To drain or not to drain: the association between residual intraperitoneal gas and post-laparoscopic shoulder pain for laparoscopic cholecystectomy

Residual intra-peritoneal gas may be associated with post-laparoscopic shoulder pain (PLSP), which is a frequently and disturbance compliant after surgery. Herein, we aimed to examine whether expiring residual gas via a surgical drain reduces the frequency and intensity of PLSP in the first day after laparoscopic cholecystectomy. 448 participants were enrolled in this prospective cohort study. The incidence and severity of PLSP after surgery were recorded. Of these, the cumulative incidence of PLSP in the drain group was lower particularly at the 12th postoperative hour (18.3% vs. 27.6%; P = 0.022), 24th postoperative hour (28.8% vs. 38.1%; P = 0.039), and throughout the first postoperative day (P = 0.035). The drain group had less severe PLSP (crude Odds ratio, 0.66; P = .036). After adjustment using inverse probability of treatment weighting, the drain group also had a significant lower PLSP incidence (adjusted hazard ratio = 0.61, P < 0.001), and less severe PLSP (adjusted odds ratio = 0.56, P < 0.001). In conclusion, the maneuver about passive force to expel residual gas, surgical drain use, contributes to reduce the incidence and severity of PLSP, suggesting that to minimize residual gas at the end of surgery is useful to attenuate PLSP.

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.

What is the ideal combination antiemetic regimen?

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after surgery. PONV and PDNV have been associated with postoperative complications and hospital discharge delays. Despite the extensive evidence describing the use of several regimens in different surgical populations, the ideal regimen has not been established. Several antiemetic drugs have been evaluated in more than 1000 clinical controlled trials for management of this complex emetogenic pathway, including the 5-hydroxytryptamine (5-HT₃) receptor antagonists, dopamine receptor antagonists, neurokinin-type receptor antagonists, antihistaminics, anticholinergics, and corticosteroids, with the 5-HT₃ receptor antagonists being the most commonly used for PONV prophylaxis. Because of the complex emetogenic pathway and multifactorial etiology of PONV, a multimodal approach using two or more drugs that act at different neuro-receptor sites is suggested in patients with one or more risk factors to successfully address PONV and reduce its incidence. Nevertheless, the most studied regimens in randomized clinical trials (RCTs) are the combination of serotonin 5-HT3 receptor antagonists with dexamethasone or dopamine receptor antagonists (droperidol). Therefore, the safest and more effective combination regimen appears to be the use of serotonin 5-HT3 receptor antagonist antiemetic drugs with dexamethasone.

Quick rehabilitation nursing improves the recovery of colon cancer patients after laparoscopy

Colon cancer is a common malignant tumor with particularly high morbidity and mortality. The aim of this study was to compare the effect of quick rehabilitation nursing and routine nursing in postoperative recovery of patients with colon cancer after laparoscopic surgery. Two hundred forty patients with colon cancer were classified into four random groups (A, B, C and D, with 60 patients in each group). All patients underwent surgery to remove the colon tumor by laparoscopy under general anesthesia. Patients in groups A and B received quick rehabilitation nursing for post-surgery recovery. In group C patients, local anesthesia associated with quick rehabilitation nursing for post-surgery recovery was used. Group D was used as control group and the patients were treated based on routine nursing. Time to get out of bed, first bowel movement time and the average time of hospitalisation in group A was lower than group D (p less than 0.05), postoperative leukocyte level as well as the occurrence rate of nausea and vomiting, ankylenteron and pelvic adhesion was decreased in group A compared to group D (p less than 0.05), but the postoperative albumin and total protein level was higher than group D (p less than 0.05). The serum level of C-Reactive Protein (CRP) and interleukin 6 (IL-6) in group A was decreased compared to group D several days after surgery (p less than 0.05); group B had 4 cases of intestinal obstruction after surgery that could be cured through conservative treatment, while group D had 10 cases of intestinal obstruction, 8 of which could be cured through conservative treatment and two needed surgery (p less than 0.05); VAS for pain degree of group C in active state was clearly lower at 1h, 5h, 7h, 15h, 30h and 42h after surgery, and side effects of postoperative analgesia were clearly reduced. Time to get out of bed was obviously decreased, while there was no evident effect on postoperative dosage, chronic pain and complications. Adopting quick rehabilitation nursing can effectively reduce occurrence of complications and postoperative pain, speed up the recovery of gastrointestinal function, shorten the length of stay, and improve patients’ satisfaction.

Effect of cerebral oxygen saturation on postoperative nausea and vomiting in female laparoscopic surgery patients

BACKGROUND

The purpose of this study was to investigate effect of cerebral oxygen saturation (SCTO2) on postoperative nausea and vomiting (PONV) in female patients who underwent laparoscopic surgery.

METHODS

This study included 90 female patients who underwent laparoscopic surgery (60 cases of gynecological operations and 30 cases of gallbladder operations). All patients were allocated into 3 groups of 30 patients each: group A (gynecological laparoscopic surgery), group B (gynecological laparoscopic surgery with mannitol treatment) and group C (laparoscopic cholecystectomy surgery). Perioperative SCTO2, mean blood flow velocity of vertebral artery (VM), vascular resistance index of vertebral artery (RI), and PONV (within 48 hours after surgery) were investigated.

