Analgesic Strategies for Urologic Videolaparoscopic or Robotic Surgery in the Context of an Enhanced Recovery after Surgery Protocol: A Prospective Study Comparing Erector Spinae Plane Block versus Transversus Abdominis Plane Block

Regional anesthesia in postoperative pain management has developed in recent years, especially with the advent of fascial plane blocks. This study aims to compare the ultrasound-guided bilateral erector spinae plane block (ESPB) versus the ultrasound-guided bilateral transversus abdominis plane block (TAPB) on postoperative analgesia after laparoscopic or robotic urologic surgery. This was a prospective observational study; 97 patients (ESPB-group) received bilateral ultrasound-guided ESPB with 20 mL of ropivacaine 0.375% plus 0.5 mcg/kg of dexmedetomidine in each side at the level of T7-T9 and 93 patients (TAPB-group) received bilateral ultrasound-guided TAPB with 20 mL ropivacaine 0.375% or 0.25%. The primary outcome was the postoperative numeric rating scale (NRS) pain score, which was significantly lower in the ESPB group on postoperative days 0, 1, 2, and 3 (p < 0.001) and, consequently, the number of patients requiring postoperative supplemental analgesic rescue therapies was significantly lower (p < 0.001). Concerning the secondary outcomes, consumption of ropivacaine was significantly lower in the group (p < 0.001) and the total amount of analgesic rescue doses was significantly lower in the ESPB-group than the TAPB-group in postoperative days from 2 to 4 (1 vs. 3, p > 0.001). Incidence of postoperative nausea and vomiting was higher in the TAPB group and no block-related complications were observed. Our data indicate that ESPB provides postoperative pain control at least as good as TAPB plus morphine, with less local anesthetic needed.

Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade in Adults and Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Cholinesterase inhibitors, such as neostigmine and edrophonium, commonly used to reverse the residual effects of nondepolarizing neuromuscular blocking drugs at the end of surgery are associated with a high rate of residual neuromuscular blockade (NMB). Due to its direct mechanism of action, sugammadex is associated with rapid and predictable reversal of deep NMB. The current analysis compares the clinical efficacy and risk of postoperative nausea and vomiting (PONV) on using sugammadex or neostigmine for routine NMB reversal in adult and pediatric populations.

METHODS

PubMed and ScienceDirect were searched as the primary databases. Randomized controlled trials comparing sugammadex with neostigmine for routine NMB reversal in adult and pediatric patients have been included. The primary efficacy endpoint was the time from initiation of sugammadex or neostigmine to the recovery of a time-of-four ratio (TOF) ≥ 0.9. PONV events have been reported as secondary outcomes.

RESULTS

A total of 26 studies have been included in this meta-analysis, 19 for adults with 1574 patients and 7 for children with 410 patients. Sugammadex, when compared to neostigmine, has been reported to take a shorter time to reverse NMB in adults (mean difference = -14.16 min; 95% CI [-16.88, -11.43], P < 0.01), as well as in children (mean difference = -26.36 min; 95% CI [- 40.16, -12.57], P < 0.01). Events of PONV have been found to be similar in both the groups in adults, but significantly lower in children treated with sugammadex, i.e., 7 out of 145 with sugammadex versus 35 out of 145 with neostigmine (odds ratio = 0.17; 95% CI [0.07, 0.40]).

CONCLUSION

Sugammadex is associated with a significantly shorter period of reversal from NMB in comparison to neostigmine in adult and pediatric patients. Regarding PONV, the use of sugammadex for NMB antagonism may offer a better option for pediatric patients.

Efficacy of an enhanced recovery after surgery pathway to manage pain, nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction

BACKGROUND

Pain and post-operative nausea and vomiting are the main factors that impair the quality of recovery after surgery. Very few reports have analyzed patient-reported outcomes to investigate the efficacy of an enhanced recovery after surgery protocol to alleviate these symptoms after head and neck surgeries with free tissue transfer reconstruction.

METHODS

We investigated post-operative pain and post-operative nausea and vomiting in 47 patients who underwent head and neck surgeries with free tissue transfer reconstruction with enhanced recovery after surgery support between February 2021 and August 2022. Patient-reported outcomes were assessed using the visual analog scale and Japanese version of the Quality of Recovery-40.

RESULTS

Significant increases in the mean visual analog scale scores for pain and post-operative nausea and vomiting were observed only on post-operative Day 1 compared with preoperative values (pain: 3.19 ± 2.78 vs. 1.96 ± 2.42, P = 0.0408; post-operative nausea and vomiting: 1.52 ± 2.09 vs. 0.54 ± 1.37, P = 0.0194). From post-operative Day 2, there were no significant differences between the pre- and post-operative visual analog scale scores, and no significant increases in the incidences of moderate or severe pain and post-operative nausea and vomiting compared with preoperatively. The Japanese version of the Quality of Recovery-40 score for post-operative pain showed no significant deterioration compared with preoperatively, while the Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting showed significant deterioration compared with the preoperative value on post-operative Days 2, 4 and 7.

CONCLUSIONS

The visual analog scale and Japanese version of the Quality of Recovery-40 scores for post-operative pain and visual analog scale score for post-operative nausea and vomiting suggested that the enhanced recovery after surgery strategy favorably controlled pain and post-operative nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction. However, as the post-operative Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting was lower than the preoperative value, there is still a need for further improvement of the enhanced recovery after surgery pathway.

Perioperative utility of amisulpride and dopamine receptor antagonist antiemetics-a narrative review

Despite advances in antiemetics and protocolized postoperative nausea vomiting (PONV) management, it remains one of the most common postoperative adverse events. In patients who developed PONV despite antiemetic prophylaxis, giving a rescue treatment from the same class of medication is known to be of limited efficacy. Given the widespread use of 5-HT3 antagonists as PONV prophylaxis, another class of effective intravenous rescue antiemetic is in dire need, especially when prophylaxis fails, and rescue medication is utilized. Dopamine antagonists were widely used for the treatment of PONV but have fallen out of favor due to some of their side effect profiles. Amisulpride was first designed as an antipsychotic medication but was found to have antiemetic properties. Here we will review the historical perspective on the use of dopamine receptor antagonist antiemetics, as well as the evidence on the efficacy and safety of amisulpride.

