Postoperative nausea and vomiting after mastoidectomy with tympanoplasty: a comparison between TIVA with propofol-remifentanil and balanced anesthesia with sevoflurane-remifentanil

Comparison of Postoperative Nausea and Vomiting Incidence between Remimazolam and Sevoflurane in Tympanoplasty with Mastoidectomy: A Single-Center, Double-Blind, Randomized Controlled Trial

Background and Objectives: Postoperative nausea and vomiting (PONV) is a common adverse effect of general anesthesia, especially in middle ear surgery. Remimazolam is a newer benzodiazepine recently approved for use in general anesthesia. This study aimed to compare the incidence rate of PONV after tympanoplasty with mastoidectomy between using remimazolam and sevoflurane. Materials and Methods: This study included 80 patients undergoing elective tympanoplasty with mastoidectomy. The patients were randomly assigned to either the remimazolam or sevoflurane group. The primary outcome was the incidence rate of PONV 12 h after surgery. The secondary outcomes were the incidence rate of PONV 12-24 and 24-48 h after surgery, severity of PONV, incidence rate of vomiting, administration of rescue antiemetics, hemodynamic stability, and recovery profiles. Results: The incidence rate of PONV 0-12 h after tympanoplasty with mastoidectomy was significantly lower in the remimazolam group compared with that in the sevoflurane group (28.9 vs. 57.9%; p = 0.011). However, the incidence rate of delayed PONV did not differ between the two groups. PONV severity in the early periods after the surgery was significantly lower in the remimazolam group than in the sevoflurane group. The incidence rate of adverse hemodynamic events was lower in the remimazolam group than in the sevoflurane group, but there was no difference in the overall trends of hemodynamic data between the two groups. There was no difference in recovery profiles between the two groups. Conclusions: Remimazolam can significantly reduce the incidence rate of early PONV after tympanoplasty with mastoidectomy under general anesthesia.

Inhaled anesthesia in neurosurgery: Still a role?

In patients undergoing craniotomy, general anesthesia should be addressed to warrant good hypnosis, immobility, and analgesia, to ensure systemic and cerebral physiological status and provide the best possible surgical field. Regarding craniotomies, it is unclear if there are substantial differences in providing general anesthesia using total intravenous anesthesia (TIVA) or balanced anesthesia (BA) accomplished using the third generation halogenates. New evidence highlighted that the last generation of halogenated agents has possible advantages compared with intravenous drugs: rapid induction, minimal absorption and metabolization, reproducible pharmacokinetic, faster recovery, cardioprotective effect, and opioid spare analgesia. This review aims to report evidence related to the use of the latest halogenated agents in patients undergoing craniotomy and to present available clinical evidence on their effects: cerebral and systemic hemodynamic, neurophysiological monitoring, and timing and quality of recovery after anesthesia.

Perioperative Pain Management Following Otologic Surgery

Otologic surgery involves a broad range of procedures. In general, postoperative pain from most otologic surgeries can be managed with little to no opioids, and surgeons should make a concerted effort to minimize narcotic prescriptions in the midst of the opioid crisis. Many procedures, including transcanal surgeries and even postauricular surgeries, may performed with local anesthetic in selected patients. Multimodal pain regimens, local anesthesia, and alternative approaches have shown promise in minimizing narcotic use, and should be considered. Preoperative counseling to appropriately manage expectations and goals is imperative for patient satisfaction and safety.

Hearing Results Following Type 1 Tympanoplasty in Elderly Patients

BACKGROUND/AIM

The outcomes of type 1 tympanoplasty in elderly patients remain controversial. Therefore, more studies are needed to clarify the prognosis of elderly patients after tympanoplasty. The purpose of this study was to evaluate the clinical outcomes of type 1 tympanoplasty in elderly patients.

PATIENTS AND METHODS

We retrospectively analyzed data from 116 patients who underwent type 1 tympanoplasty due to chronic otitis media. Seventy-one of the 116 patients were elderly individuals aged 65 years or older (study group). Forty-five patients were younger than 65 years (control group). Due to cochlear intolerance by aging in the study group, we used dexamethasone soaked gelfoam packing in the middle ear and intraoperative dexamethasone injection. To compare the outcomes between groups, we determined the mean hearing levels by averaging the hearing thresholds. The differences in the air-bone gaps before and after tympanoplasty were compared between groups.

