Nausea and vomiting after surgery under general anesthesia: an evidence-based review concerning risk assessment, prevention, and treatment

The Efficacy of Aprepitant in Preventing Post-bariatric Surgery Nausea and Vomiting: Evidence from Clinical Trials

INTRODUCTION

This study aims to evaluate the effectiveness of aprepitant in preventing postoperative nausea and vomiting (PONV) following metabolic bariatric surgery (MBS).

METHODS

Clinical trials meeting the inclusion criteria were identified through searches of PubMed, Embase, and the Cochrane Library databases, as well as clinical trials registered at clinicaltrials. gov. These trials compared aprepitant with the control or placebo groups among patients who underwent MBS. Meta-analysis was performed using StataSE 17.0 software to calculate the pooled risk ratio (RR) and its 95% confidence interval (CI) to assess the effectiveness of aprepitant in preventing PONV following MBS.

RESULTS

A total of five articles comprising six studies including 929 patients undergoing MBS were included. Meta-analysis revealed a significant reduction in the incidence of PONV among patients receiving aprepitant (pooled RR = 0.51, 95% CI: 0.38-0.68, P < 0.05). Subgroup analysis indicated that aprepitant effectively reduced PONV incidence at 0, 6, and 12 h postoperatively in patients with MBS, but did not decrease PONV occurrence at 24 and 48 h postoperatively.

CONCLUSION

Aprepitant demonstrated significant clinical efficacy in preventing PONV following MBS, effectively reducing patient discomfort, and improving postoperative recovery. Therefore, aprepitant should be considered a preventive measure in patients undergoing MBS to enhance patient satisfaction and recovery rates. Additionally, to maintain an effective drug concentration, aprepitant should be administered within the first 24 h postoperatively.

PROSPERO REGISTRATION

CRD 42024528154.

Suggested Electroacupuncture for Postoperative Nausea and Vomiting: A Comprehensive Meta-Analysis and Systematic Review of Randomized Controlled Trials

BACKGROUND The purpose of this meta-analysis was to evaluate the effectiveness of electroacupuncture in preventing and treating postoperative nausea and vomiting (PONV) after general anesthesia. MATERIAL AND METHODS We searched for papers on randomized controlled trials on electroacupuncture for PONV prevention after general anesthesia published in PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) since October 1, 2016. Primary outcome was incidence of PONV; secondary outcomes were incidence of postoperative nausea (PON) at 6 h, postoperative vomiting (POV) at 6 h, and postoperative antiemetic requirement. Data were combined and analyzed using RevMan 5.4.1 software. RESULTS Eight randomized controlled trials, with 899 total participants, were included. Findings showed (1) there was no significant difference in occurrence rate of PONV between electroacupuncture and control groups (OR=0.31, 95% CI [0.06, 1.49], P=0.14, I²=82%); (2) electroacupuncture reduced incidence of PON at 6 h postoperatively, compared with controls (OR=0.43, 95% CI [0.27, 0.67], P=0.0002, I²=0%); (3) compared with control group, electroacupuncture reduced POV incidence 0-6 h postoperatively (OR=0.38, 95% CI [0.23, 0.63], P=0.0001, I²=0%); (4) electroacupuncture group demonstrated a significant reduction in postoperative requirement for antiemetic medications (OR=0.44, 95% CI [0.25, 0.78], P=0.005, I²=61%); (5) one study reported adverse reactions during observation, with 3 patients experiencing pain and itching at acupuncture site and 2 patients refusing a second acupuncture treatment; all symptoms lasted less than 2 h. CONCLUSIONS Based on current evidence, electroacupuncture significantly reduces the occurrence rate of PON and POV at 6 h after surgery and the use of antiemetic medication postoperatively. However, more high-quality, large-sample randomized controlled trials are needed to further validate its efficacy.

Effect of Acupoint Therapies on Postoperative Sleep Quality: A Narrative Review

Several studies have reported that sleep quality often decreases in patients after surgery, especially in elderly patients, which seriously affects postoperative prognosis and outcomes, inducing diseases such as postoperative delirium, long-term chronic pain, and potentially fatal cardiovascular events. With the popularization of comfortable medicine, medical workers pay more attention to the postoperative sleep quality of patients. The causes underlying the decrease in postoperative sleep quality may include postoperative pain, the severity of surgical trauma and stress, perioperative anxiety and depression, and postoperative complications. Patients with insomnia often use acupoint therapies as a safe and effective alternative to drugs. Acupoint therapies are among the oldest medical therapies of Traditional Chinese Medicine and are gradually gaining recognition among medical workers worldwide. Various types of acupoint stimulation methods such as transcutaneous electrical acupoint simulation (TEAS), acupressure, acupuncture, and electroacupuncture can change the brain's local electrical activity, inhibit the central nervous system, and achieve deep sedation through stimulating the related acupoints, which provides a novel idea and basis for improvement in factors affecting postoperative sleep quality. This review explores the mechanism of acupoint therapies from several aspects of affecting the sleep quality of patients after surgery and its clinical results. We found that acupoint therapies effectively improve sleep quality and alleviate the postoperative complications of patients, and we emphasize the importance of acupoint therapies to guide future research and clinical practice. Large-scale, multicenter studies are needed to determine the optimal duration, frequency, and timing of acupoint stimulation for improving postoperative sleep quality.

A longitudinal assessment of appetite loss and nutritional care among postoperative patients in Vietnam

Background

Post-operative appetite loss is an important complication affecting surgical outcomes. It has been estimated that nearly 60% of patients having gastrointestinal or major elective surgeries suffer from malnutrition. Appetite refers to the physical desire for food appetite, and losing appetite after surgery may result in a decrease in body weight, impairment of intestinal absorption and eventually, malnutrition among postoperative patients. This study aims to assess appetite status and other relevant factors among abdominal postoperative patients in Vietnam.

Methods

A cross-sectional study was conducted on 169 abdominal postoperative patients from June 1st to August 30th, 2016 at Hanoi Medical University Hospital, Hanoi, Vietnam. Appetite score was computed by using the Council on Nutrition Appetite Questionnaire (CNAQ). This study used GEE to account for the potential correlation of outcomes of the longitudinal assessment, assuming an independent correlation structure.

Results

The primary and secondary outcome measures: highest average appetite score was recorded in the preoperative day and the score declined throughout seven-day duration. Patients who were female, under general anesthetics and being under open surgery tended to get lower appetite scores. The majority of patients had moderate to good appetite in both the preoperative day and seven days post-operation.

