Impact of opioid-free anaesthesia on postoperative nausea, vomiting and pain after gynaecological laparoscopy - A randomised controlled trial

STUDY OBJECTIVE

Opioid-free anaesthesia may enhance postoperative recovery by reducing opioid-related side effects such as nausea, hyperalgesia or tolerance. The objective was to investigate the impact of multimodal opioid-free general anaesthesia on postoperative nausea, vomiting, pain and morphine consumption compared to the traditional opioid-based approach.

DESIGN

This study was conducted as a prospective parallel-group randomised controlled trial.

SETTING

Perioperative Care.

PATIENTS

152 adult women undergoing elective inpatient gynaecological laparoscopy.

INTERVENTIONS

Patients were randomly assigned for opioid-free anaesthesia (Group OF) with dexmedetomidine, esketamine and sevoflurane or to have opioid-based anaesthesia (Group C) with sufentanil and sevoflurane.

MEASUREMENTS

Primary outcome was the occurrence of nausea within 24 h after surgery. Patients were assessed for the incidence and severity of PONV, postoperative pain and morphine consumption and recovery characteristics.

MAIN RESULTS

Patients in both groups had comparable clinical and surgical data. 69.7% of patients in the control group and 68.4% of patients in the opioid-free group met the primary endpoint (OR 1.06, 95% Confidence Interval (CI) (0.53; 2.12) p = 0.86). The incidence of clinically important PONV defined by the PONV impact scale was 8.1% (Group C) vs 10.5% (OF); p = 0.57). Antiemetic requirements, pain scores and morphine consumption were equivalent in both groups. Postoperative sedation was significantly increased in group OF (p < 0.001), and the median length of stay at the post-anaesthesia care unit was 69.0 min (46.5-113.0) vs 50.0 (35.3-77.0) minutes in the control group (p < 0.001).

CONCLUSIONS

Opioid-free multimodal general anaesthesia is feasible but did not decrease the incidence of PONV, or reduce pain scores and morphine consumption compared to an opioid-containing anaesthetic regimen.

Nasolaryngeal Distances in the Adult Population and an Evaluation of Commercially Available Nasotracheal Tubes

BACKGROUND

Preformed nasal endotracheal tubes (NETs) come with a predefined insertion depth due to their curved design. While size indication refers to internal diameter, there is a considerable variability in the corresponding lengths and proportions of same-sized tubes of different manufacturers which is probably based on the lack of data of nasolaryngeal distances (NLDs) in the adult population. Choosing the best-fitting NET is therefore difficult and carries the risk of endobronchial intubation or, on the contrary, cuff inflation at the vocal cord level. The aim of this study was to develop a prediction model for NLD and a selection guide to choose the appropriate NET based on a radiographic description of NLD in comparison to the measurements of available NETs of several manufacturers.

METHODS

After institutional ethics board review, 388 computed tomography (CT) scan images of head, neck, and upper thorax in a heterogeneous adult cohort were included. Mean distances from the nares to the lower border of the thyroid cartilage were measured. NETs from different manufacturers were measured and compared to the NLD derived from the radiographic analysis. The patients' sex, body height, and weight were considered as possible covariates in quantile regression models for predicting the NLD.

RESULTS

Data from 200 patients were analyzed. NLD was associated with sex, body height, and weight. A simple quantile regression model using the body height as the only covariate sufficed to achieve accurate predictions of NLD. Validation on independent test data showed that 92.8% of the NLD predictions were closer than ±20 mm to the observed NLD values. Measurements of equal-sized NETs varied considerably in outer diameter, proportion, the nasopharyngeal part, and guide marks. Length differences of the bend-to-cuff distance, containing the anatomically NLD, ranged between 218 and 270 mm at same sizes.

CONCLUSIONS

A reliable prediction of NLD can be obtained simply by body height, using the formula (Equation is included in full-text article.). As manufacturers' tube lengths vary substantially, additional information about the bend-to-cuff distance as corresponding tube section would allow for more accurate tube selection.