RESULTS

No differences in age, body weight, operation time, and hemoglobin levels were observed among the patients (P > .05). The SCTO2 values for groups B and C were lower than those for group A in both brain hemispheres at T4 and T5 (P < .05). The VM was higher in group B than in groups A and C at T3 (P < .05), but differences in VM were not observed between groups B and C at T4 or T5. However, the VM of group A was still lower than the other groups (P < .05), and no difference in VM was observed among the 3 groups at T6 (P > .05). The RI was higher in group C than in groups A and B at T4 (P < .05). The incidence of PONV within 48 hours after surgery was significantly higher in group A than in the other 2 groups (P < .05).

CONCLUSION

Strategies that maintain normal SCTO2 may reduce the incidence of PONV in female patients who underwent laparoscopy surgery by reducing perioperative intracranial pressure.

Postoperative nausea and vomiting: physiopathology, risk factors, prophylaxis and treatment

Recognising the importance of the prevention and early treatment of postoperative nausea and vomiting (PONV) is essential to avoid postoperative complications, improve patient satisfaction and enable the development of major outpatient surgery and fast-track surgery. The topic of PONV might seem to have become stagnant, but we are moving forward. New concepts and problems like post-discharge nausea and vomiting, new risk factors and new drugs are appearing. However, there continue to be mistaken notions about PONV, such as the association between PONV and post-anaesthesia care unit stays, or assuming that it is a risk factore characteristic of the patient, anaesthesia or surgery when it is not. Perhaps, now is the moment to tackle PONV in a different manner, implementing guidelines and going for more aggressive prophylaxis in some groups of patients. We present an extensive review of this topic.

Total intravenous anesthesia produces outcomes superior to those with combined intravenous-inhalation anesthesia for laparoscopic gynecological surgery at high altitude

Objective We compared efficacy and adverse outcomes following totally intravenous anesthesia (TIVA) versus combined intravenous-inhalation anesthesia (CIVIA) on hemodynamics and postoperative recovery following laparoscopic gynecological (LG) surgery at high altitudes. Methods We enrolled 80 ASA I or II patients scheduled for LG surgery and randomly assigned them to TIVA with propofol (group P, n = 40) or CIVIA with isoflurane (group I, n = 40). Mean arterial pressure, heart rate, pulse oxygen saturation, and partial pressure of end-tidal carbon dioxide were measured at various time points. Outcome measures were interval to spontaneous ventilation, eye opening, return to consciousness, extubation, operating room duration. Intraoperative awareness and postoperative nausea/vomiting were assessed at follow-up. Results No differences in hemodynamic parameters were detected in either group. Group P had a significantly shorter postoperative anesthetic recovery time and lower incidence of postoperative nausea/vomiting. Conclusion TIVA is superior to CIVIA for GL surgery at high altitudes.

Prediction of intraoperative nausea and vomiting in caesarean delivery under regional anaesthesia

Objectives

This study aimed to predict patients who have caesarean operations under regional anaesthesia and are at risk for intraoperative nausea and vomiting (IONV), for ultimately prompting anaesthetists and surgeons to take preventive measures.

Methods

This was a retrospective study on 209 patients who had caesarean section under spinal-epidural combined regional anaesthesia. The relevant medical history, such as severe nausea and vomiting in the first trimester, smoking, a history of motion sickness, and premenstrual syndrome (PMS), were obtained from the patients’ records and interviews.

Results

Patients who had a female neonate, a history of severe nausea and vomiting in the first trimester, and a history of PMS and motion sickness before pregnancy experienced a significantly higher rate of IONV. Smokers were less susceptible to IONV, but this was not significant.

Conclusion

This study shows that some factors in the medical history of a patient can help identify those who are more likely to suffer from IONV.

[Impact of genetic factors on severity of side effects of opioids in patients after major surgical interventions]

The rate of the opioids side effects (SE) occurrence, as well as their mutual connection with possible variants of a single-nucleotide polymorphism (SNP) of genes of a μ1-opioid receptor (OPRM1) 118A>G and catechol-O-methyltranspherase (COMT) 1947G>A were studied in patients after surgical interventions of large volumes in the first postoperative day the rate of the narcotic analgetics SE occurrence have constituted: nemesis--56%, vomiting--17%, dizziness--61%, cutaneous pruritis--17%. Occurrence of central SE of opioids may be caused by the SNP COMT 1947G>A genes: the sedation depth is two times more in the genes AA and GA carriers, in comparison with such in the gene GG carrier (p < 0.05). Gastrointestinal SE may be connected with genes SNP OPRM1 118A>G and COMT 1947G>A: the nemesis occurrence rate is more in the genes OPRM1 AG+GG, COMT GA and GG carriers (p < 0.05), vomiting--in 2,8 times more in the OPRM1 AG+GG genes carriers, than in the group OPRM1 AA (p < 0.05). The severity of cutaneous SE of opiates may be dependent on the variant of SNP COMT 1947G>A: in genotype GG the cutaneous pruritis rate is in 2.9 times more, than in the AA+GA group (p < 0.05).

Comparison of postoperative nausea between benign and malignant brain tumor patients undergoing awake craniotomy: a retrospective analysis

BACKGROUND

Benign and malignant brain tumors have different histopathological characteristics, including different degrees of tissue infiltration and inflammatory response. The aim of this retrospective study was to compare the incidence of postoperative nausea between the two categories of brain tumors in patients undergoing awake craniotomy.

METHODS

After IRB approval, we retrospectively extracted data from perioperative records between January 2005 and December 2010. Patients were divided based on the postoperative histopathological diagnosis into two groups, benign and malignant. The incidence of nausea, rescue anti-emetics, pain scores and postoperative analgesic requirements were compared between the two groups up to 12 hours postoperatively. Intraoperative anti-emetic, anesthetic, and analgesic regimens were also assessed. Limitations of this study include the retrospective design, the arbitrary dichotomization of tumors as benign or malignant, and the inability to gather accurate data regarding vomiting from the medical record.