Conclusion

Women should receive more care and help in regaining their appetite after surgery. Treatment for appetite loss through non-pharmaceutical measures should be prioritized. Interventions that increase the appetite of patients after abdominal surgery should be targeted on patients being under general anesthetic as well as open surgery and be undertaken with caution.

The effects of anesthesia methods and anesthetics on postoperative delirium in the elderly patients: A systematic review and network meta-analysis

Study objective

Postoperative delirium (POD) is one of the serious postoperative complications in elderly patients, which is always related to long-term mortality. Anesthesia is often considered a risk factor for POD. This systematic review and network meta-analysis (NMA) aimed to assess the impact of different anesthesia methods and anesthetics on POD.

Measurements

We searched for studies published in PubMed, Embase, Web of Science, Scopus, and Cochrane Library (CENTRAL) from inception to 18 March 2022. RevMan 5.3 and CINeMA 2.0.0 were used to assess the risk of bias and confidence. Data analysis using STATA 17.0 and R 4.1.2. STATA 17.0 was used to calculate the surface under the cumulative ranking curve (SUCRA) and provide network plots with CINeMA 2.0.0. NMA was performed with R 4.1.2 software gemtc packages in RStudio.

Main results

This NMA included 19 RCTs with 5,406 patients. In the pairwise meta-analysis results, only regional anesthesia (RA) with general anesthesia (GA) vs. GA (Log OR: –1.08; 95% CI: –1.54, –0.63) were statistically different in POD incidence. In the NMA results, there was no statistical difference between anesthesia methods, and psoas compartment block (PCB) with bupivacaine was superior to the desflurane, propofol, sevoflurane, and spinal anesthesia with bupivacaine of POD occurrence.

Conclusion

Our study indicated that RA and GA had no significant effect on POD, and there was no difference between anesthesia methods. Pairwise meta-analysis showed that, except for RA with GA vs. GA, the rest of the results were not statistically different. Besides, PCB with bupivacaine may benefit to reduce POD incidence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/dis play_record.php?ID=CRD42022319499, identifier PROSPERO 2022 CRD42022319499.

A Randomised Controlled Trial to Compare the Effect of Ramosetron and Ondansetron in Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Gynaecological Procedures

Background and objective

The antiemetic drug is one of the most common armamentariums in an anaesthesiologist's pharmacopoeia to prevent postoperative nausea and vomiting (PONV). PONV is one of the usual side effects after general anaesthesia, especially in female patients (21%) and after laparoscopic surgery (60%). This study aimed to compare the efficacy of ondansetron with ramosetron.

Methodology

After institutional ethical clearance and informed written consent, one hundred female patients scheduled for laparoscopic gynaecological surgeries were selected for this prospective, double-blinded, randomised interventional study. These patients were further subdivided into two equal groups (50 in groups R and O). Group R received ramosteron 0.3mg, and group O received ondansetron 8mg 30 minutes before the end of surgery. Patients were assessed between 0-2, 2-6, 6-12 and 12-24 hrs in the postoperative period. The primary objective of this study was to compare the effect of a single dose of ramosetron (0.3mg) with a single dose of ondansetron (8mg) for the prevention of PONV after general anaesthesia in laparoscopic surgeries. The secondary goal was to record the time of occurrence of the first episode of PONV, the need for rescue antiemetics, patient satisfaction scores, and to look for any side effects.

Results

This study shows no significant difference in the reduction of PONV incidence between group O and group R in the first 24 hours of the postoperative period. The overall incidence of PONV was significantly higher in the early postoperative (0-6 hrs) than in the late postoperative period (6-24 hrs), i.e., 51% and 13%, respectively. The requirement of rescue antiemetic was higher in group O than in group R but not statistically significant. In our study, both groups had similar patient satisfaction scores. Headache was the most common side effect and was noted in 9% of the patient population.

Conclusion

We conclude that ramosetron is as effective as ondansetron in preventing the incidence and severity of PONV up to 24 hours postoperatively.

Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients – A Post hoc Analysis of a Randomized Controlled Trial

Postoperative nausea and vomiting (PONV) are one of the most adverse events after general anesthesia, a distressing experience, and pose a risk to the patient. Despite advances in drug prophylaxis and PONV treatment, the incidence remains high and additional non-pharmacological treatments are needed. In this post hoc analysis of a recently published double-blind multicenter randomized controlled trial on the efficacy of intraoperative therapeutic suggestions on postoperative opioid dosage, we analyzed the effects of intraoperative therapeutic suggestions on PONV. We focus on patients with a high risk of PONV (Apfel risk score of 3–4) and distinguished early (first two postoperative hours) and delayed PONV (2–24 h). A total of 385 patients with a moderate or high risk for PONV were included. The incidence of early and delayed PONV was reduced (22.7–18.3 and 29.9–24.1%, respectively), without statistical significance, whereas in high-risk patients (n = 180) their incidence was nearly halved, 17.2 vs. 31.2% (p = 0.030) and 20.7 vs. 34.4% (p = 0.040), corresponding to a number needed to treat of 7 to avoid PONV. In addition, there was a significant reduction in PONV severity. In a multivariate logistic regression model, assignment to the control group (OR 2.2; 95% CI: 1.1–4.8) was identified as an independent predictor of the occurrence of early PONV. Our results indicate that intraoperative therapeutic suggestions can significantly reduce the incidence of PONV in high-risk patients. This encourages the expansion of therapeutic suggestions under general anesthesia, which are inexpensive and virtually free of side effects.

Clinical Trial Registration: German Clinical Trials Register, https://drks.de, registration number: DRKS00013800.

Study protocol for a randomised, patient- and observer-blinded evaluation of P6 acustimulation for the prevention of nausea and vomiting in the postoperative period in patients receiving routine pharmacological prophylaxis (P6NV-Trial)

BACKGROUND

The efficacy of pericardium 6 (P6) acupoint stimulation to reduce the incidence of postoperative nausea and vomiting (PONV) has been proven in several randomised controlled clinical trials. However, little is known about the effectiveness in daily practice and its use in combination with traditional pharmacologic approaches.