Antiemetics and Apfel Scores in Orthopedic Surgery

Background

Postoperative nausea and vomiting (PONV) is a common complication following surgery. Only a few risk factors have consistently been reported to be independent predictors for PONV.

Aim

To report Apfel scores for orthopedic patients then correlate these scores to the number of antiemetics prescribed and subsequently administered in both the perioperative and post operative setting and determine if screening for Apfel scores is beneficial to predict PONV.

Methods

A retrospective analysis of patients admitted under orthopedic units between 1st July 2020 and 31st July 2020 was conducted at a tertiary teaching hospital in Australia. Patients were screened and allocated an Apfel score and antiemetics agents prescribed and subsequently administered were recorded.

Results

A total of 115 patients were screened for inclusion. Of these 4 patients met this exclusion criteria, resulting in a total sample size of 111 patients. An Apfel score of 2 was reported in 45.0% of patients, followed by 28.8% of patients scoring 3, with 12.6% scoring one. Only 5.4% of patients scored the highest risk of 4, with 8.2% of patients with no Apfel score documented.

Conclusion

Orthopedic patients tend to score 2 or more in their Apfel score placing them at higher risk of postoperative nausea and/or vomiting according to the collectively validated Apfel's simplified risk score. There was no statistically significant relationship between the Apfel score and the number of antiemetic agents prescribed or administered from both the perioperative and post-operative setting following orthopedic surgery in this cohort of adult patients.

Clinical and genetic factors associated with post-operative nausea and vomiting after propofol anaesthesia

BACKGROUND

The incidence of post-operative nausea and vomiting (PONV) remains at about 30% despite all therapeutic efforts to reduce it. The clinical risk factors guiding the prophylactic treatment are well established, but genetic factors associated with PONV remain poorly known. The aim of this study was to explore clinical and genetic factors impacting PONV by performing a genome-wide association study (GWAS) together with relevant clinical factors as covariates, and systematically attempt to replicate previously reported PONV associations. Relevant clinical factors are explored with logistic regression model.

METHODS

This was an observational case control study in Helsinki University Hospital between 1 August 2006 and 31 December 2010. One thousand consenting women with elevated risk for PONV, undergoing breast cancer surgery with standardised propofol anaesthesia and antiemetics. After exclusions for clinical reasons and failed genotyping, 815 patients were included with 187 PONV cases and 628 controls. Emergence of PONV up to 7th post-operative day was recorded. PONV at 2-24 h after surgery was selected to be the primary outcome. The GWAS explored associations between PONV and 653 034 genetic variants. Replication attempts included 31 variants in 16 genes.

RESULTS

The overall incidence of PONV up to 7th post-operative day was 35%, where 3% had PONV at 0-2 h and 23% at 2-24 h after surgery. Age, American Society of Anaesthesiologists status, the amount of oxycodone used in the post-anaesthesia care unit, smoking status, previous PONV, and history of motion sickness were statistically significant predictive factors in the logistic model. The receiver operating characteristic-area under the curve of 0.75 (95% CI 0.71-0.79) was calculated for the model. The GWAS identified six variants with suggestive association to PONV (p < 1 × 10-5 ). Of the previously reported variants, association with the DRD2 variant rs18004972 (TaqIA) was replicated (p = .028).

CONCLUSIONS

Our GWAS approach did not identify any high-impact PONV susceptibility variants. The results provide some support for a role of dopamine D2 receptors in PONV.

The impact of the Apfel scoring system for prophylaxis of post-operative nausea and vomiting: A randomized controlled trial

Background and Aims

Post-operative nausea and vomiting (PONV) is common, undesirable, and stressful following surgery. By focusing attention and resources on those groups of patients most likely to develop PONV, the quality of care provided to the patients can be improved. The primary objective was to compare the incidence of PONV after implementation of the Apfel scoring system with the control group receiving prophylaxis for every surgery. The secondary objective was to identify the effect on the patient's expenditure/savings with respect to management of PONV.

Material and Methods

This prospective randomized controlled double-blinded study enrolled 70 patients undergoing surgeries under general anesthesia. Patients were randomized to group A (control group - all received PONV prophylaxis) and group B (Apfel stratification performed for PONV prophylaxis). Based on the Apfel system, the risk of PONV was classified as the grades low, moderate, and high risk. Patients at moderate and high risk received PONV prophylaxis in group B. Patients were monitored for PONV during 24 h after surgery and rescue medication given as required. The effect of implementing Apfel risk stratification on the incidence of PONV (primary outcome measure) and on patient expenditure was compared.

Results

Compared to administering prophylaxis for all patients, the incidence of PONV [group A-5 patients (14.3%)] did not increase (P = 0.428) after implementing the Apfel scoring system [group B-2 patients (5.7%)]. The number of patients spending on prophylaxis for PONV in group A [35 (100%)] was higher than that in group B [17 (48%)], without increasing expenditure on PONV treatment.

Conclusion

Withholding prophylaxis on the basis of the Apfel scoring system did not increase the incidence of PONV compared to providing prophylaxis for all the patients. The overall cost of prevention and treatment of PONV is less when the Apfel scoring system is used.

Health professionals' attitudes towards acupuncture/acupressure for post-operative nausea and vomiting: a survey and implications for implementation

PURPOSE

Level 1 evidence supports the use of acupuncture/acupressure (A/A) to manage post-operative nausea and vomiting (PONV). This study aimed to survey healthcare professionals' attitudes towards A/A, influencing factors and barriers to implementing this effective non-drug intervention into peri-operative care.

METHODS

A validated, anonymous survey with 43 questions was emailed or distributed as a hard copy at meetings to anaesthetists, midwives, nurses, obstetricians, gynaecologists and surgeons at a public hospital in Australia. Descriptive data were presented. Influencing factors were explored using chi-square analysis. Multinomial logistical regression was used to identify the influences of confounding factors.

RESULTS

A total of 155 completed surveys were returned, reflecting a response rate of 32%. The majority of participants were female (69%), nurses/midwives (61%) and aged between 20 and 50 years old (76%). Eighty-three percent of respondents considered A/A 'clearly alternative' medicine or 'neither mainstream nor alternative'. Eighty-one percent would encourage patients to use acupressure for PONV if it was offered at the hospital. Previous personal use of A/A was the key factor influencing attitudes and openness to clinical use. The key barriers to implementation were perceived lack of evidence and lack of qualified providers and time.