[Pro: Epidural Analgesia Remains the Gold Standard for Abdominal and Thoracic Surgery]

Pain relief with epidural analgesia is superior compared to systemic opioid analgesia after major abdominal and thoracic surgery. It remains a safe procedure, as long as it is embedded in a concept covering the whole perioperative period. This includes the knowledge of the anesthesiologist how to operate the process of catheter insertion as well as to treat complications like the hypotension, associated with the application of epidural local anesthetics. A close postoperative monitoring by an acute pain service team is a responsible task and should be available 24/7. Despite the low incidence of complications, their consequences could be disastrous for patients. To avoid persisting neurological damage, standardized diagnostic procedures must be established and surgical intervention should be available within six hours if necessary. Non-analgetic benefits of epidural analgesia include reduced pulmonary complications like pneumonia and lower incidences for cardiac arrhythmia. Furthermore, perioperative mortality could be decreased by epidural analgesia. These effects should be considered as "add-on". The excellent pain relief is more than enough to recommend this method.

Creation of a head and face protection device for children undergoing procedures in prone position

BACKGROUND

Positioning the head of patients undergoing procedures in lateral or prone position remains a difficult task for the anesthesiologists. Associated risks have attracted increasing attention because they range from minor facial soft tissue injuries to catastrophic complications such as stroke or postoperative blindness. Earlier, we reported on the use of a boxing sports helmet for simple and easy positioning of the head. However, as available helmets are limited in sizes and materials, that system is not easily transferable to children. Therefore, we sought to create a face and head protection device for children undergoing procedures in prone position.

METHODS/MATERIALS

We re-engineered a standard boxing sports helmet making it suitable as an on-head support cushion. By using WHO standard growth charts, various sizes were calculated and prototypes of different foam materials produced. Facial surface pressures were measured in 15 volunteers.

RESULTS

A lightweight foam-based face mask was created. Minimum necessary foam thickness was 2.5 cm. Different materials were tested and pressure in different facial zones never exceeded 30 mmHg.

CONCLUSION

Bringing a face protection device onto the patient's face instead of placing the face into support cushions is an elegant way of keeping control over airway devices and providing support for facial structures in various positions simultaneously. Skin surface pressure on facial structures remained low due to the specific mask design and choice of foam materials, which could lead to decreased incidences of undesired sequelae of prone position such as skin damage or even more devastating complications.

Early effects of irradiation on [(123)I]-IMT and [(18)F]-FDG uptake in rat C6 glioma cells

BACKGROUND

Single-photon emission computed tomography (SPECT) using 3-[(123)I]-iodo-L-alpha-methyltyrosine ([(123)I]-IMT) and positron emission tomography (PET) using 2-[(18)F]-fluoro-2-deoxy-D-glucose ([(18)F]-FDG) are valuable tools for the distinction between viable tumor and radionecrosis in patients receiving radiotherapy for high-grade gliomas. However, to date, little is known about the early effects of radiation on [(123)I]-IMT and [(18)F]-FDG uptake in gliomas.

MATERIAL AND METHODS

To determine the early effects of irradiation on [(123)I]-IMT and [(18)F]-FDG uptake in gliomas, in vitro studies were performed using rat C6 glioma cells. The glioma cells were irradiated with 20 Gy which is a common dose applied to patients receiving intraoperative radiotherapy. Subsequently, the early kinetics of [(123)I]-IMT and [(18)F]-FDG uptake in glioma cells were monitored for 3 days.

RESULTS

Micromorphometric examinations of the irradiated glioma cells revealed that about 25% of the viable cells transformed into giant cells. [(123)I]-IMT uptake per 10(5) viable glioma cells was unchanged on the 1st day post irradiation, but showed a significant increase on the 2nd and 3rd day following radiotherapy (p < 0.01). In addition, there was a moderate increase in [(18)F]- FDG accumulation per 10(5) viable glioma cells during the first 3 days after irradiation (p < 0.05). The maximum increase in early [(123)I]-IMT uptake 1 h after application surpassed that of [(18)F]-FDG (p < 0.01).

CONCLUSION

Rat C6 glioma cells show an early increase in [(123)I]-IMT and [(18)F]-FDG uptake following irradiation which may be partly due to giant cell formation. These data suggest that [(123)I]-IMT SPECT and [(18)F]-FDG PET may be promising procedures for the early prediction of the therapeutic response of gliomas to radiotherapy.