METHODS

The primary objective of the P6NV study is to determine whether intraoperative acustimulation (acupuncture or acupressure) at the point P6 provides additional benefit when applied along with customary prophylactic intravenous antiemetics administered according to the local standard operating procedures (SOP). The primary endpoint is the incidence and severity of PONV within the first 24 h postoperatively reported with a validated postoperative nausea and vomiting intensity scale. The patient-reported outcome of perioperative quality of life (using the PPP33-questionnaire) and the detection of antiemetic-related side effects as well as the severity of PONV (via a standardised questionnaire) are secondary study objectives. P6NV is a national, multicentre, randomised, prospective, patient- and examiner-blinded interventional study and will be performed on 3500 adult patients with ASA classification I-III undergoing elective surgery under general anaesthesia and hospitalised for at least 24 h. Participating anaesthesiologists commit themselves to administer customised conventional antiemetic prophylaxis according to the local SOP by signing a statement before randomisation. The intervention group receives bilateral acupuncture or acupressure at P6. The control group receives no intervention. Before extubation, acustimulation is removed.

DISCUSSION

Since P6 acustimulation is performed by a wide range of anaesthesiologists receiving written and verbal information on acustimulation beforehand, this trial will provide information on the effectiveness of an ad hoc implementation of P6 stimulation techniques in anaesthesia departments using traditional pharmacologic PONV prophylaxis.

TRIAL REGISTRATION

DRKS DRKS00015272 . Registered on August 15, 2018.

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

Background

Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups.

Methods

A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed.

Results

One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction.

Conclusions

Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up.

Trial registration

Clinical Trial NCT02886221. Registered 1 September 2016.

[Implementation of fast-track measures in colorectal resections : A survey among members of the DGAI]

PURPOSE

The fast-track (FT) concept is a multimodal, interdisciplinary approach to perioperative patient care intended to reduce postoperative complications. Despite good evidence implementation seems to need improvement, whereby almost all studies focused on the implementation of surgical modules regardless of the interdisciplinary aspect. Adherence to the anesthesiological measures (prehabilitation, premedication, volume and temperature management, pain therapy), on the other hand, has been insufficiently studied. To assess the status quo a survey on the implementation of anesthesiological FT measures was conducted among members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) to analyze where potential for improvement exists.

METHODS

Using the SurveyMonkey® online survey tool, 28 questions regarding perioperative anesthesiological care of colorectal surgery patients were sent to DGAI members in order to analyze adherence to FT measures.

RESULTS

While some of the FT measures (temperature management, PONV prophylaxis) are already routinely used, there is a divergence between current recommendations and clinical implementation for other components. In addition to premedication, interdisciplinary measures (prehabilitation) and measures that affect multiple interfaces (operating theatre, recovery room, ward), such as volume management or perioperative pain management, are particularly affected.

CONCLUSION

The anesthesiological recommendations of the FT concept are only partially implemented in Germany. This particularly affects the interdisciplinary components as well as measures at the operating theatre, recovery room and ward interfaces. The establishment of an interdisciplinary FT team and interdisciplinary development of SOPs can optimize adherence, which in turn improves the short-term and long-term outcome of patients.

Risk factors for chemotherapy-induced vomiting after general anesthesia in children with retinoblastoma: a retrospective study

BACKGROUND

The chemotherapy-induced vomiting (CIV) severely affects the daily function, nutritional status, treatment compliance, therapeutic efficacy, curability, and the quality of life of patients. The aim of this study was to find the risk factors for CIV after general anesthesia in patients with retinoblastoma (RB).

METHODS

A retrospective review of the hospital records of children with RB, who underwent chemotherapy between January 2017 and December 2019, was conducted at our hospital.

RESULTS

Data of a total of 803 children with RB were reviewed. The incidence of CIV in children with RB was 19.30%. Univariate analysis showed statistically significant differences in age, height, weight, chemotherapy regimen, anesthesia dose, duration of surgery and general anesthesia, platelet count, platelet distribution width, lymphocytes, and indirect bilirubin between patients with and without vomiting (P<0.05). Multivariate logistic regression analysis showed that the main predictors of CIV in children with RB included older age [odds ratio (OR), 1.32; 95% confidence interval (CI): 1.11-1.56; P<0.01], low platelet count (OR, 0.997; 95% CI: 0.995-0.999; P<0.05), and chemotherapy regimen (intravenous chemotherapy versus intra-arterial chemotherapy; OR, 0.47; 95% CI: 0.29-0.76; P<0.01).

CONCLUSIONS

This study revealed age, chemotherapy regimen, and platelet count as risk factors of CIV after general anesthesia in children with RB. Younger age and higher platelet count were protective factors for CIV. Compared with intravenous chemotherapy, the incidence of CIV was lower than that of intra-arterial chemotherapy. Although these factors cannot be modified, they can predict whether a patient may experience vomiting, assisting medical staff to formulate measures and intervenes in advance.

KEYWORDS

Retinoblastoma (RB); chemotherapy-induced vomiting (CIV); general anesthesia; multivariate analysis; risk factors.

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Total Hip Arthroplasty

Objective

To investigate the effects of dexmedetomidine on postoperative delirium in elderly patients undergoing total hip arthroplasty.

Methods

A total of 100 patients, 42 male and 58 female, ages 60 to 85 years, American Society of Anesthesiologists grade I or II, who were undergoing total hip arthroplasty were randomly divided into 2 groups: a dexmedetomidine group (group D; n = 50) and a control group (group C; n = 50). Group D patients were infused with 0.3 μg · kg−1 · h−1 of dexmedetomidine from 5 minutes prior to anesthesia induction until the end of surgery. Group C patients received an equal volume of saline. Heart rate and mean arterial pressure (MAP) were recorded before anesthesia induction (T0), 1 minute before extubation (T1), and 30 minutes after extubation (T2). The Visual Analog Score (VAS) at 1, 2, and 3 days after surgery, the incidence and duration of postoperative delirium, and the length of hospital stay were recorded. Adverse reactions, such as nausea, vomiting, and lethargy, were also recorded.

Results

The Visual Analog Scores in the 2 groups were similar. In group D, there was no significant difference in heart rate (P = 0.232) and MAP (P = 0.056) between T0 and T1. However, in group C, heart rate significantly increased by 15.3 bpm (P = 0.000) and MAP significantly increased by 10.7 mmHg (P = 0.001) at T1 compared with those at T0. The incidence of postoperative delirium in group D (10%) was significantly lower than that in group C (26%; P = 0.037). The duration of delirium in group D (1.3 ± 0.6 days) was shorter than that in group C (3.0 ± 0.5 days; P = 0.000). The length of hospital stay in group D (13.2 ± 0.9 days) was shorter than that in group C (16.1 ± 0.7 days; P = 0.000). No significant differences were observed in adverse effects between the 2 groups.