CONCLUSION

Hospital-based healthcare professionals strongly supported the evidence-based use of A/A for PONV despite considering the therapy to be non-mainstream and having limited A/A education or history of personal use, providing a positive context for an acupressure implementation study. Significant gaps in training and a desire to learn were identified.

Post-operative vomiting and enhanced recovery after congenital cardiac surgery

BACKGROUND

Post-operative nausea and vomiting is frequent after congenital cardiac surgery.

AIMS

We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes.

METHODS

Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis.

RESULTS

From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2-12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89).

CONCLUSIONS

Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.

The effect of intraperitoneal ropivacaine on post-operative pain and recovery after diagnostic laparoscopy and hysteroscopy: A randomised double-blind placebo-controlled trial

BACKGROUND

Intraperitoneal local anaesthetic has shown benefit in operative laparoscopy; however, no randomised controlled trial has been reported with patients having diagnostic laparoscopy.

AIMS

To determine the effect of intraperitoneal ropivacaine on post-operative analgesic requirements, pain, nausea scores and recovery following gynaecological diagnostic laparoscopy and hysteroscopy.

MATERIALS AND METHODS

Randomised double-blind placebo-controlled trial. Well women aged 18-50 years, undergoing day case hysteroscopy and diagnostic laparoscopy for gynaecological indications were randomised to 20 mL of 150 mg intraperitoneal ropivacaine diluted in saline, or 20 mL normal saline instillation (placebo) at the end of the procedure. Women were followed up until eight hours post-discharge.

RESULTS

Slower than anticipated recruitment meant that the study was finished before the sample size of 100 patients was achieved. Fifty-nine patients were included for analysis. Thirty-one patients were randomised to ropivacaine and 28 patients to control. Sixty-one percent of patients in both arms required opioid medication in recovery. The total median equivalent morphine dose was significantly higher in the patients randomised to control (11.7 mg) vs ropivacaine (6.7 mg), P = 0.03. Time to discharge was 20 min faster in patients randomised to ropivacaine, but this finding did not reach significance. Overall pain and nausea scores in the first eight hours showed no significant differences.

CONCLUSION

There was significantly reduced opioid use in recovery when using intraperitoneal ropivacaine compared to placebo, in this randomised placebo-controlled trial on women undergoing day case diagnostic laparoscopy and hysteroscopy.

Early post-operative nausea and vomiting: A retrospective observational study of 2030 patients

BACKGROUND

The overall risk of post-operative nausea and vomiting (PONV) after general anaesthesia is reportedly 20%-40%. The first episode of PONV may occur early in the post-anaesthesia care unit (PACU) or later at the ward or after discharge at home in an ambulatory setting. This study aimed to investigate and describe the risk of early PONV in a PACU, and we hypothesised that patients and perioperative factors were associated with early PONV.

METHODS

This single-centre retrospective observational study was conducted in a Swedish county hospital from January to June 2017 and included adult patients who underwent surgical procedures under general anaesthesia. Perioperative data were obtained by reviewing the local registry for surgical procedures, medical records and anaesthesia and post-operative charts. Early PONV was defined as PONV occurring up to 4 hours post-operatively at the PACU. Any notification in the medical records, perioperative charts or the registry regarding nausea, vomiting or PONV treatment was regarded as PONV. Univariate and multivariate analyses were performed for factors associated with early PONV.

RESULTS

A total of 2030 patients were included in the study, of which 9.6% (n = 194) experienced early PONV. Factors associated with a high risk of early PONV were suboptimal PONV prophylaxis, need for opioids, female sex, body mass index >35 kg m^-2 and major surgery and anaesthesia time ≥60 minutes.

CONCLUSION

We found that every 10th patient under general anaesthesia experienced early PONV. Suboptimal PONV prophylaxis and previously acknowledged risk factors for PONV were associated with early PONV.

Effect of Peri-Operative Hyperoxygenation on Surgical Site Infection in Patients Undergoing Emergency Abdominal Surgery: A Randomized Controlled Trial

Background: The rationale for hyperoxygenation in controlling surgical site infection (SSI) has been described in many studies yet has not been defined clearly. Some studies in colorectal surgery have reported beneficial effects, whereas studies in gynecologic surgery have reported either no effect or a deleterious effect. This study assessed the effectiveness of hyperoxygenation on the reduction of SSI in patients undergoing emergency abdominal surgery. Patients and Methods: Eligible patients were assigned randomly to two groups (study group, 80% oxygen or control group, 30% oxygen). The patients in the study group received 80% oxygen and the patients in the control group received 30% oxygen intra-operatively and for two hours after surgery. Arterial blood gas analysis was done after resuscitation, at the end of the surgery, and at two hours after extubation. All patients were assessed for SSI, post-operative nausea and vomiting, and respiratory complications. Patients were followed post-operatively for 14 days. Surgical site infection was diagnosed according to U.S. Centers for Disease Control and Infection (CDC) criteria and by aerobic wound cultures. Results: After exclusion, 85 patients in the control group and 93 patients in the study group were analyzed. There was no difference for baseline, intra-operative, and post-operative characteristics between the two groups, except for higher oxygen saturation at closure and two hours post-operatively, in the 80% group (p = 0.01). Surgical site infection occurred in 29 patients (34.11%) in 30% fraction of inspired oxygen (F_IO₂) group and in 19 patients (20.43%) in 80% F_IO₂ group (p = 0.04). The risk of SSI was 59% lower in the 80% F_IO₂ group (adjusted odds ratio, 0.41; 95% confidence interval [CI], 0.19-0.88 vs. the 30% F_IO₂ group). There were no differences in post-operative nausea and vomiting and respiratory complications between the two treatment groups. Conclusions: Administration of 80% peri-operative hyperoxygenation in emergency abdominal surgery reduces SSI and is a cost-effective method.

