomiting scales, the Rhodes Index of Nausea, Vomiting, and Retching, and the WACHS Neurovascular Observation Chart were used to assess the outcomes before and after the intervention (in the recovery room and 4, 8, 12, and 16 h post-surgery). The data were analyzed using the Wilcoxon test, ANCOVA, and Repeated Measure ANCOVA.

RESULTS

A significant difference was observed between the groups in terms of the intensity of pain (P < 0.001) and nausea and vomiting (P = 0.001) during the study period. Moreover, a significant difference was found between groups as to the frequency and severity of nausea, vomiting, and retching. The amount and duration of postoperative vomiting and nausea were significantly lower in the intervention group compared to the control group. In addition, lemon inhalation aromatherapy decreased the frequency of anti-emetic drug administration in the recovery room (P = 0.04) and 16 h post-surgery (P = 0.03).

CONCLUSIONS

This study indicated that aromatherapy reduced pain intensity, postoperative nausea, vomiting, and retching, as well as the incidence of anti-emetic drug administration. Therefore, using lemon inhalation aromatherapy to relieve pain and reduce nausea and vomiting is suggested for lower extremity fracture patients who have undergone surgery.

TRIAL REGISTRATION

This study was registered in the Iranian Registry of Clinical Trail (Number = 57,331, IRCT20130616013690N10, approved 24/07/2021) ( https://www.irct.ir/trial/57331 ).

External validation of postoperative nausea and vomiting risk scores in patients with liver cancer: A single-centre prospective cohort study

OBJECTIVES

This study aimed to test the external validity of postoperative nausea and vomiting (PONV) risk assessment tools in patients undergoing hepatectomy, and to guide healthcare professionals' assessment of postoperative patients.

BACKGROUND

The identification of PONV risk is particularly important in the context of prevention. However, the predictive performance of the current PONV risk scores has not been confirmed in patients with liver cancer, and its applicability is still unknown. These uncertainties pose difficulties in performing routine risk assessment of PONV for patients with liver cancer in a clinical practice setting.

METHODS

Patients diagnosed with liver cancer and undergoing hepatectomy were prospectively consecutively recruited. All enrolled patients received PONV assessments and PONV risk assessments via the Apfel risk score and the Koivuranta risk score. Receiver operating characteristic curves (ROC curves) and calibration curves were used to assess the external validity. This study was reported according to the TRIPOD Checklist.

RESULTS

Among 214 PONV-assessed patients, 114 patients (53.3%) developed PONV. For the Apfel simplified risk score, the ROC area was 0.612 (95% confidence interval [CI]: 0.543-0.678) in the validation dataset, which demonstrated imperfect discrimination; the calibration curve showed poor calibration with a slope of 0.49. For the Koivuranta score, the ROC area was 0.628 (CI: 0.559-0.693) in the validation dataset, which showed limited discrimination; the calibration curve indicated an unsatisfactory calibration with a slope of 0.71.

CONCLUSIONS

The Apfel risk score and the Koivuranta risk score were not well validated in our study and disease-specific risk factors should be taken into account when updating or developing PONV risk stratification instruments.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

Predictors of Postoperative Nausea and Vomiting After Same-Day Surgery: A Retrospective Study

PURPOSE

Postoperative nausea and vomiting (PONV) are main issues after same-day surgery. This study aimed to retrospectively evaluate the electronic medical records of patients who underwent same-day operations under general anesthesia to identify the potential risk factors for PONV.

METHODS

Records of 7759 adult patients who received general anesthesia with remifentanil were reviewed. The patients were assessed for the incidence and severity of PONV. Multiple logistic regression was used to identify risk factors for PONV. A nomogram was established to predict PONV after same-day operations.

FINDINGS

Of 7759 patients, 2317 (29.9%) experienced PONV. In multiple logistic regression analysis, female sex, nonsmoker status, history of motion sickness or nausea, high body mass index (BMI), long surgical duration, laparoscopic procedure, and preoperative analgesic intake within 30 days were independent risk factors for PONV. No correlation was found between the severity of PONV and remifentanil exposure (odds ratio = 1.018; 95% CI, 0.861-1.204; P = 0.834) or remifentanil dose (odds ratio = 1.294; 95% CI, 0.760-2.205; P = 0.343). For the nomogram, which involved sex, laparoscopic procedure, BMI, history of nausea or motion sickness, and analgesic intake within 30 days, the receiver operating characteristic analysis revealed that the AUC values in the training and validation cohorts were 0.81 and 0.83, respectively.