Conclusion

Intravenous infusion of dexmedetomidine can not only reduce the incidence and duration of postoperative delirium, but also shorten the length of hospital stay in elderly patients undergoing total hip arthroplasty.

Safety and efficacy of single-dose preoperative intravenous dexamethasone on post-operative nausea and vomiting following breast surgery at Korle-Bu Teaching Hospital

Objectives

Dexamethasone has beneficial effects on postoperative nausea and vomiting, however, many clinicians have raised legitimate concerns regarding its effect on blood glucose concentrations. This study determined the safety and efficacy of a single pre-operative dose of dexamethasone for PONV prophylaxis in patients undergoing breast surgery.

Design

Prospective, double-blind, placebo-controlled trial.

Setting

Surgical wards of the Korle-Bu Teaching Hospital, Accra, Ghana.

Participants

The study was conducted among breast surgery patients. They were consecutively recruited and randomized into two groups: dexamethasone (n = 47) and placebo (n = 47).

Interventions

Patients in the dexamethasone group received 8mg (2mls of 4mg/ml) dexamethasone while those in the placebo group received 2mls of saline intravenously. PONV impact scores and blood glucose levels were recorded at 4, 8 and 24 hours postoperatively.

Main outcome measures

Incidence of PONV and blood glucose levels.

Results

The incidence of postoperative nausea (PON) was lower in the dexamethasone group compared with the placebo group (12.8% vs. 29.8%; p-value= 0.044). There was no significant difference in the incidence of postoperative vomiting (POV) and PONV between the two groups. Blood glucose levels were higher in the dexamethasone group throughout the study period and significant at 8 and 24 hours postoperatively (p < 0.05). There was no difference in the incidence of clinically significant hyperglycemia between the groups (p-value = 0.169).

Conclusion

A preoperative intravenous dexamethasone 8mg, reduces PON but not POV or PONV in breast surgery without clinically significant postoperative hyperglycemia.

Funding

Non declared.

Effect of combinations of dexamethasone-ondansetron and dexamethasone-ondansetron-aprepitant versus aprepitant alone for early postoperative nausea and vomiting after day care gynaecological laparoscopy: A randomised clinical trial

Background and Aims:

This study was designed to compare the effectiveness of the combination of dexamethasone–ondansetron with oral aprepitant alone and triple combination therapy with all three agents (dexamethasone-ondansetron and oral aprepitant) in the prevention of postoperative nausea and vomiting (PONV) in day care gynaecologic laparoscopy.

Methods:

This was a randomised clinical trial conducted at a university teaching hospital. A total of 105 female patients were randomised into the aprepitant (A), dexamethasone-ondansetron (DO) and aprepitant-dexamethasone-ondansetron (ADO) groups. The patients in the A group received only 80 mg oral aprepitant 1 h before surgery. The patients in the DO group, received dexamethasone 8 mg at induction with ondansetron 4 mg before extubation. Patients in the ADO group received 80 mg oral aprepitant 1 h before surgery, dexamethasone 8 mg at induction and ondansetron 4 mg before extubation. Incidence of nausea and vomiting was compared between groups using the Chi-square test/Fisher's test. Bellville score for severity of PONV was analysed using the Kruskall-Wallis test. P value < 0.05 was regarded as significant.

Results:

The incidence of PONV did not show a statistically significant difference between the three groups, with a P value of 0.13 (12.5%, 30.3% and 32.3% in groups ADO, DO and A, respectively). The severity of PONV measured using Bellville score was also not significantly different among the groups [median values (IQR) of 0 (0-0), 0 (0-1), and 0 (0-1)].

Conclusion:

The combination of aprepitant, dexamethasone and ondansetron failed to demonstrate a statistically significant superiority over the other two antiemetic regimens.

[Complications and emergencies in the recovery room]

The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.

Postoperative Nausea and Vomiting in Pediatric Patients

Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.

Intraoperative systemic vascular resistance is associated with postoperative nausea and vomiting after laparoscopic hysterectomy

BACKGROUND

The incidence of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic hysterectomy is very high compared with other surgeries, even when many prophylactic measures have been taken. However, the pathogenesis of PONV is multifactorial. Female sex, a history of motion sickness or PONV, nonsmokers, and perioperative opioid use are the most closely related factors. Among the multiple risk factors, suboptimal gastrointestinal (GI) perfusion may be attributed to some cases of PONV, and increased systemic vascular resistance (SVR) may lead to GI ischemia. The hypothesis of this research was that SVR is related to PONV.

AIM

To investigate the relationship between SVR and PONV in patients undergoing laparoscopic hysterectomy.

METHODS

A total of 228 patients who underwent elective laparoscopic hysterectomy were included in this prospective observational study. SVR was monitored using a noninvasive hemodynamic monitoring system. Four indices of SVR, the baseline, mean, area under the curve (AUC), and weighted AUC, were used for analysis. The incidence and severity of nausea and vomiting were evaluated while patients were awake and throughout the intervals from 0 to 2 h, 2 to 6 h, and 6 to 24 h starting upon arrival at the post-anesthesia care unit. The associations between various SVR indices and PONV were investigated by logistic regression. P < 0.05 was considered statistically significant.

RESULTS

The incidence of PONV in the study was 56.14% (128/228), and PONV tended to appear within 6 h after surgery. Five variables were significant in univariate analyses, however, only SVR mean [odds ratio (OR) = 1.015, 95%CI: 1.005-1.109, P = 0.047] and duration of surgery (OR = 1.316, 95%CI: 1.003-2.030, P = 0.012) were associated with PONV after logistic regression analysis. Furthermore, patients with high SVR mean were more likely to suffer from PONV after laparoscopic hysterectomy. On average, patients who developed PONV needed more time to tolerate diet and demonstrated poorer sleep quality on the first night after surgery.

CONCLUSION

In this study, PONV was a common complication after laparoscopic hysterectomy. SVR was associated with PONV, and high SVR mean was associated with a significantly increased risk of PONV.

[Perioperative dexamethasone]

Dexamethasone is a synthetic steroid that has been used for many years in the clinical routine due to its anti-inflammatory, anti-allergic and immunosuppressive properties. Furthermore, dexamethasone has been used for a long time for prophylaxis and treatment of chemotherapy-induced nausea and vomiting. In the meantime dexamethasone has been approved as standard for the prophylaxis and treatment of postoperative nausea and vomiting (PONV). This review article outlines the indications and side effects of the perioperative administration of dexamethasone.