The coronal aorto-mesenteric orientation theory for post-operative nausea and vomiting following scoliosis surgery in children: a pilot study

BACKGROUND

Post-operative nausea and vomiting (PONV) is often encountered following corrective scoliosis surgery in children, frequently attributed to high-dose opiate administration. PONV is a frequent cause of prolonged hospital stay. Mechanisms related to transient partial duodenal compression by narrow angulation of the superior mesenteric artery (SMA) and aorta following scoliosis surgery are poorly understood and might be implicated in PONV. This study investigates relationships between biomechanical anatomic variations of the SMA and aorta, and its relationship with clinically significant PONV following scoliosis surgery in children.

METHODS

Children undergoing elective spinal arthrodesis for adolescent idiopathic scoliosis were assessed by preoperative abdominal ultrasound and spinal X-ray prior to surgery. Post-operative assessment of clinically significant PONV is compared to preoperative imaging and clinical variables.

RESULTS

Thirteen patients (11 female and two male), with a mean age of 14 years and 1 month were included. Five patients (38.5%) developed clinically significant PONV. A significant association was observed between the coronal aorto-mesenteric orientation and PONV (P = 0.035). Of the five patients who developed PONV, two had direct coronal angulation of the SMA, one had left angulation and two had right angulation. Patients with significant PONV had narrower aorto-mesenteric distances which approached significance (P = 0.06). No other preoperative variable reached significance.

CONCLUSION

Patients with coronal aorto-mesenteric orientation preoperatively appear at greater risk of developing significant PONV following scoliosis surgery, independent of opiate requirements, prompting consideration of transient partial duodenal obstruction as an important factor in the mechanisms of PONV. A coronal aorto-mesenteric orientation theory (CAMOT) is proposed to explain this biomechanical vascular 'scissor'.

Dexmedetomidine Combined With Butorphanol or Sufentanil for the Prevention of Post-operative Nausea and Vomiting in Patients Undergoing Microvascular Decompression: A Randomized Controlled Trial

Background: Patients undergoing microvascular decompression are often accompanied with high risk of post-operative nausea and vomiting (PONV). In this study, we compare the antiemetic efficacy of butorphanol or sufentanil combined with dexmedetomidine in patients undergoing microvascular decompression.

Methods: Patients undergoing microvascular decompression were randomized into two groups. The primary outcome was the occurrence and severity of PONV during the 72 h after surgery. Secondary outcomes included levels of pain intensity and sedation and consumption of opioids at 1, 2, 6, 12, 24, 48, and 72 h after surgery. We also recorded the intraoperative hemodynamics, consumption of narcotic drugs, operation and anesthesia time, estimated blood loss, infusion volume and urine output, requirements of rescue antiemetics or analgesics, the satisfaction scores of patients and surgeons, complications, and length of stay.

Results: The overall incidence rates of nausea and vomiting during the 72 h after surgery were significantly reduced in group DB (76.00 and 44.00% in group DS vs. 54.17% and 22.92% in group DB, P < 0.05). Patients in group DB had a lower incidence of nausea than those in group DS at intervals of 1–6 and 6–24 h (P < 0.05). However, patients in group DB had a lower incidence of vomiting than those in group DS only at intervals of 1–6 h (P < 0.05). Similarly, the number of patients requiring rescue antiemetics was also significantly reduced in group DB compared with that in group DS at intervals of 1–6 h (P < 0.05). The number of patients experiencing moderate to severe PONV was comparable between the two groups during 72 h after surgery (P > 0.05). The consumption of opioid morphine equivalent was significantly reduced in group DB (P < 0.05). Compared with those in group DS, the satisfaction scores of both patients and surgeons were significantly increased in group DB (P < 0.05).

Conclusion: Butorphanol combined with dexmedetomidine could reduce early PONV and the number of patients requiring rescue antiemetics, especially at intervals of 1–6 h, while the satisfaction scores of both patients and surgeons were significantly increased.

Expanding Pharmacotherapy Data Collection, Analysis, and Implementation in ERAS® Programs-The Methodology of an Exploratory Feasibility Study

Surgical organizations dedicated to the improvement of patient outcomes have led to a worldwide paradigm shift in perioperative patient care. Since 2012, the Enhanced Recovery After Surgery (ERAS^®) Society has published guidelines pertaining to perioperative care in numerous disciplines including elective colorectal and gynecologic/oncology surgery patients. The ERAS^® and ERAS-USA^® Societies use standardized methodology for collecting and assessing various surgical parameters in real-time during the operative process. These multi-disciplinary groups have constructed a bundled framework of perioperative care that entails 22 specific components of clinical interventions, which are logged in a central database, allowing a system of audit and feedback. Of these 22 recommendations, nine of them specifically involve the use of medications or pharmacotherapy. This retrospective comparative pharmacotherapy project will address the potential need to (1) collect more specific pharmacotherapy data within the existing ERAS Interactive Audit System^® (EIAS) program, (2) understand the relationship between medication regimen and patient outcomes, and (3) minimize variability in pharmacotherapy use in the elective colorectal and gynecologic/oncology surgical cohort. Primary outcomes measures include data related to surgical site infections, venous thromboembolism, and post-operative nausea and vomiting as well as patient satisfaction, the frequency and severity of post-operative complications, length of stay, and hospital re-admission at 7 and 30 days, respectively. The methodology of this collaborative research project is described.

An update on the management of PONV in a pediatric patient

Postoperative nausea and vomiting (PONV) is a major cause of patient dissatisfaction following anesthesia. The difficulty in diagnosing nausea in much of the pediatric population has led to an emphasis on anti-emetic prophylaxis for all. Assessment scores and prognostic tools enable the anesthesiologist to identify patients who are at a greater risk and appropriately apply more aggressive prophylactic, multi-drug strategies. New antiemetics emerging from other medical disciplines, particularly oncology, may have potential use in prophylaxis and treatment of nausea and vomiting in the pediatric surgical population. New agents, many of which have a long duration of action, will augment the anesthesiologist's ability to adequately prevent PONV, and to treat persistent nausea and vomiting that extend beyond the immediate post-operative period.

A pharmacological profile of intravenous amisulpride for the treatment of postoperative nausea and vomiting

INTRODUCTION

The issue of postoperative nausea and vomiting (PONV) remains important in surgical practice, contributing to patient distress, slower recovery, and increased use of healthcare resources. Many surgical patients report it to be a worse problem than the pain. New antiemetics of different classes are still needed to help manage PONV effectively, especially the treatment of established PONV after the failure of common prophylactic antiemetics such as 5-HT₃-antagonists and corticosteroids. Intravenous amisulpride, a drug with a long history of safe use in oral form as an antipsychotic, has recently been approved in the US (trade name: Barhemsys) as an intravenous antiemetic for the prevention and treatment of PONV.