RESULTS

Data from 415 patients were available for analysis, with 115 patients in the benign group and 300 patients in the malignant tumor group. A higher postoperative mean pain score was found in the benign brain tumor group compared to the malignant brain tumor group (P < 0.05). However, there was no difference in the incidence of nausea between the two groups.

CONCLUSION

The different histopathological characteristics of brain tumors have no association with postoperative nausea in patients undergoing awake craniotomy. Patients with benign brain tumors experience more pain than patients with malignant brain tumors. This difference in postoperative pain may be due to the younger age of the patients in the benign group.

Does midline shift predict postoperative nausea in brain tumor patients undergoing awake craniotomy? A retrospective analysis

BACKGROUND

The presence of midline shift on neuroradiologic studies in brain tumor patients represents mass effect from the tumor and surrounding edema. We hypothesized that baseline cerebral edema as measured by midline shift would increase postoperative nausea (PON). We studied the incidence of PON in brain tumor patients, with and without midline shift on preoperative magnetic resonance (MRI) or computed tomographic (CT) imaging, undergoing awake craniotomy.

METHODS

After IRB approval, we retrospectively extracted data from perioperative records between January 2005 and December 2010. Post-craniotomy nausea and pain scores were collected. Intraoperative anti-emetic, anesthetic, and analgesic regimens were assessed. Both the rescue anti-emetic and cumulative postoperative analgesic requirements were collected up to 12 hours postoperatively. The amount of midline shift on preoperative neuroimaging was gathered from radiology reports. Univariate comparisons between groups (no midline shift vs. midline shift) were made with t-tests for continuous variables, and chi-square tests for categorical variables. A multivariable analysis was performed to identify predictors of postoperative nausea. Limitations of this study include the retrospective design and the inability to gather accurate data regarding vomiting from the medical record.

RESULTS

Data from 386 patients were available for analysis. Patients were divided into two groups: no midline shift (n = 283) and midline shift (n = 103). The mean midline shift distance was 5.96 mm (95% CI [5.32, 6.59]). There was no difference in the incidence of nausea or pain scores between the two groups. More malignant brain tumor patients were in the midline shift group, as determined by the postoperative histopathological diagnosis (P < 0.05). Patients in the midline shift group also had longer anesthesia and surgical times (P < 0.05).

CONCLUSION

In patients undergoing a standardized anesthetic for awake craniotomy for tumor resection, the presence of preoperative midline shift did not correlate with postoperative nausea.

Preventing postoperative nausea and vomiting: refresh your knowledge of how to recognize and respond to this common complication

For surgical patients, postoperative nausea and vomiting (PONV) is one of the most undesired complications of anesthesia and surgery.

Immune mediators of postoperative ileus

CLINICAL BACKGROUND: In all patients undergoing abdominal surgery, a transient phase of interruption of bowel motility, named postoperative ileus (POI) occurs. POI is often accepted as an unavoidable "physiological" response and a self-limiting complication after surgery although it has a significant impact on patient morbidity with prolonged hospitalization and increased costs. Annual economic burden has been estimated as much as US $1.47 billion in the USA (Iyer et al. in J Manag Care Pharm 15(6):485-494, 2009).

PATHOPHYSIOLOGY

The pathophysiology has been elucidated within the last decades, demonstrating that both, neurogenic and inflammatory mechanisms are involved in response to the surgical trauma. It is now generally accepted that POI pathogenesis processes in two phases: a first neurogenic phase is accountable for the immediate postoperative impairment of bowel motility. This is followed by a second immunological phase that can last for days and mainly affects strength and length of POI. More recent findings demonstrate a bidirectional interaction between the nervous and the immune system, and this interaction significantly contributed to our present understanding of POI pathophysiology. Although nerval mechanisms have a significant impact in the early phase of POI, the contribution of the immune system and subsequently its manipulation has risen as the most promising strategy in prevention or treatment of the clinically relevant prolonged form of POI.

AIMS

The present manuscript will give an update on the inflammatory responses, the involved cell types, and participating immune mediators in POI.

Effects of fentanyl on gastric myoelectrical activity: a possible association with polymorphisms of the mu-opioid receptor gene?

BACKGROUND

Opioids have inhibitory effects on gastric motility, but the mechanism is far from clear. Electrical slow waves in the stomach determine the frequency and the peristaltic nature of gastric contractions. The primary aim of this study was to investigate the effects of the opioid fentanyl on gastric myoelectric activity. As there were large variations between the subjects, we investigated whether the variation was correlated to single nucleotide polymorphisms (SNP) of the mu-opioid receptor (MOR) gene.

METHODS

We used cutaneous multichannel electrogastrography (EGG) to study myoelectrical activity in 20 patients scheduled for elective surgery. Fasting EGG was recorded for 30 min, followed by intravenous administration of fentanyl 1 microg/kg and subsequent EGG recording for 30 min. Spectral analysis of the two recording periods was performed and the variables assessed were dominant frequency (DF) of the EGG and its power (DP). Genetic analysis of the SNP A118G and G691C of the MOR gene was performed with the polymerase chain reaction technique.

RESULTS

There was a significant reduction in DF and DP after intravenous fentanyl. However, there was a large variation between the patients. In eight subjects EGG was unaffected, five subjects had a slower DF (bradygastria) and in six subjects the slow waves disappeared. We found no correlation between the EGG outcome and the presence of A118G or G691C in the MOR gene.