[Iatrogenic anisocoria after using a scopolamine patch for PONV prophylaxis]

This is a case report of a 29-year-old female patient who developed unilateral mydriasis following the use of a scopolamine patch for the prevention of postoperative nausea and vomiting (PONV).Given a medical history showing multiple risk factors for PONV, a preauricular scopolamine patch was applied prior to the induction of anesthesia. General anesthesia was induced with 150 mg propofol and 25 μg sufentanil and maintained with total intravenous anesthesia, using propofol (5 mg/kg per h) and remifentanil (2-3 μg/kg per h).Following an uneventful surgery of 90min duration, the patient was extubated and transferred to the recovery room, where the patch was removed. During the orthopedic ward round the following day, the clinical examination revealed anisocoria of the left eye in the form of unilateral mydriasis. In order to determine the cause of this clinical presentation, further neurological and ophthalmological examinations and investigations were carried out. In addition, magnetic resonance imaging was conducted to rule out a central nervous cause. The results of the investigations were negative and no pathology was identified. In addition, the symptoms resolved within 24 h of onset without any therapeutic intervention. Therefore, a suspected diagnosis of a pharmacologically induced anisocoria from the scopolamine patch was made, whereby the substance accidentally reached the affected left eye.Previous studies showed that scopolamine patches may reduce early emetic symptoms. Case reports describing the occurrence of anisocoria following the application of scopolamine patches have been previously published. In all of these cases the patches were used to prevent PONV and each case was comprehensively investigated using various diagnostic and clinical tools. It should be noted, however, that a dysfunctional accommodation is listed as a common side effect of the drug, affecting more than 1 in 10 patients.Even though the efficacy of scopolamine patches for the prevention of PONV is proven, clinicians should be aware of the common ophthalmological side effect. Particularly with respect to various surgical disciplines, where anisocoria may indicate an underlying surgery-related complication, the application of scopolamine patches should be well- considered.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Long-term stability of an infusion containing paracetamol, alizapride, ketorolac and tramadol in glass bottles at 5±3°C

Background and objective

Infusion containing paracetamol, alizapride, ketorolac and tramadol is used after a general anaesthesia in order to limit pain, fever and nausea. Currently, these infusions are prepared according to demand in the anaesthesia unit, but the preparation in advance could improve quality of preparation and time management. The aim of this study was to investigate the long-term stability of this infusion in glass bottles at 5°C ± 3 °C.

Method

Five bottles of infusion were stored at 5°C ± 3 °C for 60 days. A visual and microscope inspection were performed periodically to observe any particle appearance or colour change. pH and absorbance at three wavelengths were measured. The concentrations were measured by ultra-high performance liquid chromatography - diode array detection.

Results

Multiple verifications were performed during the first 35 days and no crystal, impurity or colour change were observed. At the next time point (42nd day), crystals were visible to the naked eye. pH and absorbance at 350 nm and 550 nm were stable. A slight increase in the absorbance at 410 nm was observed during the study, suggesting that a degradation product could be formed and absorb at this wavelength. The infusion was considered chemically stable while the lower one-sided prediction limit at 95% remains superior to 90% of the initial concentration. Concentration measurements demonstrated that ketorolac and alizapride remained stable in the infusion for 35 days. The stability of tramadol was 28 days. However, degradation of paracetamol was much faster given that concentration has fallen below 90% of the initial concentration after 7 days.

Conclusion

Infusion of paracetamol, alizapride, ketorolac and tramadol remains stable for 7 days in glass bottles at 5°C ± 3 °C and could be prepared in advance with these storage conditions.

Transversus Abdominis Plane Block versus Wound Infiltration with Conventional Local Anesthetics in Adult Patients Underwent Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

How to effectively control the postoperative pain of patients is extremely important to clinicians. Transversus abdominis plane (TAP) block is a novel analgesic method reported to greatly decrease postoperative pain. However, in many areas, there still exists a phenomenon of surgeons using wound infiltration (WI) with conventional local anesthetics (not liposome anesthetics) as the main means to decrease postoperative pain because of traditional wisdom or convenience. Here, we compared the analgesic effectiveness of the two different methods to determine which method is more suitable for adult patients. Materials and methods. A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing TAP block and WI without liposome anesthetics in adult patients were performed. Frequently used databases were extensively searched. The main outcomes were postoperative pain scores in different situations (at rest or during movement) and the time until the first use of rescue analgesics. The secondary outcomes were postoperative nausea and vomiting (PONV) incidence and patient satisfaction scores.

Results

Fifteen studies with 983 participants met the inclusion criteria and were included in the present study. The heterogeneity in the final analysis regarding the pain score was low to moderate. The major results of the sensitivity analysis were stable. WI had the same analgesic effect as TAP block only at the one-hour postoperative time point (mean difference = -0.32, 95% confidence interval (-0.87, 0.24), P = 0.26) and was associated with a shorter time until the first rescue analgesic and poorer patient satisfaction.

Conclusion

TAP block results in a more effective and steady analgesic effect than WI with conventional local anesthetics in adult patients from the early postoperative period and obtains higher patient satisfaction.

Dose Ginger Have Preventative Effects on PONV-Related Eye Surgery? A Clinical Trial

Background

Postoperative nausea and vomiting (PONV) is considered a common complication of anesthesia, which, particularly in eye surgery, may exert pressure on stitches and open or leak the surgical wound, leading to bleeding.

Objectives

We aimed to study the effect of ginger on PONV and changes in vital signs after eye surgery.

Methods

In this triple-blind randomized controlled trial, 120 candidate patients for eye surgery were divided into group A (n = 40) and group B (n = 40). Patients in group A received the capsules of ginger 1 g while patients in group B received a placebo one hour before the procedure with 30 mL water. The incidence of nausea and the frequency of vomiting were evaluated at 0, 15, 30 minutes, and 2 hours after the operation. Also, the vital signs of the participants were recorded at certain times.

Results

The results demonstrated a statistically significant difference in the frequency of nausea between group A and group B (P < 0.05). The severity of nausea was lower in group A than in group B immediately and 2 hours after recovery (P < 0.05). The incidence of vomiting was significantly lower in group A than in group B (P < 0.05). The vital signs were not significantly different between group A and group B (P > 0.05).

Conclusions

Ginger was effective in the prevention of PONV after eye surgery but had no impact on vital signs. Hence, ginger is proposed to use as a low-cost, prophylactic measure for PONV reduction.