AREAS COVERED

This review article summarizes the published data on the clinical pharmacology, safety, and efficacy of intravenous amisulpride as an antiemetic, supplemented by published data on oral amisulpride, where relevant to the intravenous form. Literature was obtained via the PubMed search terms 'intravenous amisulpride' and 'amisulpride AND safety.' Both primary and secondary pharmacology are covered, along with clinical pharmacokinetics (distribution, metabolism, and excretion). The review of clinical safety and efficacy includes data from four studies in the prevention of PONV, two in the treatment of PONV and two investigating effects on the QT interval of the electrocardiogram in healthy volunteers.

EXPERT OPINION

Given the importance of sufficient PONV prevention for patients and the healthcare system, the availability of intravenous amisulpride is helpful, restoring the dopamine-antagonist class as a potential mainstay in both combination prophylaxis and treatment.

Comparison of the Baska mask and the i-gel supraglottic airway devices in patients undergoing elective surgery

INTRODUCTION

The Baska mask and i-gel are two new types of second-generation supraglottic airway devices. The aim of this study was to compare these two devices in terms of quality of insertion, quality of ventilation and post-insertion complications.

MATERIAL AND METHODS

A total of 80 adult patients who were scheduled for elective surgery under general anaesthesia were randomised to two groups: Group BM: Baska mask (n = 40) and Group IG: i-gel (n = 40). The assessment focused on ease of insertion, number of attempts, insertion time, number of corrective manoeuvres, oropharyngeal leak pressure, tidal volume, peak airway pressure (PAP) and post-insertion complications.

RESULTS

Group IG showed a significantly shorter median insertion time (13.3 [interquartile range, IQR 7.8] vs. 17.0 [IQR 9.6] s; P < 0.001), a higher percentage in the 'very easy' ease of insertion category (62.5% vs. 10.0%; P < 0.001), a higher percentage in the no corrective manoeuvre category (92.5% vs. 72.5%; P = 0.003) and a higher percentage in the no post-operative throat pain category (67.5% vs. 32.5%; P = 0.011) than Group BM. However, Group BM showed a significantly higher generated PAP than Group IG (12.7 [1.8] and 11.5 [2.2] cm H₂O, respectively; P = 0.010). There were no significant differences in other parameters.

CONCLUSIONS

The i-gel was better than the Baska mask in terms of ease of insertion, speed of insertion, fewer corrective manoeuvres and less post-operative throat pain. However, the Baska mask had a better cuff seal, as shown by a higher generated PAP.

Role of Prophylactic Dexamethasone Before Thyroidectomy in Reducing Postoperative Pain, Nausea and Vomiting

Introduction Post-operative nausea, vomiting (PONV) and pain are the most frequently encountered complains after thyroid surgery. Steroids effectively reduce pain, nausea, and inflammation, therefore prophylactic administration of steroids improve these outcomes. The aim of our study was to compare the prophylactic administration of dexamethasone with placebo in terms of PONV and pain. Patients and methods We conducted a double-blinded randomized controlled trial including 100 patients who underwent thyroid surgery from January 2017 to December 2017 in Surgical Unit-I of the Holy Family hospital, Pakistan. The outcome in terms of post-operative pain, nausea and vomiting were measured. Results The mean age of the patients was 39.62 ± 12.73 years in group A, while in group B it was 39.06 ± 13.25 years. Out of the 100 patients included in our trial, 52 (52%) patients were males and 48 (48%) patients were females. The mean value of pain in group A patients was 1.60 ± 1.26, while in group B it was 3.60 ± 1.94. A statistically significant difference was found between the study groups with regard to the pain score of the patients i.e. p-value = 0.001. The PONV was found in 28 patients from group A and 19 patients from group B and no significant improvement was seen (p-value = 0.071). Conclusion A single dose of prophylactic dexamethasone significantly reduces the mean pain score in patients undergoing thyroidectomy; however, insignificant relation was noted in terms of PONV condition.

Efficacy of intravenous lidocaine in improving post-operative nausea, vomiting and early recovery after laparoscopic gynaecological surgery

Post-operative nausea and vomiting (PONV) is a major peri-operative complication. It has numerous adverse consequences that seriously affect the post-operative recovery of patients. The aim of the present study was to investigate the efficacy of intravenous lidocaine in improving PONV and recovery after laparoscopic gynaecological surgery. A total of 40 patients were randomly assigned to 2 groups: Group L (lidocaine group) and Group C (control group). The patients in Group L received intravenous lidocaine throughout the operation, while patients in Group C were given a saline infusion. Vital signs, recovery time, extubation time, dosage of remifentanil, first flatus time and defecation time of each patient were recorded. The incidence of PONV after surgery was also recorded. The recovery of the patients was evaluated by using the quality of recovery score (QoR-40). The total dose of remifentanil was significantly lower in Group L (P<0.05). However, the recovery time and extubation time were shorter in Group C (P<0.05). The first flatus time and defecation time were longer in Group C (P<0.05). The mean arterial pressure and heart rate in Group L were lower and more stable (P<0.05). At 6 h after surgery, the incidence of PONV was significantly lower in Group L vs. that in Group C (P<0.05). The QoR-40 score in Group C was significantly lower at 1 and 3 days after the operation compared with that in Group C (P<0.05). In conclusion, intravenous lidocaine administered to patients undergoing laparoscopic gynaecological surgery may reduce PONV and supports their early recovery [trial registration number in Chinese Clinical Trial Registry: ChiCTR-IOR-17010782 (March 5, 2017)].

Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries

Background and Aims:

Aprepitant, a Neurokinin-1 receptor antagonist, has been evaluated in abdominal and neurosurgeries, but its effect is less clear in breast and thyroid surgeries, which are also known to be high risk for post-operative nausea and vomiting (PONV). This study was done to compare the antiemetic efficacy of ondansetron and aprepitant in women undergoing mastectomy and thyroidectomy.