RESULTS

In the study group, 54 patients had an underlying disease (76%). Hypertension was the most common underlying disease. The postoperative air conduction (AC) and bone conduction (BC) improved in both the study group and the control group. In the control group, postoperative air-bone gap (ABG) was significantly higher than preoperative ABG. Although the postoperative ABG improved in the study group, the improvement was insignificant.

CONCLUSION

Although significant improvement of ABG was not achieved, postoperative AC and BC were improved. Intraoperative dexamethasone injection and dexamethasone soaked gelfoam packing in the middle ear was effective to prevent deterioration of BC after operation.

Does Propofol Anesthesia Lead to Less Postoperative Pain Compared With Inhalational Anesthesia?: A Systematic Review and Meta-analysis

BACKGROUND

Many studies have compared propofol-based anesthesia with inhalational anesthesia. Results from several studies have shown improved postoperative analgesia after propofol anesthesia, but other studies showed contradictory results. There are no large prospective studies that compare postoperative pain after propofol versus inhalational anesthesia. This meta-analysis was designed to focus on this question.

METHODS

A systematic literature search for randomized controlled trials that compared propofol-based anesthesia with volatile agents-based anesthesia in adults undergoing surgery was conducted. Published data were pooled for the meta-analysis with Review Manager (ie, RevMan). The main outcomes included postoperative pain intensity, opioid consumption, need for rescue analgesics, and time to first analgesia.

RESULTS

Thirty-nine clinical trials with a combined subject population of 4520 patients came within the purview of this meta-analysis. The investigated volatile agents included isoflurane, sevoflurane, and desflurane. Compared with inhalational anesthetics, the propofol use was associated with a reduced postoperative pain intensity at rest at 30 minutes, 1 hour, and 12 hours (mean difference in pain scores, 30 minutes, -0.48 [visual analog scale, 0-10]; 99% confidence interval [CI], -1.07 to 0.12, P = 0.04) and reduced morphine-equivalent consumption 0 to 24 hours postoperatively (mean difference in morphine-equivalent consumption, -2.68 mg; 99% CI, -6.17 to 0.82; P = 0.05). Fewer patients required postoperative rescue analgesics during 0 to 24 hours after surgery under propofol anesthesia (risk ratio, 0.87; 99% CI, 0.74-1.03; P = 0.04). In addition, patients anesthetized with propofol required administration of postoperative analgesia later than those anesthetized with volatiles (mean difference in time to first analgesic administration, 6.12 minutes; 99% CI, 0.02-12.21; P = 0.01). Considering that Z statistic in RevMan 5.3 does not perform optimally in highly heterogeneous samples among groups or many combinations of groups with small sample sizes, a P value of <.01 was considered statistically significant. On the basis of this threshold, none of the aforementioned results are statistically significant.

CONCLUSIONS

The current results are affected by substantial heterogeneity, which makes it difficult to predict significant differences in postoperative pain control between propofol anesthesia and inhalational anesthesia. Further large, randomized controlled trials are needed to corroborate these results and to detect differences (if any) between propofol and inhalational anesthesia on postoperative pain.

A comparison of sedation with midazolam-ketamine versus propofol-fentanyl during endoscopy in children: a randomized trial

PURPOSE

We aimed to compare the efficacy and safety of midazolam plus ketamine versus fentanyl plus propofol combination administered to children undergoing upper gastrointestinal endoscopy (UGE) and to determine the most appropriate sedation protocol.

MATERIALS AND METHODS

This prospective, randomized, single-blind study included patients between the ages of 4 and 17 years who underwent UGE for diagnostic purposes. Patients were divided randomly into groups A (midazolam-ketamine combination, n=119) and B (fentanyl plus propofol combination, n=119). The effectiveness of the sedation and complications during the procedure and recovery period were recorded.