Anaesthesia-related complications and side-effects in TAVI: a retrospective study in Germany

OBJECTIVES

This study was performed to analyse anaesthesia-related complications and side effects in patients undergoing transcatheter aortic valve implantation (TAVI) under general anaesthesia.

DESIGN

Retrospective study.

SETTING

The study was performed as a single-centre study in a hospital of tertiary care in Germany.

PARTICIPANTS

All 853 patients, who underwent TAVI at the Universitätsklinikum Regensburg between January 2009 and July 2015, were included. 52.5% were female patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

We gathered information, such as recent illness, vital parameters and medication administered during the intervention and postoperatively for 12 hours. We analysed all anaesthesia-related complications and anaesthesia-related side effects that occurred during the intervention and entire hospital stay.

RESULTS

We analysed all 853 TAVI procedures. The mean patient age was 79 ± 6 years. In 99.5% of cases, we used volatile-based anaesthesia. 2.8% (n=24; transfemoral (TF): n=19 [3.8%]; transapical (TA): n=5 [1.4%]) of all cases suffered from anaesthesia-related complications. 819 (TF: n=447; TA: n=372) anaesthesia-related side effects occurred in 586 (68.7%, TF: n=325 [64.2%], TA: n=261 [75.2%]) patients. Neither the complications nor the side effects had any serious consequences. Intraoperative hypothermia in 44% of cases (TF: n=202 [39.9%]; TA: n=173 [49.9%]) and postoperative nausea and vomiting in 27% (n=232; TF: n=131 [25.9%], TA: n=101 [29.1%]) of cases were the most common anaesthesia-related side effects.

CONCLUSION

In this study, serious anaesthesia-related complications were rarely seen, and non-critical anaesthesia-related side effects could have been avoided through consistent prophylaxis and management. Therefore, despite their high anaesthetic risk, general anaesthesia is justifiable in patients who underwent TAVI.

Investigation of Ondansetron, Haloperidol, and Dexmedetomidine Efficacy for Prevention of Postoperative Nausea and Vomiting In Patients with Abdominal Hysterectomy

AIM

This study was aimed to compare the effects of ondansetron, haloperidol, and dexmedetomidine for reducing postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy.

METHODS

This randomised clinical trial study was performed on p.patients who were candidates for abdominal hysterectomy referring to Taleghani hospital in Arak. In this study, 114 patients with abdominal hysterectomy were randomly assigned to three groups (ondansetron, haloperidol, and dexmedetomidine) using the cubull randomisation method.

RESULTS

The results revealed a significant difference between the three groups of ondansetron, haloperidol and dexmedetomidine in terms of scorpion vomiting in recovery, 2 and 4 hours after surgery, and vomiting score was significantly lower in the ondansetron group compared with the other two groups (P = 0.04; P = 0.02; P = 0.001). There was a significant difference between the three groups of e ondansetron, haloperidol and dexmedetomidine regarding the mean dose of metoclopramide in mg for 24 hours after surgery. Therefore, the dosage of dexmedetomidine in the ondansetron group was less than the other two groups (P = 0.001).

CONCLUSION

these three drugs are effective in reducing PONV in patients undergoing a hysterectomy. However, the effect of ondansetron was found to be more than the other two drugs in reducing PONV.

Use of Direct Oral Anticoagulants in Patients with Cancer: Practical Considerations for the Management of Patients with Nausea or Vomiting

Direct oral anticoagulants (DOACs) have proven efficacy and safety and are approved for use in the prevention and treatment of thromboembolic events in patients with venous thromboembolism (VTE) and those with atrial fibrillation (AF). There is no clear guidance on the use of DOACs in the significant proportion of these patients who have or will develop concomitant cancer. The occurrence of nausea and vomiting in these patients, despite implementation of guideline-recommended antiemetic strategies, is a particular concern because it may affect oral drug intake and consequently outcomes with anticoagulation therapy.Here, we review recent data on the incidence and management of cancer-associated nausea and vomiting and the current evidence and guidance relating to the use of DOACs in patients with cancer. On the basis of this evidence, an international working group of experts in the fields of cancer-associated thrombosis/hemostasis, hematology, and oncology discussed key issues related to the use of DOACs in patients with VTE or AF and cancer who are at risk of nausea and vomiting and developed some consensus recommendations. We present these consensus recommendations, which outline strategies for the use and management of anticoagulants, including DOACs, in patients with VTE or AF and cancer for whom oral drug intake may pose challenges. Guidance is provided on managing patients with gastrointestinal obstruction or nausea and vomiting that is caused by cancer treatments or other cancer-related factors.The recommendations outlined in this review provide a useful reference for health care professionals and will help to improve the management of anticoagulation in patients with VTE or AF and cancer.

IMPLICATIONS FOR PRACTICE

Direct oral anticoagulants (DOACs) offer several advantages over traditional anticoagulants, including ease of administration and the lack of need for routine monitoring. However, the management of patients with an indication for anticoagulation and concomitant cancer, who are at high risk of thromboembolic events, presents several challenges for administering oral therapies, particularly with regard to the risk of nausea and vomiting. In the absence of robust data from randomized trials and specific guidelines, consensus recommendations were developed for healthcare professionals regarding the use of DOACs in patients with cancer, with a focus on the management of patients who are at risk of nausea and vomiting.

The effect of intraperitoneal chemotherapy on early pain hyperalgesia in patients following elective laparoscopic transabdominal resection of rectal cancer

Background

Chemotherapy has been associated with hyperalgesia. This prospective study was designed to investigate the effect of intraperitoneal chemotherapy with lobaplatin on post-operative pain intensity and sufentanil requirements after laparoscopic transabdominal resection of rectal cancer.

Methods

Eighty subjects (40 subjects treated with intraperitoneal chemotherapy and 40 subjects without chemotherapy treatment) scheduled for laparoscopic transabdominal resection of rectal cancer were included in this study. All subjects received standardized anesthetic and patient-controlled analgesia using sufentanil for 72 h post-surgery, as the only analgesics. Pain intensity scores, cumulative sufentanil requirements and side effects were recorded until 72 h post-surgery.