CONCLUSIONS

Fentanyl inhibited gastric myoelectrical activity in about half of the subjects. The variation could not be explained by SNP in the MOR gene. Because of small sample size, the results must be regarded as preliminary observations.

Mechanisms underlying postoperative nausea and vomiting and neurotransmitter receptor antagonist-based pharmacotherapy

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications following surgery, and understanding the mechanism(s) underlying PONV is essential to providing optimal prophylaxis and/or treatment of PONV. The knowledge base of PONV physiology has significantly expanded over the past decade. This article reviews the risk factors for the development of PONV and the mechanisms of action of pharmacological agents (including antagonists of serotonin 5-HT(3), dopaminergic D(2), histamine H(1), muscarinic cholinergic, opioid and neurokinin NK(1) receptors) for the management (i.e. prophylaxis and treatment) of PONV. NK(1) receptor antagonists, with their unique mechanism of action, are a particularly promising area of research as they appear to be efficacious in preventing PONV during both the early and the late postoperative periods. A successful PONV management strategy includes: (i) identifying patients at risk; (ii) keeping the baseline risk low; and (iii) using a combination of antiemetics acting on different receptors in moderate- to high-risk patients.

Management of postoperative nausea and vomiting in children

Postoperative nausea and vomiting (PONV) continues to be a frequent and important cause of morbidity in children. Postoperative vomiting (POV) is more commonly studied in children than postoperative nausea because of a child's inability to effectively express distress after experiencing nausea. POV is problematic in children and is one of the leading postoperative complaints from parents and the leading cause of readmission to the hospital. POV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult incidence rates. Gender differences are not seen before puberty. POV remains a main cause of morbidity in children because severe vomiting can be associated with dehydration, postoperative bleeding, pulmonary aspiration, and wound dehiscence. While children have an increased potential for dehydration and the resulting physiologic impairments, other associated results such as a delay in hospital discharge or an overnight or longer hospital admission also must be considered. The two most common emetogenic surgical procedures evaluated in children are strabismus repair and adenotonsillectomy. The approach to the management of PONV and POV in children is similar to that in adults. However, as the rate of POV is more frequent in children than in adults, more children are candidates for antiemetic prophylaxis. The management approach is multifactorial and involves proper preoperative preparation, risk stratification, rational selection of antiemetic prophylaxis, choice of anesthesia technique, and a plan for postoperative antiemetic therapy. It is important to identify children at moderate-to-high risk for POV as prophylactic antiemetic therapy is useful in these children. Antiemetics of choice for POV in children include dexamethasone, dimenhydrinate, perphenazine, ondansetron, dolasetron, granisetron, and tropisetron. The serotonin (5-hydroxytryptamine; 5-HT(3)) antagonists are the antiemetic drugs of first choice for POV prophylaxis in children because as a group they have greater efficacy for preventing vomiting than nausea. The 5-HT(3) antagonists can be effectively combined with dexamethasone with an increase in efficacy. If possible, regional anesthesia should be considered. For those undergoing general anesthesia, the baseline POV risk should be reduced. Children at moderate-to-high PONV risk should receive combination therapy with two or three prophylactic antiemetics from different antiemetic drug classes. Reference to and the use of PONV guidelines and management algorithms help improve cost-effective postoperative care.

A randomized, double-blind comparison of the NK1 antagonist, aprepitant, versus ondansetron for the prevention of postoperative nausea and vomiting

BACKGROUND

Antiemetics currently in use are not totally effective. Neurokinin-1 receptor antagonists are a new class of antiemetic that have shown promise for chemotherapy-induced nausea and vomiting. This is the first study evaluating the efficacy and tolerability of the neurokinin-1 receptor antagonist, aprepitant, for the prevention of postoperative nausea and vomiting.

METHODS

In this multicenter, double-blind trial, we randomly assigned 805 patients receiving general anesthesia for open abdominal surgery to a preoperative dose of aprepitant 40 mg orally, aprepitant 125 mg orally, or ondansetron 4 mg IV. Vomiting, nausea, and use of rescue therapy were assessed over 48 h after surgery. Treatments were compared using logistic regression.

RESULTS

Incidence rates for the primary end point (complete response [no vomiting and no use of rescue] over 0-24 h after surgery, tested for superiority of aprepitant) were not different across groups (45% with aprepitant 40 mg, 43% with aprepitant 125 mg, and 42% with ondansetron). The incidence of no vomiting (0-24 h) was higher with aprepitant 40 mg (90%) and aprepitant 125 mg (95%) versus ondansetron (74%) (P < 0.001 for both comparisons), although between-treatment use of rescue and nausea control was not different. Both aprepitant doses also had higher incidences of no vomiting over 0-48 h (P < 0.001). No statistically significant differences were seen among the side effect profiles of the treatments.

CONCLUSIONS

Aprepitant was superior to ondansetron for prevention of vomiting in the first 24 and 48 h, but no significant differences were observed between aprepitant and ondansetron for nausea control, use of rescue, or complete response.

Postoperative granuloma after stapedectomy: is it destiny or avoidable?

OBJECTIVE

The aims of this study were (1) to investigate the pathophysiological characteristics of the middle ear mucoperiosteum against the caustic nature of the gastric content (GC), which consists largely of acid and pepsin components, and (2) to investigate the possible role of gastroesophageal reflux and postoperative vomiting (POV) in the etiology of poststapedectomy granuloma.