IMPLICATIONS

Predictors for PONV in same-day surgery include female sex, nonsmoker, history of motion sickness or nausea, high BMI, surgical duration >1 hour, laparoscopic procedure, and preoperative analgesic intake within 30 days. A new predictive model is feasible for predicting the incidence of PONV based on the preoperative and intraoperative predictors.

Impact of Perioperative Dexamethasone on Hospital Length of Stay and Glycemic Control in Patients With Type 2 Diabetes Undergoing Total Hip Arthroplasty

Purpose

This study aimed to evaluate effects of perioperative dexamethasone on hospital length of stay (LOS) and glycemic control for patients with type 2 diabetes mellitus undergoing total hip arthroplasty (THA).

Methods

We performed retrospective case review of THA performed in adults (≥18 years old) with type 2 diabetes at Springfield Memorial Hospital (Springfield, IL) immediately before (2013), during (2014), and after (2015) publication of consensus guidelines for use of perioperative dexamethasone. Hospital LOS was the primary endpoint. Capillary blood glucose by hospital day, proportion of patients treated with insulin, and median insulin dose by hospital day were secondary endpoints.

Results

A total of 209 patients were included: 109 not dosed with dexamethasone ("no dexamethasone"), and 100 treated with perioperative dexamethasone. The most common dose of dexamethasone was 4 mg (63% of patients). Mean (95% CI) reduction in adjusted hospital LOS for dexamethasone-treated patients, compared to controls, was -2.8 (-3.7 to -1.9) days for all patients, -1.6 (-2.7 to -0.5) days for those with arthritis as the indication for THA, and -4.0 (-5.9 to -2.1) days for those with fracture as indication for THA (P<0.001 for all). Glycemic control measured by median capillary blood glucose was no different or slightly better in the dexamethasone group than the no dexamethasone group, except for postoperative day 1 among patients treated with insulin prior to surgery.

Conclusions

Perioperative dexamethasone significantly reduces hospital LOS for patients with type 2 diabetes undergoing THA, with modest effects on hyperglycemia.

Incidence and risk factors of postoperative nausea and vomiting in lung cancer patients following lobectomy and application of analgesic pumps

Objective

To investigate the occurrence rate and risk factors of postoperative nausea and vomiting (PONV) in lung cancer patients following lobectomy and application of analgesic pumps.

Methods

This retrospective study reviewed clinical data from patients that had undergone lobectomy for lung cancer under general anaesthesia. The risk factors of PONV were analysed using binary logistic regression models.

Results

A total of 203 patients (97 females) were enrolled. The rate of PONV was 29.6% (60 of 203 patients) for all patients, 42.3% (41 of 97 patients) for female patients and 17.9% (19 of 106 patients) for male patients. Female patients undergoing thoracotomy (odds ratio [OR] 7.770, 95% confidence interval [CI] 1.747, 34.568) or having surgery durations ≥120 min (OR 4.493, 95% CI 1.502, 12.851) were significantly more susceptible to PONV. The risk of PONV in female patients that received postoperative dolasetron (100 mg, once a day) was significantly lower (OR 0.075, 95% CI 0.007, 0.834). For male patients, the risk of PONV was significantly lower in those with a body mass index ≥24 kg/m² (OR 0.166; 95% CI 0.035, 0.782).

Conclusion

Female and male patients have different risk factors for PONV following lobectomy for lung cancer and application of analgesic pumps.

Effect of Mobilization on the Day of Surgery After Total Hip Arthroplasty in Elderly, Obese, and Severely Diseased Patients

BACKGROUND

Mobilization on the day of surgery after total hip arthroplasty (THA) is widely used. However, elderly, obese and severely diseased patients are often excluded from early mobilization. Therefore, it was our aim to investigate the effect of mobilization on the day of surgery with focus on these patients.

METHODS

167 patients underwent THA via direct anterior approach. Exclusion criterion was the use of wound drainage. The patients were randomly allocated to two groups. Day 0 group was mobilized 4 hours after surgery, day 1 group the day after surgery. Primary outcome was the time to readiness for discharge (TRD). Secondary outcome was the occurrence of adverse events (vertigo, nausea, vomiting, severe pain) on the day of surgery. Group comparisons were calculated with respect to elderly (age ≥75 years), obese (BMI ≥30 kg/m²) and severely diseased patients (ASA≥3).