Methods:

One hundred and twenty-five ASA I and II, female patients, aged between 18 and 65 years were randomly assigned into Group I (ondansetron group, n = 62) or Group II (aprepitant group, n = 63), by computer-generated random sequencing. Per protocol analysis was done to assess the incidence and severity of PONV, use of rescue antiemetics, and patient satisfaction with PONV control between the two groups, till 24 h post-surgery.

Results:

In the immediate postoperative period, 79.7% of patients in Group I and 85.2% in Group II were free of emesis (P value: 0.49). In Group I, the first episode of vomiting occurred within a median duration 90 min (IQR 2575: 45-147) postoperatively, whereas the median duration in Group II was 160 min (IQR 25-75: 26-490), with request for rescue antiemetic at 60 min in Group I (IQR 25-75: 27-360) and 147 min in Group II (IQR 25-75: 11-457).

Conclusion:

A single dose of oral aprepitant has comparable effects to injection ondansetron administered eighth hourly in preventing PONV, the severity of nausea, number of rescue antiemetics, and the time to first emetic episode in the 24-h postoperative period.

CTRI Reg No:

REF/2017/06/014637.

Extended release granisetron: Review of pharmacologic considerations and clinical role in the perioperative setting

In this review, we evaluate recent literature on use of ER granisetron in clinical practice as compared with current antiemetics and describe its potential uses for perioperative PONV prophylaxis and treatment. Recent literature was evaluated on ER granisetron use compared with currently used antiemetic agents ondansetron, droperidol, metoclopramide, promethazine, and dexamethasone with a focus on procedural anti-emesis. Though promising great effect, application of extended release granisetron to clinical use may be limited by it's increased relative cost.

Reasons for delayed patient discharge following day surgery: a literature review

Aim The aim of this literature review was to explore the reasons why some patients are not suitable for discharge following day surgery. Method A pragmatic, mixed-methods approach was used to undertake a critical evaluation of the literature and current practice to determine what is already known about discharge following day surgery. Thematic analysis was used to identify the main themes and issues, enabling recommendations to be made to reduce the incidence of patients unable to be discharged following day surgery. Findings The main themes or reasons for delayed discharge following day surgery identified from the literature review were: post-operative nausea and vomiting, post-operative pain, going late to theatre and social factors. These themes were supported by the findings of an unpublished audit carried out in one day surgery unit in an NHS healthcare organisation in the south of England between June and August 2014, which indicated that 54 out of 1,180 day surgery patients required an overnight stay during this 12-week period. The audit also showed that a patient going late to theatre had the greatest effect on discharge outcomes. Conclusion Recommendations for practice include: the introduction of post-operative nausea and vomiting risk scoring and prophylactic protocols; reorganisation of theatre lists to ensure patients have enough time to recover; and provision of information during the pre-assessment process about the requirement for a responsible adult escort to take patients home and stay with them for the first 24 hours. These changes may help NHS organisations to improve discharge outcomes for day surgery patients and reduce unplanned costs.

Low-dose dexamethasone during arthroplasty: What do we know about the risks?

Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI).

The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty.

We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a ‘pro’ and ‘con’ discussion.

After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27 205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone.

Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI.

Conversely, animal studies showed that high dose dexamethasone inhibits wound healing.

A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk–benefit ratio of peri-operatively applied steroids for individual arthroplasty patients.

We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies.

Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.

The effect of intravenous dextrose administration for prevention of post-operative nausea and vomiting after laparoscopic cholecystectomy: A double-blind, randomised controlled trial

Background and Aims:

Post-operative nausea and vomiting (PONV) is a common and distressing complication after laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the effect of intravenous (IV) dextrose administration for the prophylaxis of PONV after LC.

Methods:

In a double-blind, randomised controlled trial, a total of 150 female patients who were scheduled for elective LC were randomly assigned into two groups (A and B). Thirty minutes before induction of anaesthesia, patients received an infusion of 500 cc lactated Ringer's solution (Group A) and 5% dextrose in lactated Ringer's solution (Group B) and over a period of 30 min. All patients rated their nausea and vomiting intensity using the verbal rating scale immediately at post-anaesthesia care unit (PACU) arrival; 30, 60, 90 and 120 min after arriving at the PACU and 6, 12 and 24 h after surgery.

Results:

There was a statistically significant time trend and group effect along with significant differences in time/group interaction effect in both groups for nausea and vomiting scores (P < 0.05). A low negative correlation coefficient was found (r = −0.394, P < 0.001) between blood glucose levels and nausea scores upon PACU arrival. Dextrose administration reduced the odds of vomiting events compared to placebo (estimate: −0.87, odds ratio = 0.42, 95% confidence interval: 0.28–0.64).

Conclusion:

Administration of IV dextrose before anaesthesia induction may be recommended as an effective, and safe method for the prophylaxis of PONV after LC.

Intravenous palonosetron compared with a combination of ramosetron and dexamethasone in preventing post operative nausea and vomiting in patients undergoing gynaecological surgeries under spinal anaesthesia, a randomised study

Background and Aims:

Post-operative nausea and vomiting (PONV) is one of the most common complications in patients undergoing gynaecological surgeries under spinal anaesthesia (SA). Palonosetron has the unique property of controlling 'delayed chemotherapy-induced nausea and vomiting' when compared to older serotonin antagonists. This study compared the effectiveness of palonosetron with a combination of ramosetron and dexamethasone in preventing PONV.

Methods:

Sixty patients undergoing gynaecological surgeries under SA were randomly allocated into two groups of thirty each, to receive either a combination of 0.3 mg of ramosetron and 8 mg of dexamethasone intravenously (IV) (Group RD) or 0.075 mg of palonosetron IV (Group P). The incidence of PONV, number of complete responders (no nausea, vomiting or use of rescue anti-emetics) and severity of nausea were evaluated during intra- and post-operative period.

Results:

The incidence of complete responders during intraoperative period was 80.0% in Group RD and 76.7% in Group P (P = 0.074) whereas postoperatively at 0–2 h and 2–6 h, it was 73.3% and 83.3% in Group RD respectively as compared to 46.6% and 56.6% in Group P respectively (P = 0.016 and P = 0.024). The incidence of PONV during 24 h of post-operative period was 30.00% in Group RD as compared to 60.00% in Group P (P = 0.0195). Nausea severity score and use of rescue anti-emetics did not vary between the groups.