METHODS

40 Spraque-Dawley rats of either sex and with a body weight of 200-300 g were used, and divided into different study groups: group 1: GC administration to the middle ear (n = 8); group 2: phosphate-buffered saline administration to the middle ear (n = 8); group 3: GC (pH: 2) administration in the presence of a Teflon piston (TP) (n = 6); group 4: phosphate-buffered saline administration in the presence of a TP (n = 6); group 5: GC administration in the presence of a wired piston (WP) (n = 6); group 6: phosphate- buffered saline administration in the presence of a WP (n = 6). GC was administrated to the middle ear cavities by way of the eustachian tube (ET). In order to overcome the pressure of the ET, a pump mechanism was used. The increased nasopharyngeal pressure caused a passive opening of the ET, and transferred a bolus to the middle ear. The animals were decapitated after 1 week, and the bullae were isolated. The tympanic bullae were serially cut and examined with light microscopy.

RESULTS

In the saline controls, there was only a mild amount of polymorphonuclear cell (PMN) infiltration in the mildly thickened subepithelial space, indicating a less pronounced inflammation as compared to the gastric acid group. In the GC group, in addition to focal hemorrhage and severe subepithelial infiltration of PMNs, the middle ear mucosa was dramatically thickened with subepithelial edema and dilated capillaries. In the subepithelial tissue, retention cysts and granulation tissue were present. In the piston groups (TP and WP), there was extensive subepithelial inflammation and edema after GC and saline administrations. Granulation tissue filling the entire bulla around the piston segments was detected.

CONCLUSION

The relationship between the administration of GC and middle ear inflammation, and the possible role of POV in the etiology of poststapedectomy granuloma are emphasized with our experimental study. The length of the TP may be considerably important to prevent POV which may lead to gastric reflux to the middle ear.

Therapeutic Modalities for the Prophylactic Management of Postoperative Nausea and Vomiting

The occurrence of postoperative nausea and vomiting (PONV) remains one of the most common complications after general anesthesia. The causes of PONV are multimodal, involving several physiologic pathways that stimulate the vomiting center, including the chemoreceptor trigger zone, the gastrointestinal tract, the vestibular system, the cerebral cortex, and the midbrain. Significant research has been published focusing on the use of different pharmacologic agents and varying anesthetic techniques to prevent and manage PONV. The addition of therapeutic modalities to the arsenal of prophylactic management techniques may decrease patient incidence of PONV by directing treatment to various pathways that stimulate the vomiting center. The purpose of this article is to review briefly the literature and discuss three therapeutic modalities for preventing PONV: perioperative oxygen administration, perioperative intravenous fluid administration, and differing fasting protocols.

The Twenty-Degree Reverse-Trendelenburg Position Decreases the Incidence and Severity of Postoperative Nausea and Vomiting After Thyroid Surgery

BACKGROUND

In this randomized, single-blind, controlled study, we evaluated whether the 20 degrees reverse-Trendelenburg position had an effect on postoperative nausea and vomiting in patients undergoing thyroid surgery.

METHODS

Patients (n = 224) were given a standardized propofol anesthetic. Intraoperatively, patients were randomly assigned into two groups according to the tilt of the table maintained during surgery: patients were positioned with the neck extended and the table tilted with 20 degrees reverse-Trendelenburg or with the neck extended and the table positioned at a horizontal tilt. All episodes of postoperative nausea, vomiting, nausea severity score, frequency of vomiting, and the use of antiemetics were recorded during the first 24 h after anesthesia. We divided this time period into 0-3 h and 3-24 h.

RESULTS

During the 0-3 h postoperative period, all observed episodes were comparable between groups. However, during the 3-24 h and the overall postoperative period, the incidence of nausea and/or vomiting, the nausea severity score, and frequency of vomiting were significantly less in the 20 degrees reverse-Trendelenburg position.

CONCLUSION

The 20 degrees reverse-Trendelenburg position effectively ameliorates postoperative nausea and/or vomiting.

Alleviation of intracranial air using carbon dioxide gas during intraventricular tumor resection

OBJECTIVES/PURPOSES

Postoperative vomiting occurs more frequently in patients after intraventricular surgery than after other intracranial surgeries. This has been attributed to intracranial air. Carbon dioxide gas (CO2) has properties beneficial to the treatment of some medical disorders, displaying a higher specific gravity and more rapid absorption into surrounding tissues than air. We therefore, attempted to replace air with CO2 during intra- and paraventricular tumor resections. The aim of the present study was to elucidate whether intracranial air after intraventricular surgery could be alleviated safely using CO2, and investigate its clinical usefulness.

PATIENTS AND METHODS

CO2 was introduced into the subdural space at 2l/min through a silicon tube from time of dural incision to closure. Subjects comprised 40 patients alternately assigned to one of two groups: the trial group (n=20) receiving CO2 treatment; and controls (n=20) without CO2 treatment.

RESULTS

Intra- and postoperatively, no patients showed complications caused by CO2 treatment. Postoperatively, intraventricular gas shown on CT scans disappeared significantly sooner in the trial group than in controls. Frequency of postoperative vomiting was significantly lower in the trial group than in controls.

CONCLUSION

Intracranial air after intraventricular surgery can be safety alleviated using CO2.