Results

Following intraperitoneal chemotherapy, patients had a significantly higher total post-operative sufentanil requirement (193 μg vs. 142 μg; P = 0.008), significantly higher verbal rating scale post-surgery pain intensity scores at rest and with coughing (P < 0.05), and a significantly worse functional activity score (P < 0.05) over 72 h, compared with those without intraperitoneal chemotherapy. There were no post-operative differences in the incidence of side-effects (post-operative nausea [P = 0.189], vomiting [P = 0.311], pruritus [P = 0.263], respiratory depression [P = 1.000], and dizziness [P = 0.712]) between the two groups.

Conclusion

Intraperitoneal chemotherapy is associated with significantly increased post-operative sufentanil requirements and pain intensity, suggesting chemotherapy-associated hyperalgesia.

An update on the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.

Postoperative nausea and vomiting after general anesthesia for oral and maxillofacial surgery

Background

Postoperative nausea and vomiting (PONV) is one of the most common postoperative complications. Despite this, few papers have reported the incidence and independent risk factors associated with PONV in the context of oral and maxillofacial surgery (OMFS). Therefore, we sought to determine the incidence of PONV, as well as to identify risk factors for the condition in patients who had undergone OMFS under general anesthesia.

Methods

A total of 372 patients' charts were reviewed, and the following potential risk factors for PONV were analyzed: age, sex, body mass index, smoking status, history of PONV and/or motion sickness, duration of anesthesia, amount of blood loss, nasogastric tube insertion and retention and postoperative opioid used. Univariate analysis was performed, and variables with a P-value less than 0.1 were entered into a multiple logistic regression analysis, wherein P-values < 0.05 were considered significant.

Results

The overall incidence of PONV was 25.26%. In the multiple logistic regression analysis, the following variables were independent predictors of PONV: age < 30 years, history of PONV and/or motion sickness, and anesthesia duration > 4 h. Furthermore, the number of risk factors was proportional to the incidence of PONV.

Conclusions

The incidence of PONV in patients who have undergone OMFS varies from center to center depending on patient characteristics, as well as on anesthetic and surgical practice. Identifying the independent risk factors for PONV will allow physicians to optimize prophylactic, antiemetic regimens.

Higher occurrence of nausea and vomiting after total hip arthroplasty using general versus spinal anesthesia: an observational study

BACKGROUND

Under the assumption that postoperative nausea and vomiting (PONV) may occur after total hip arthroplasty (THA) regardless of the anesthetic technique used, it is not clear whether general (GA) or spinal (SA) anesthesia has higher causal effect on this occurrence. Conflicting results have been reported.

METHODS

In this observational study, we selected all elective THA interventions performed in adults between 1999 and 2008 in a Swiss orthopedic clinic under general or spinal anesthesia. To assess the effect of anesthesia type on the occurrence of PONV, we used the propensity score and matching methods, which allowed us to emulate the design and results of an RCT.

RESULTS

Among 3922 procedures, 1984 (51 %) patients underwent GA, of which 4.1 % experienced PONV, and 1938 underwent SA, of which 3.5 % experienced PONV. We found that the average treatment effect on the treated, i.e. the effect of anesthesia type for a sample of individuals that actually received spinal anesthesia compared to individuals who received GA, was ATET = 2.00 % [95 % CI, 0.78-3.19 %], which translated into an OR = 1.97 [95 % CI 1.35; 2.87].

CONCLUSION

This suggests that the type of anesthesia is not neutral regarding PONV, general anesthesia being more strongly associated with PONV than spinal anesthesia in orthopedic surgery.

Effect of supplemental oxygen 80 % on post-tonsillectomy nausea and vomiting: a randomized controlled trial

Nausea and vomiting are two of the most common complications of tonsillectomy in children. Administration of supplemental 80 % oxygen during surgery reduces the incidence of postoperative nausea and vomiting. We aimed to test the efficacy of supplemental 80 % oxygen during tonsillectomy on postoperative nausea and vomiting. In a randomized controlled trial in Shahid Mostafa Khomeini Hospital in Tehran, 102 children scheduled for tonsillectomy (± adenoidectomy) under general anesthesia were divided randomly in two groups according to percent of administered oxygen (group 1:30 % oxygen, group 2:80 % oxygen). The incidence of postoperative nausea and vomiting were assessed and compared in 0-2, 2-6 and 6-24 h after surgery. Incidence of post-tonsillectomy nausea and vomiting after 2, 2-6, and 6-24 h was 13.72, 1.96 and 1.96 % for group 1 and 3.92, 0 and 1.96 % in group 2, respectively. We found no statistically significant difference between two groups (P = 0.08) but 80 % oxygen was beneficial for reducing postoperative nausea and vomiting in the first 2 h after surgery in group 2.

Time Savings and Surgery Task Load Reduction in Open Intraperitoneal Onlay Mesh Fixation Procedure

Background. This study assessed the reduction in surgeon stress associated with savings in procedure time for mechanical fixation of an intraperitoneal onlay mesh (IPOM) compared to a traditional suture fixation in open ventral hernia repair. Study Design. Nine general surgeons performed 36 open IPOM fixation procedures in porcine model. Each surgeon conducted two mechanical (using ETHICON SECURESTRAP^TM Open) and two suture fixation procedures. Fixation time was measured using a stopwatch, and related surgeon stress was assessed using the validated SURG-TLX questionnaire. T-tests were used to compare between-group differences, and a two-sided 95% confidence interval for the difference in stress levels was established using nonparametric methodology. Results. The mechanical fixation group demonstrated an 89.1% mean reduction in fixation time, as compared to the suture group (p < 0.00001). Surgeon stress scores measured using SURG-TLX were 55.5% lower in the mechanical compared to the suture fixation group (p < 0.001). Scores in five of the six sources of stress were significantly lower for mechanical fixation. Conclusions. Mechanical fixation with ETHICON SECURESTRAP^TM Open demonstrated a significant reduction in fixation time and surgeon stress, which may translate into improved operating efficiency, improved performance, improved surgeon quality of life, and reduced overall costs of the procedure.

Anesthesia for ORL surgery in children

ORL procedures are the most common operations in children – an optimal anesthetic management provides an uncomplicated, safe perioperative process with as little discomfort for the child as possible. Children at risk must already be identified preoperatively: the combination of ORL surgery, airway susceptibility and age below 3 years can increase the risk of perioperative respiratory adverse events. Postoperatively, it is important to prevent complications such as pain and PONV by dedicated prevention and treatment strategies, as well as to recognize and treat respiratory or circulatory complications competently. Interdisciplinary guidelines and agreements as well as the overall competence of the team have the potential to improve patient safety and outcome in children.