RESULTS

The processes started without an additional dose of the drug for 118 patients (99.1%) in group A and for 101 patients (84.8%) in group B (P=0.001). The average dose of ketamine administered to the patients in group A was 1.03±0.15 mg/kg and the average dose of propofol administered to the patients in group B was 1.46±0.55 mg/kg. None of the patients stopped the endoscopic procedure in group A, but one patient (0.8%) had to discontinue the endoscopic procedure in group B. 27 patients in group A (22.7%) and 41 patients (34.5%) in group B developed complications during the procedure (P=0.044). The rate of complications during the recovery of group A (110 patients, 92.4%) was significantly higher than that in group B (48 patients, 40.3%) (P=0.001).

CONCLUSION

In children, UGE procedures can be quite comfortable when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Prevention of postoperative nausea and vomiting with a subhypnotic dose of Propofol in patients undergoing lower abdominal surgery: A prospective, randomized, double-blind study

Background:

Postoperative nausea and vomiting (PONV) is a common complication after general anesthesia in patients undergoing elective lower abdominal surgery. We aimed to compare the effect of a sub hypnotic dose of Propofol in the prevention of PONV after lower abdominal surgery with that of the conventional antiemetic drug Metoclopramide.

Materials and Methods:

In this prospective, randomized, double-blind, placebo-controlled study, 104 patients with American Society of Anesthesiologists (ASA) class I or II status, aged 18–65 years, and undergoing elective lower abdominal surgery were randomized to one of four groups (n = 26 each). The patients in the four groups were administered intravenously Propofol 20 mg (G1), Propofol 30 mg (G2), Metoclopramide 10 mg (G3), and placebo (G4), 15 min before skin closure. All episodes of PONV during the first 24 h after anesthesia were recorded by an investigator who was blinded to treatment assignment.

Results:

There were no significant differences between the treatment groups with regard to their gender, age, ASA class, duration of surgery, duration of recovery time and hospital stay, and also body mass index (BMI) (P > 0.05). The prevalence of PONV 0-6 h after anesthesia was 23.08% with Propofol 20 mg (P = 0.005), 15.38% with Propofol 30 mg (P = 0.016), 15.38% with Metoclopramide 10 mg (P = 0.016), compared to 30.77% with placebo (P = 0.005).

Conclusions:

Administration of a subhypnotic dose of Propofol (30 mg) was found to be as effective as 10 mg Metoclopramide in reducing the incidence and severity of PONV in adult patients undergoing elective lower abdominal surgeries under Isoflurane-based anesthesia in the early postoperative period.

Endoscopic removal of a self-expanding metallic airway stent: A case report

Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from the airway can pose extreme challenges for both clinical airway management as well as for the administration of general anesthesia. We report on a 61-year-old man with a complex cardiac history presenting for endoscopic stent removal necessitated by the formation of extensive granulation tissue. Comorbidities included a history of myocardial infarction, an ischemic cardiomyopathy with severe left heart failure (ejection fraction of 25%), mild right heart failure, 2+ tricuspid regurgitation status post tricuspid valve repair, and atrial fibrillation. An automatic external (wearable) cardiac defibrillator (Zoll Life Vest) was also in place. Induction of anesthesia was carried out using etomidate, with maintenance of anesthesia carried out with a propofol infusion (total intravenous anesthesia). Rocuronium was used for neuromuscular blockade. A size 4 iGel supraglottic airway and, later, rigid bronchoscopy formed the basis for airway management. Stable conditions were met through the 2-h procedure, and the patient recovered uneventfully. Our successful experience in this case leads us to propose further use of a supraglottic airway in conjunction with total intravenous anesthesia for these procedures.

Considerations for the use of short-acting opioids in general anesthesia

Anesthesiologists play a critical role in facilitating a positive perioperative experience and early recovery for patients. Depending on the kind of procedure or surgery, a wide variety of agents and techniques are currently available to anesthesiologists to administer safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment requires the use of agents that enable rapid induction, maintenance, and emergence combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid onset/offset of effect; that short effect is both predictable and precise. It also ensures easier titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of remifentanil, these agents have several applications in general anesthesia.

General anesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture

BACKGROUND

Reduction of nasal bone fracture can be performed under general or local anesthesia. The aim of this study was to compare general anesthesia (GA) and monitored anesthetic care (MAC) with dexmedetomidine based on intraoperative vital signs, comfort of patients, surgeons and nurses and the adverse effects after closed reduction of nasal bone fractures.

METHODS

Sixty patients with American Society of Anesthesiologists physical status I or II were divided into a GA group (n = 30) or MAC group (n = 30). Standard monitorings were applied. In the GA group, general anesthesia was carried out with propofol-sevoflurane-N2O. In the MAC group, dexmedetomidine and local anesthetics were administered for sedation and analgesia. Intraoperative vital signs, postoperative pain scores by visual analog scale and postoperative nausea and vomiting (PONV) were compared between the groups.

RESULTS

Intraoperatively, systolic blood pressures were significantly higher, and heart rates were lower in the MAC group compared to the GA group. There were no differences between the groups in the patient, nurse and surgeon's satisfaction, postoperative pain scores and incidence of PONV.

CONCLUSIONS

MAC with dexmedetomidine resulted in comparable satisfaction in the patients, nurses and surgeons compared to general anesthesia. The incidence of postoperative adverse effects and severity of postoperative pain were also similar between the two groups. Therefore, both anesthetic techniques can be used during the reduction of nasal bone fractures based on a patient%s preference and medical condition.

Postoperative nausea and vomiting: incidence, characteristics and risk factors--a prospective cohort study

BACKGROUND

Postoperative nausea and vomiting are a common complication after surgery. The objective of the study was to identify risk factors, and to determine the incidence of postoperative nausea and vomiting in a cohort of patients in a tertiary university hospital.

METHODS

Prospective cohort study was conducted in a Post Anesthetic Care Unit during a period of 3 weeks. One hundred and fifty-seven adult patients subjected to scheduled non-cardiac and non-intracranial surgery were eligible for the study. Patient perioperative characteristics data were analyzed. The postoperative nausea and vomiting intensity scale and nausea visual analog scale were applied to measure postoperative nausea and vomiting at 6h and 24h after surgery. Descriptive analysis was performed and the Mann-Whitney U, Fisher's exact, or Chi-square tests were applied. A univariate and multivariate logistic binary regressions with calculation of odds ratio (OR) and its 95% confidence interval (95% CI) were performed.

RESULTS

Thirty-nine (25%) patients and 54 (34%) patients had postoperative nausea and vomiting at 6h and 24h, respectively. Of the patients who experienced postoperative nausea and vomiting, 6 (15%) had clinically significant postoperative nausea and vomiting (postoperative nausea and vomiting intensity scale>50) at 6h and 9 (23%) at 24h. The majority of patients classified nausea as mild at 6h (57%) and 24h (56%). At 6h, 3 (10%) patients classified nausea as severe, and at 24h 5 (9%) patients reported the same. The median and interquartile ranges for nausea visual analog scale were 40 (20-60) at 6h and 50 (20-60) at 24h. Six patients (14%) at 6h, and 7 (18%) at 24h had a nausea visual analog scale score>75. Patients with postoperative nausea and vomiting intensity scale>50 had higher scores in the nausea visual analog scale at 6h (75 versus 30, P<.05) and 24h (70 versus 40, P<.05). The univariate analysis identified risk factors for postoperative nausea and vomiting: Apfel score>2 (OR 3.2, 95% CI 1.6-6.4, P=.001), previous history of postoperative nausea and vomiting (OR 2.9 95% CI 1.3-6.5, P=.009) and female patients (OR 2.7, 95% CI 1.4-5.4, P=.005). In the multivariate analysis previous history of postoperative nausea and vomiting (adjusted OR 2.5, 95% CI 1.1-5.7, P=.030) and female gender (adjusted OR 2.4, 95% CI 1.2-4.9, P=.015) were considered as independent risk factors for postoperative nausea and vomiting.

CONCLUSION

Most of the patients do not have clinically significant postoperative nausea and vomiting. The patients who presented with postoperative nausea and vomiting intensity scale>50 had higher scores in the nausea visual analog scale. Independent risk factors for postoperative nausea and vomiting were previous history of postoperative nausea and vomiting and being female.