Postoperative nausea and vomiting

Nausea and vomiting following surgery may either occur as postoperative nausea and vomiting, which is a condition that is mainly related to anesthesia, or as secondary to postoperative ileus, which denotes inhibition of gastrointestinal motility following surgery. Postoperative ileus is a multifactorial event with several contributing mechanisms. Although postoperative nausea and vomiting pathophysiology has been quite well-studied little is known about it. There are multiple targets for treatment, prevention, and its successful empirical management e.g. by 5-HT(3) receptor antagonists. This review describes different aspects of the pathophysiology of postoperative ileus and postoperative nausea and vomiting, their relevance to postoperative care, and the standardized approach to manage postoperative nausea and vomiting that was established by Apfel and coworkers. Despite the recent advances in the understanding and treatment of conditions that trigger nausea and vomiting in the postoperative period, these symptoms remain a significant problem that affects patients' recovery, comfort, and treatment cost.

Correlation of postoperative pain to quality of recovery in the immediate postoperative period

BACKGROUND AND OBJECTIVES

It is unclear whether the severity of postoperative pain may affect patients' quality of recovery in the immediate postoperative period (within 2 weeks of surgery).

METHODS

This was a prospective, observational study in patients undergoing elective radical retropubic prostatectomy. All patients received a standardized intraoperative general or spinal anesthetic followed by intravenous patient-controlled analgesia. Visual analog scores for pain at rest, pain with activity, and nausea along with the QoR, an instrument validated to assess quality of recovery in the postoperative period, and Brief Fatigue Inventory were assessed on postoperative days 1 to 3, 7, and 30. The Epworth Sleepiness Scale was assessed on postoperative days 7 and 30.

RESULTS

We found that the severity of pain both at rest and with activity correlated with a decrease in quality of recovery as assessed by the QoR.

CONCLUSIONS

Our findings suggest that an increase in postoperative pain is correlated with a decrease in a patient's quality of recovery in the immediate postoperative period.

The Role of 5-HT3 Receptor Antagonists in Preventing Postoperative Nausea and Vomiting

Postoperative nausea and vomiting (PONV) is a frequent complication of surgery. Guidelines recommend using a 5-HT3 receptor antagonist (eg, ondansetron, dolasetron, granisetron) combined with a second agent (eg, dexamethasone) for patients at moderate to high risk for PONV. Although all 5-HT3 antagonists are effective, ondansetron and granisetron have been found to be effective at substantially lower doses than those approved by the US Food and Drug Administration. Metabolism of granisetron differs from metabolism of other 5-HT, antagonists, so it is less likely to adversely interact with other medications. This article explains the clinical pharmacology of 5-HT3 antagonists and provides recommendations for nursing management of PONV.

Prevention of postoperative nausea and vomiting after thyroidectomy: combined antiemetic treatment with dexamethasone and ginger versus dexamethasone alone

BACKGROUND

The aim of this study was to compare the prophylactic effects of dexamethasone plus ginger and dexamethasone alone on postoperative nausea and vomiting (PONV) in patients undergoing thyroidectomy.

METHODS

One hundred and twenty patients undergoing general anaesthesia for thyroidectomy were enrolled in this randomised, double-blind study. Patients received oral diazepam 10mg with either oral placebo (group I) or 0.5g of ginger (group II) as premedication 1 hour prior to surgery. Standard general anaesthetic techniques and postoperative analgesia were employed. Both group I and group II received intravenous dexamethasone 150 microg/kg immediately before the induction of anaesthesia. Data were recorded over a 24-hour observation period after surgery.

RESULTS

In the dexamethasone-treated group, 14 patients experienced nausea, two patients retched, three patients vomited once, two patients vomited repeatedly, and 14 patients required a rescue antiemetic. In the dexamethasone-plus-ginger-treated group, 12 patients experienced nausea, one patient retched, four patients vomited once, no patients vomited repeatedly, and 13 patients required a rescue antiemetic. Dexamethasone plus ginger did not significantly reduce nausea and vomiting compared with dexamethasone alone during the observation period.

CONCLUSION

In conclusion, the prophylactic combination of antiemetic treatment with dexamethasone and ginger was not clinically or statistically superior to dexamethasone alone in preventing PONV in patients undergoing thyroidectomy.

A prospective randomized blinded study of the effect of intravenous fluid therapy on postoperative nausea and vomiting in children undergoing strabismus surgery

BACKGROUND

Nausea and vomiting is a common postoperative complication that often necessitates the use of antiemetic agents.

METHODS

In a prospective, randomized, double blind trial, the effect of perioperative fluid administration on postoperative adverse outcomes following anesthesia was studied. One hundred children undergoing strabismus repair were randomly assigned to receive 10 ml x kg(-1) x h(-1) (control group) or 30 ml x kg(-1) x h(-1) (superhydration group) of lactated Ringer's solution during the operation. During the first 24 h postoperatively, nausea and vomiting, thirst, pain, and fever were evaluated.

RESULTS

Groups were similar with respect to demographic data, surgical procedures and baseline hemodynamic variables. In the first 24 h postoperatively, nausea and vomiting occurred in 27 patients (54%) of the control group and 11 (22%) of patients in the superhydration group (P = 0.001). Comparison of the superhydration group with the control group also showed a statistically significant benefit of superhydration on postoperative thirst (P = 0.0002) and fever (P = 0.02). The differences in nausea and vomiting, thirst, and fever remained significant after adjustment for age, gender, weight, and duration of surgery. There was no significant difference between the two groups in postoperative pain.

CONCLUSIONS

Intravenous superhydration administration is an inexpensive and safe therapy for reducing postoperative nausea and vomiting and discomfort.

Interaction between tramadol and two anti-emetics on nociception and gastrointestinal transit in mice

BACKGROUND

Clinical studies suggest that tramadol-induced analgesia is partially antagonized by ondansetron.

AIMS

To investigate the type of interaction between tramadol and two anti-emetics on antinociception and gastrointestinal transit in mice.