Evaluation of ECHO PS Positioning System in a Porcine Model of Simulated Laparoscopic Ventral Hernia Repair

Purpose. Operative efficiency improvements for laparoscopic ventral hernia repair (LVHR) have focused on reducing operative time while maintaining overall repair efficacy. Our objective was to evaluate procedure time and positioning accuracy of an inflatable mesh positioning device (Echo PS Positioning System), as compared to a standard transfascial suture technique, using a porcine model of simulated LVHR. Methods. The study population consisted of seventeen general surgeons (n = 17) that performed simulated LVHR on seventeen (n = 17) female Yorkshire pigs using two implantation techniques: (1) Ventralight ST Mesh + Echo PS Positioning System (Echo PS) and (2) Ventralight ST Mesh + transfascial sutures (TSs). Procedure time and mesh centering accuracy overtop of a simulated surgical defect were evaluated. Results. Echo PS demonstrated a 38.9% reduction in the overall procedure time, as compared to TS. During mesh preparation and positioning, Echo PS demonstrated a 60.5% reduction in procedure time (P < 0.0001). Although a trend toward improved centering accuracy was observed for Echo PS (16.2%), this was not significantly different than TS. Conclusions. Echo PS demonstrated a significant reduction in overall simulated LVHR procedure time, particularly during mesh preparation/positioning. These operative time savings may translate into reduced operating room costs and improved surgeon/operating room efficiency.

Seizure developed after palonosetron intravenous injection during recovery from general anesthesia -A case report-

Seizure associated with antiemetics is rare. We report seizure associated with a 5-HT₃ receptor antagonist in a 38 years old female. The patient underwent ureterorenoscopic lithotripsy due to left upper ureter stone. After operation, the patient complained of nausea in the postanesthetic recovery unit. In order to subside symptom, the patient was administrated 5-HT₃ receptor antagonist, palonosetron, 0.075 mg intravenously. Shortly after administration of that, the patient developed generalized tonic-clonic seizures. The symptom was subsided after midazolam and thiopental sodium were injected. But 40 minutes later, seizure recurred and subsided with midazolam again. The patient recovered completely without any specific sequelae.

The effect of crystalloid versus medium molecular weight colloid solution on post-operative nausea and vomiting after ambulatory gynecological surgery - a prospective randomized trial

Background

Intravenous fluid is recommended in international guidelines to improve patient post-operative symptoms, particularly nausea and vomiting. The optimum fluid regimen has not been established. This prospective, randomized, blinded study was designed to determine if administration of equivolumes of a colloid (hydroxyethyl starch 130/0.4) reduced post operative nausea and vomiting in healthy volunteers undergoing ambulatory gynecologic laparoscopy surgery compared to a crystalloid solution (Hartmann’s Solution).

Methods

120 patients were randomized to receive intravenous colloid (N = 60) or crystalloid (N = 60) intra-operatively. The volume of fluid administered was calculated at 1.5 ml.kg^-1 per hour of fasting. Patients were interviewed to assess nausea, vomiting, anti-emetic use, dizziness, sore throat, headache and subjective general well being at 30 minutes and 2, 24 and 48 hours post operatively. Pulmonary function testing was performed on a subgroup.

Results

At 2 hours the proportion of patients experiencing nausea (38.2 % vs 17.9%, P = 0.03) and the mean nausea score were increased in the colloid compared to crystalloid group respectively (1.49 ± 0.3 vs 0.68 ± 0.2, P = 0.028). The incidence of vomiting and anti-emetic usage was low and did not differ between the groups. Sore throat, dizziness, headache and general well being were not different between the groups. A comparable reduction on post-operative FVC and FEV-1 and PEFR was observed in both groups.

Conclusions

Intra-operative administration of colloid increased the incidence of early postoperative nausea and has no advantage over crystalloid for symptom control after gynaecological laparoscopic surgery.

Sufentanil infusion before extubation suppresses coughing on emergence without delaying extubation time and reduces postoperative analgesic requirement without increasing nausea and vomiting after desflurane anesthesia

Background

Coughing, hypertension, tachycardia, and even laryngospasm can occur due to airway irritation during emergence from anesthesia. We investigated the effect of maintaining a sufentanil infusion during emergence from anesthesia by evaluating the incidence of cough and recovery profiles at extubation.

Methods

In total, eighty-four patients undergoing an elective laparoscopic hysterectomy were randomly divided into two sufentanil groups and a control group. During emergence, sufentanil was administered in the sufentanil groups at a rate of 0.2 µg/kg/hr (Group S1) or 0.3 µg/kg/hr (Group S2), and saline was administered to the control group. Cough score, hemodynamic changes, and recovery profiles, such as duration from skin closure to a bispectral index of 80, to eye opening at verbal command, to tracheal extubation and the total duration of study solution infusion, were recorded. The pain score, the total volume of administered patient-controlled analgesia (PCA), and the postoperative nausea and vomiting (PONV) score were evaluated 1, 6, and 24 hours after surgery.

Results

Groups S1 and S2 showed significantly lower cough scores and smaller hemodynamic changes on extubation compared to Group C. Recovery profiles showed no significant differences among the three groups. Pain score, PONV at 1 hour postoperatively, and the total volume of PCA administered at all evaluation times were significantly lower in Groups S1 and S2 than in the control group. However, pain score, and PONV at 6 hours and 24 hours postoperatively showed no significant differences.

Conclusions

A sufentanil infusion (0.2-0.3 µg/kg/hr) during emergence from desflurane anesthesia may suppress coughing on extubation in patients with body mass indexes (BMI) of 21-26 without delaying extubation time. It may also reduce the postoperative analgesic requirement without increasing PONV.

[Effects of alcohol and smoking in pregnancy]

Nicotine and alcohol are legal drugs, which damage not only the health of the consumer, but also the society due to health-economic costs. In pregnancy, the consequences of alcohol consumption and smoking for the unborn life in pregnancy are dramatic. The irreversibly damaging effect of alcohol is proven in each stage of the pregnancy, whereby the phase of the organogenesis is the most sensitive period. Beside a higher incidence for deformations of all organs, the damage of the central nervous system is leading, since mental-intellectual retardation of children after alcohol consumption in pregnancy is proven. Smoking in pregnancy leads likewise to harmful effects, with the intrauterine growth retardation of the fetus being the leading smoking-induced pathology. Smoking- and alcohol-induced damages for the unborn life are irreversible with no therapeutic options. The only therapy is prevention, which means complete cessation of alcohol and smoking in pregnancy.