Conclusion:

Combination of ramosetron and dexamethasone is more effective than palonosetron alone in preventing PONV in patients undergoing gynaecological surgeries under SA.

Revisiting the applicability of adult early post-operative nausea and vomiting risk factors for the paediatric patient: A prospective study using cotinine levels in children undergoing adenotonsillectomies

Background and Aims:

Post-operative vomiting (POV) in children remains a significant clinical problem. This prospective study aims to investigate the applicability of well-established adult early post-operative nausea and vomiting (PONV) risk factors on paediatric POV after adenotonsillectomies under regulated anaesthetic conditions.

Methods:

After Institutional Review Board approval, 213 children aged 3–10-year-old were enrolled. The participants had pre-operative questionnaires completed, followed protocolised anaesthetic plans and had saliva analysed for cotinine. The primary outcomes were POV as correlated with age, gender, family or personal history of PONV, motion sickness history, opioid use, surgical time, anaesthetic time and environmental tobacco smoke (ETS) exposure, as assessed by cotinine levels and questionnaire reports. Data on analgesics, antiemetics and POV incidence before post-anaesthesia care unit discharge were collected. Statistical analysis was done through multiple logistic regression.

Results:

A total of 200 patients finalised the study. Early POV occurred in 32%. Family history of PONV (odds ratio [OR] = 5.3, P < 0.01) and motion sickness history (OR = 4.4, P = 0.02) were highly significant risk factors. Age reached borderline statistical significance (OR = 1.4, P = 0.05). None of the other factors reached statistical significance.

Conclusion:

Early POV occurs frequently in paediatric patients undergoing adenotonsillectomies. In this paediatric-aged group, the incidence of POV was affected by the family history of PONV, and history of motion sickness. Age, female gender, opioid use, surgical and anaesthetic times did not affect the incidence of POV. ETS exposure, as assessed by cotinine levels and questionnaire reports, had no protective effect on early paediatric POV.

Consensus statement on anaesthesia for day care surgeries

The primary aim of day-care surgery units is to allow for early recovery of the patients so that they can return to their familiar 'home' environment; the management hence should be focused towards achieving these ends. The benefits could include a possible reduction in the risk of thromboembolism and hospital-acquired infections. Furthermore, day-care surgery is believed to reduce the average unit cost of treatment by up to 70% as compared to inpatient surgery. With more than 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hence, there is an immense opportunity for expansion in day-care surgery in India to ensure faster and safer, cost-effective patient turnover. For this to happen, there is a need of change in the mindset of all concerned clinicians, surgeons, anaesthesiologists and even the patients. A group of nine senior consultants from various parts of India, a mix of private and government anaesthesiologists, assembled in Mumbai and deliberated and discussed on the various aspects of day-care surgery. They formulated a consensus statement, the first of its kind in the Indian scenario, which can act as a guidance and tool for day-care anaesthesia in India. The statements are derived from the available published evidence in peer-reviewed literature including guidelines of several bodies such as the American Society of Anesthesiologists, British Association of Day Surgery and International Association of Ambulatory Surgery. The authors also offer interpretive comments wherever such evidence is inadequate or contradictory.

Uterotonics for Non-emergent Caesarean Section: Protocol Change During UK-Licensed Drug Shortage

The aim was to assess the efficacy of Syntometrine ^® (500 micrograms ergometrine with 5 units oxytocin) as an appropriate alternative first-line uterotonic for use in elective caesarean section (CS) during a national shortage of UK-licensed IV oxytocin from April-June 2014. An observational study was performed involving 2 groups of 22 women undergoing elective CS in a UK DGH during this period. Primary endpoints included mean estimated blood loss (EBL), haemoglobin drop post-operatively and transfusion requirement. Secondary endpoints were use of antiemetics and mean post-operative nausea and vomiting (PONV) score. Results for Syntometrine ^® groups and syntocinon groups respectively: mean EBL (ml) 527.3 vs. 550.0 (p=0.5820), mean haemoglobin drop (g/dL) 0.977 vs. 0.982 (p=0.98), blood transfusion 1/22 vs. 0/22 (p=1). Intra-operative antiemetics 20/22 vs. 6/22 (p=<0.001), post-operative antiemetics 2/22 vs. 2/22 (p=1), mean PONV score 11.5 vs. 3.5 (p=0.099). As no significant difference in primary endpoints or PONV scores was observed between regimes, we conclude Syntometrine ^® was a safe first-line haemostatic agent for elective CS during oxytocin shortage.

Population pharmacokinetics and prophylactic anti-emetic efficacy of ramosetron in surgical patients

AIMS

This study characterized the pharmacokinetics of ramosetron and compared prophylactic anti-emetic efficacy with that of ondansetron in a large population.

METHODS

Fifty-eight patients consented to the pharmacokinetic analysis and were assigned randomly to receive 0.3, 0.45 or 0.6 mg ramosetron after induction of anaesthesia. Blood samples were acquired at preset intervals. Non-compartmental and population pharmacokinetic analyses were performed. In total, 1102 patients consented to the evaluation of prophylactic anti-emetic efficacy and were allocated randomly to receive 0.3 mg ramosetron or 4 mg ondansetron at the end of surgery. An additional 16 mg ondansetron were mixed in the intravenous patient-controlled analgesia pump of the ondansetron group. Post-operative nausea and vomiting (PONV) were evaluated 6, 24 and 48 h post-operatively using the Rhodes index of nausea, vomiting and retching (RINVR). Administration of rescue anti-emetics and adverse events were evaluated.

RESULTS

The pharmacokinetic parameter estimates were V1 (l) = 5.12, V2 (l) = 108, CL (l⋅min(-1) ) = 0.08 + (59⋅age(-1) ) × 0.09, Q (l⋅min(-1) ) = 1.42. The incidences of PONV in the ramosetron and ondansetron groups were 77 (13.9%) and 113 (20.6%) and 44 (7.9%) and 66 (12.0%) at 24 and 48 h post-operatively, respectively (P = 0.004, 0.030). RINVR was significantly lower in the ramosetron than the ondansetron group 24 and 48 h post-operatively (P = 0.003, 0.025). Use of rescue anti-emetics and incidence of adverse events were comparable.