RESULTS

TRD was shorter in day 0 group (3.25 vs 3.99 days, P < .01). The rate of adverse events on the day of surgery was similar in both groups (0.28 vs 0.25, P = .73). TRD differences were higher within all subgroups (3.85vs4.81; 3.25vs4.39; 4.08vs5.11days) while the rate of immediate adverse events was reduced (0.15vs0.24; 0.25vs0.3; 0.25vs0.33). Within 90 days 3 patients of group 0 underwent revision surgery, none of group 1 (P = .12).

CONCLUSION

Mobilization on the day of surgery reduces the TRD without increasing the rate of immediate adverse events, regardless of age, BMI and ASA score. Future studies are needed to investigate if early mobility increases the 90-days complication rate.

Impact of preoperative body mass index on perioperative outcomes is optimized by enhanced recovery protocols in laparoscopic radical cystectomy with intracorporeal urinary diversion

Background

We aimed to examine whether body mass index (BMI) had an impact on clinical outcomes of laparoscopic radical cystectomy with intracorporeal urinary diversion. Furthermore, we analyzed the optimization of enhanced recovery protocols (ERPs) on the impact of BMI on clinical outcomes.

Methods

By searching our database, data of 83 consecutive patients were retrospectively collected, including 37 patients with a BMI <24 kg/m² (group A) and 46 patients with a BMI ≥24 kg/m² (group B). The baseline and peri-operative variables of the two groups were compared. Subgroup analysis was conducted for ERPs (11 patients in group A₁, 18 patients in group B₁) and conventional recovery protocols (CRPs; 26 patients in group A₂, 28 patients in group B₂). The primary outcomes were 30-day overall complication rate and ΔALB_min (reduction proportion of minimum albumin). The secondary outcomes were operative time and length of stay.

Results

The baseline variables were similar between the two groups (P>0.05). The 30-day overall complication rate, operative time, and length of stay were similar between the two groups (P>0.05). But post-operative nausea and vomiting (PONV) was higher in group A than in group B (32.4% vs. 8.7%, P=0.014). Group A was associated with lower serum albumin level pre-operatively and on post-operative days 1–3. ΔALB_min was higher in group A than in group B (33.08%±9.88% vs. 27.92%±8.52%, P<0.05). In the subgroup analysis, the CRPs group presented similar results, with group A₂ showing higher PONV rate, lower albumin level pre- and post-operatively, and higher level of reduction proportion (P<0.05). For the ERPs group, the PONV rate, pre-operative albumin level, and reduction proportion were similar between group A₁ and B₁ (P>0.05). Multivariable analysis showed that PONV and CRPs were independently associated with ΔALB_min ≥34% (P<0.05).

Conclusions

BMI had no impact on the 30-day overall complication rate, operative time, and length of stay of patients who underwent laparoscopic radical cystectomy with intracorporeal urinary diversion. BMI <24 kg/m² was associated with higher PONV rate and more albumin loss, both of which could be optimized by ERPs.

Effect of electroacupuncture on postoperative cognitive dysfunction for patients undergoing total knee arthroplasty: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Electroacupuncture is increasingly used in rehabilitation for postoperative cognitive dysfunction (POCD), but relevant evidence remains unclear for patients receiving total knee arthroplasty (TKA).

METHODS

The databases research of PubMed, EMBASE, CINAHL, and China National Knowledge Infrastructure (CNKI) will be conducted from inception to December 31, 2020. The relevant randomized controlled trials (RCTs) from data will be screened one by one. The remaining studies that meet the inclusion criteria will be extracted and analyzed using RevMan V.5.3 software. Paired 2 reviewers will assess quality of the included studies and publication bias by using the Cochrane Collaboration risk of bias tool, and Egger test and Begg test respectively. And grading of recommendations assessment, development and evaluation (GRADE) will be used to estimate the quality of evidence.

RESULTS

In this study, we will analyze the effect of electroacupuncture on Mini-Mental State Examination (MMSE), interleukin 1β (IL-1β), tumor necrosis factor-α (TNF-α), S100-β protein, and adverse events for patients with TKA.

CONCLUSION

Our findings will provide evidence for the effectiveness of electroacupuncture on the treatment and prevention of POCD for TKA patients.

REGISTRATION NUMBER

Available at: https://osf.io/azyt9 (DOI number: 10.17605/OSF.IO/AZYT9).