CONCLUSIONS

A two compartment mammillary model was used to describe ramosetron pharmacokinetics. Prophylactic anti-emetic efficacy of ramosetron was significantly better 24 and 48 h post-operatively than that of ondansetron, particularly when the Apfel score was ≥ 3.

Comparison of ramosetron with ondansetron for the prevention of post-operative nausea and vomiting in high-risk patients

Background and Aims:

Post-operative nausea and vomiting (PONV) has an 80% incidence in high-risk patients. This is despite the availability of several antiemetic drugs. Selective 5-hydroxytryptamine type 3 (5-HT₃) receptor antagonists are considered first-line for prophylaxis, ondansetron being the most commonly used agent. Ramosetron, another selective 5-HT₃ receptor antagonist, is more potent and longer acting than ondansetron. This study was conducted to evaluate the antiemetic efficacy of ramosetron in comparison with ondansetron in patients at a high risk of PONV.

Methods:

This was a prospective randomised double-blind study carried out over a 6-month period in which 206 patients with at least two risk factors for PONV were randomised to receive ramosetron 0.3 mg or ondansetron 8 mg, 30 min before the end of surgery. The incidence of PONV, severity of nausea and need for rescue antiemetic were recorded over the next 24 h. Primary outcome was the incidence of PONV. Secondary outcomes included severity of nausea and need for rescue. The data were analysed using the Predictive Analytics Software (PASW, version 18: Chicago, IL, USA).

Results:

The incidence of PONV was found to be 35% in the ramosetron group as opposed to 43.7% in the ondansetron group (P = 0.199). Need for rescue antiemetic was 23.3% in the ramosetron group and 32% in the ondansetron group (P = 0.156) in the 24 h following surgery.

Conclusion:

Ramosetron 0.3 mg and ondansetron 8 mg were equally effective in reducing the incidence of PONV in high risk patients.

Granisetron versus ondansetron for post-operative nausea and vomiting prophylaxis in elective craniotomies for brain tumors: A randomized controlled double-blind study

Context:

Post-operative nausea and vomiting (PONV) pose unique challenges in neurosurgical patients that warrant its study separate from other surgical groups.

Setting and Design:

This prospective, randomized, double-blind study was carried out to compare and to evaluate the efficacy and safety of three antiemetic combinations for PONV prophylaxis following craniotomy.

Materials and Methods:

A total of 75 anesthesiologist status I/II patients undergoing elective craniotomy for brain tumors were randomized into three groups, G, O and D, to receive single doses of dexamethasone 8 mg at induction with either granisetron 1 mg, ondansetron 4 mg or normal saline 2 ml at the time of dural closure respectively. Episodes of nausea, retching, vomiting and number of rescue antiemetic (RAE) were noted for 48 h post-operatively.

Statistical Analysis:

Analysis of variance with post-hoc significance and Chi-square test with fisher exact correction were used for statistical analysis. P <0.05 was considered to be significant and P < 0.001 as highly significant.

Results:

We found that the incidence and number of vomiting episodes and RAE required were significantly low in Group G and O compared with Group D; P < 0.05. However, incidence of nausea and retching were comparable among all groups. The anti-nausea and anti-retching efficacy of all the three groups was comparable.

Conclusions:

Single dose administration of granisetron 1 mg or ondansetron 4 mg at the time of dural closure with dexamethasone 8 mg provide an effective and superior prophylaxis against vomiting compared with dexamethasone alone without interfering with post-operative recovery and neurocognitive monitoring and hence important in post-operative neurosurgical care.

Preoperative carbohydrate nutrition reduces postoperative nausea and vomiting compared to preoperative fasting

BACKGROUND

The aim of this prospective, randomized, single-blinded study was to compare the effects of a carbohydrate drink 400 mL given 2 h before the surgery with preoperative overnight fasting on the gastric pH and residual volume, postoperative nausea and vomiting (PONV) and antiemetic consumption in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

Forty American Society of Anesthesiologists physical status I-II patients who underwent elective laparoscopic cholecystectomy. Randomized, prospective, controlled study, Gulhane Medical Faculty and Guven Hospital Department of Anesthesiology and Reanimation. Patients were randomly assigned into two groups: Pre-operative carbohydrate drink group (group C, n = 20) and preoperative fasting group (group F, n = 20). Group C was given a 400 mL carbohydrate drink 2 h before to the surgery. The patients of group F were fasted 8 h before the surgery. Both groups were operated under general anesthesia with volatile anesthetics.

RESULTS

Hemodynamic parameters, demographic data, gastric acidity and residual volumes were similar for both groups. No complications were observed. PONV and antiemetic consumption was lower in group C compared to group F (P = 0.001). Patient's satisfaction was higher in group C (P < 0.001).

CONCLUSION

This study showed that pre-operative carbohydrate drink may be used safely and also improves patient's satisfaction and comfort in patients undergoing laparoscopic cholecystectomy.

Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS)

BACKGROUND

Postoperative nausea and vomiting is one of the most common complications affecting patients after surgery and causes significant morbidity and increased length of hospital stay. It is accepted that patients undergoing surgery on the bowel are at a higher risk. In the current era of minimally invasive colorectal surgery combined with enhanced recovery, reducing the incidence and severity of postoperative nausea and vomiting is particularly important. Dexamethasone is widely, but not universally used. It is known to improve appetite and gastric emptying, thus reduce vomiting. However, this benefit is not established in patients undergoing bowel surgery, and dexamethasone has possible side effects such as increased risk of wound infection and anastomotic leak that could adversely affect recovery.

DESIGN

DREAMS is a phase III, double-blind, multicenter, randomized controlled trial with the primary objective of determining if preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing elective gastrointestinal resections. DREAMS aims to randomize 1,350 patients over 2.5 years.Patients undergoing laparoscopic or open colorectal resections for malignant or benign pathology are randomized between 8 mg intravenous dexamethasone and control (no dexamethasone). All patients are given one additional antiemetic at the time of induction, prior to randomization. Both the patient and their surgeon are blinded as to the treatment arm.Secondary objectives of the DREAMS trial are to determine whether there are other measurable benefits during recovery from surgery with the use of dexamethasone, including quicker return to oral diet and reduced length of stay. Health-related quality of life, fatigue and risks of infections will be investigated.

TRIAL REGISTRATION

ISRCTN21973627.