METHODS

We assessed the antinociceptive (acetic acid writhing test, plantar test) and antitransit (charcoal meal) effects of tramadol individually, and combined with ondansetron or droperidol in female Swiss CD-1 mice. Isobolograms and analysis of variance were used to determine the type of interaction.

RESULTS

In the writhing test, tramadol, ondansetron and droperidol, each induced dose-related inhibition of nociception. The ED(50)'s were: tramadol 4.2+/-0.33 mg kg(-1); ondansetron 1.03+/-0.05 mg kg(-1), and droperidol 1.00+/-0.14 mg kg(-1). Dose-response curves were also obtained with tramadol combined with ondansetron or droperidol at 1:1 fixed ratios. The isobolographic analysis demonstrated antagonism for both combinations. In the plantar test, the ED(50) for tramadol was 51.4+/-2.3 mg kg(-1), but no dose-response curves could be obtained with ondansetron or droperidol individually. The interaction was assessed from dose-response curves to tramadol in the presence of a fixed dose of ondansetron (0.1 mg kg(-1)) or droperidol (0.05 mg kg(-1)). The results show antagonism between tramadol-ondansetron (p<0.05) and no interaction for the tramadol-droperidol combination. Both anti-emetics antagonized the antitransit effects of tramadol.

CONCLUSIONS

The interaction of tramadol with ondansetron or droperidol on antinociception can be antagonistic or additive, depending on the type of stimuli. Both anti-emetics antagonize the anti-transit effects of tramadol. The results demonstrate antagonism between tramadol and the two anti-emetics for analgesia and inhibition of gastrointestinal transit, supporting previous clinical studies.

PONV: a problem of inhalational anaesthesia?

Even nowadays every third or fourth patient suffers from postoperative nausea and vomiting (PONV) after general anaesthesia with volatile anaesthetics. There is now strong evidence that volatile anaesthetics are emetogenic and that there are no meaningful differences between halothane, enflurane, isoflurane, sevoflurane, and desflurane in this respect. However, when propofol is substituted for volatile anaesthetics the risk for PONV is reduced by only about one fifth, indicating that there are other even more important causes for PONV following general anaesthesia. A main causative factor might be the use of perioperative opioids, but their impact--relative to other factors including volatile anaesthetics--has never been quantified. Patient-specific risk factors have also been shown to be clinically relevant; they are therefore included in the calculation of simplified risk scores that allow prediction of a patient's risk independent of the type of surgery. Although controversial, the well-known different incidences following certain types of surgery are most likely caused by patient-specific and anaesthesia-related risk factors. There is a common consensus that prophylaxis with anti-emetic strategies is rarely justified when the risk of PONV is low, while it is warranted in case of imminent medical risk associated with vomiting or in a patient with a high risk for PONV. A recently published large multicentre trial of factorial design, IMPACT, has demonstrated that various anti-emetic strategies are associated with a very similar and constant relative reduction rate of about 25-30% and that the main predictor for the efficacy of prophylaxis is the patient's risk for PONV. Interestingly, all anti-emetics (dexamethasone, droperidol and ondansetron) work independently, so that their combined benefit can be derived directly from the single effects. The effectiveness of the anti-emetics was also independent of a variety of risk factors, including volatile anaesthetics. This means that any anti-emetic prophylaxis for PONV induced by volatile anaesthetics is equally effective. Of course, the most logical approach for prevention would be the omission of volatile anaesthetics and nitrous oxide using a total intravenous anaesthesia with propofol. However, since volatile anaesthetics are probably not the most important risk factors, it might be even better--if appropriate--to avoid general anaesthesia by using a regional, opioid-free anaesthesia if PONV is a serious problem.

Blood-borne factors possibly associated with post-operative nausea and vomiting: an explorative study in women after breast cancer surgery

BACKGROUND

The pathophysiology behind post-operative nausea and vomiting (PONV) is still not fully understood, especially with respect to gender. According to PONV risk scores, female gender is the strongest predictor for PONV. The risk for PONV after general anaesthesia for breast cancer surgery is 50-80%. The aim of the present explorative study was to identify blood-borne factors that might be associated with the development of PONV in women undergoing breast cancer surgery as a basis for further studies.

METHODS

Fifty patients were enrolled prospectively in the study. A standardized sevoflurane-based anaesthetic was used. Blood samples for the analysis of vasopressin, gastrin, cholecystokinin, epinephrine, norepinephrine, dopamine, serotonin, platelet count and blood glucose were taken at six pre-determined time points peri-operatively, and PONV was assessed during 24 h.

RESULTS

PONV was found in 27 of 47 patients completing the study. Patients with PONV had a larger variability of the platelet count (P = 0.001), a reduced platelet count on the first post-operative day (P = 0.02) and a less pronounced relationship between the platelet count and whole blood serotonin (P = 0.004) compared with non-PONV patients. A lack of a decrease in epinephrine levels in response to the induction of anaesthesia (P = 0.03) and increased levels of vasopressin (P < 0.001), epinephrine (P = 0.005) and blood glucose (P = 0.004) were observed in the early post-operative period in PONV patients.

CONCLUSION

Three different platelet-associated factors and an altered epinephrine pattern were found to be associated with the occurrence of PONV after breast cancer surgery.

Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron

BACKGROUND

At dosages above 0.1 mg/kg, droperidol induces a dose-dependent QTc interval prolongation. Although subject to controversy, low-dose droperidol has recently been suspected to induce cardiac arrhythmias. Hence, 5-hydroxytryptamine type 3 antagonists have become the first-line drug for management of postoperative nausea and vomiting. These drugs are also known to prolong the QTc interval at high dosages. This study describes QTc interval changes associated with postoperative nausea and vomiting treatment by droperidol or ondansetron at low doses.

METHODS

Eighty-five patients with postoperative nausea and vomiting were included in this prospective, single-blind study. Patients received either 0.75 mg intravenous droperidol (n = 43) or 4 mg intravenous ondansetron (n = 42). Electrocardiographic recordings were obtained before administration of antiemetic drug and then 1, 2, 3, 5, 10, and 15 min after. Electrocardiographic monitoring was maintained for 3 h in eight patients in each group.

RESULTS

The QTc interval was prolonged (> 450 ms in men, > 470 ms in women) in 21% of the patients before antiemetic drug administration. This was significantly correlated with lower body temperature and longer duration of anesthesia. Compared with predrug QTc measurement, both antiemetics were associated with a significant QTc interval prolongation (P < 0.0001). The mean maximal QTc interval prolongation was 17 +/- 9 ms after droperidol occurring at the second minute and 20 +/- 13 ms after ondansetron at the third minute (both P < 0.0001). Compared with predrug measurement, the QTc interval was significantly lower after the 90th minute in both groups.

CONCLUSIONS

Droperidol and ondansetron induced similar clinically relevant QTc interval prolongations. When used in treatment of postoperative nausea and vomiting, a situation where prolongation of the QTc interval seems to occur, the safety of 5-hydroxytryptamine type 3 antagonists may not be superior to that of low-dose droperidol.

Inspired Oxygen Fraction of 0.8 Does Not Attenuate Postoperative Nausea and Vomiting after Strabismus Surgery

Background

Postoperative nausea and vomiting (PONV) is a distressing problem after strabismus surgery. An inspired oxygen fraction has been reported to decrease PONV in patients after colon resection and to be more effective than ondansetron after gynecologic laparoscopy. Therefore, in a randomized, prospective, placebo-controlled study, the authors tested whether an inspired oxygen fraction of 0.8 decreases PONV in patients undergoing strabismus surgery and whether oxygen is more effective than ondansetron.

Methods

With approval of the authors' institutional review board, 210 patients were randomly assigned to receive one of three treatments: (1) 30% inspired oxygen in air plus intravenous administration of saline, (2) 80% inspired oxygen in air plus intravenous administration of saline, or (3) 30% inspired oxygen in air plus 75 microg/kg ondansetron intravenously during induction. General anesthesia was standardized and included etomidate, alfentanil, and mivacurium for induction and sevoflurane for maintenance. PONV was evaluated 6 and 24 h postoperatively by an investigator unaware of treatment assignment.

Results

Overall postoperative incidence of nausea and vomiting was 41% for inspired oxygen fraction of 0.3 plus placebo, 38% for inspired oxygen fraction of 0.8 plus placebo, and 28% for inspired oxygen fraction of 0.3 plus ondansetron, respectively (P = 0.279). Therefore, there was no statistically significant difference of PONV incidence among groups.

Conclusions

An inspired oxygen fraction of 0.8 during general anesthesia with sevoflurane does not decrease PONV in patients undergoing strabismus repair. Ondansetron also did not significantly decrease PONV in our study setting.

Multimodal antiemetic therapy and emetic risk profiling

INTRODUCTION

Postoperative nausea and vomiting (PONV) is a common problem with no simple solution. This review highlights factors that are known to increase the risk of PONV. It examines the various data on pharmacological and non-pharmacological methods that have been used to prevent PONV.

METHODS

Peer-reviewed journals on the subject were covered.

CONCLUSION

Patient, surgical and anaesthetic factors increase the risk of PONV. While patient and surgical factors are understandably difficult to control, a multimodal approach involving both pharmacological and non-pharmacological interventions has been successfully adopted to reduce the incidence of PONV. Various factors have been identified to categorise patients into different profiles to determine their risk of PONV. Perioperative strategies can then be targeted at these patient groups.

Use of intravenous midazolam and clonidine in cyclical vomiting syndrome: a case report

We report a case of a teenage boy with cyclical vomiting syndrome (CVS) who was referred to the anesthesia-run postoperative pain service for symptom management. His symptoms were uncontrolled by oral pizotifen prophylaxis and acute therapy with intravenous (IV) hydration and ondansetron. A continuous low dose IV midazolam infusion was added to his treatment regimen (as is instituted for recalcitrant postoperative nausea and vomiting) with benefit, but not total symptom resolution. Recent literature review suggested links between migraine, CVS and adrenergic autonomic dysfunction. Consequently, IV clonidine was administered, in addition, with recovery. This combination was reinstituted successfully on subsequent admissions and emergency department presentations with shortened episode durations from 4-5 days to 16-48 h. It is uncertain if clonidine's sympatholytic effects were significantly beneficial or if associated sedation or natural resolution were contributors. Many agents have been used in CVS therapy but no trials have been done. Neither midazolam nor clonidine has been reported previously as used in the treatment of CVS. The apparent success of this combination raises possibilities both for future trials and research into the pathogenesis of CVS.

Prophylaxis of postoperative nausea and vomiting with oral, long-acting dimenhydrinate in gynecologic outpatient laparoscopy

Dimenhydrinate is an inexpensive antiemetic with few side effects available as an oral, long-acting (LA) formulation (Gravol L/A) containing 25 mg of immediate and 50 mg of sustained release drug. We designed this double-blind comparison trial to assess the efficacy of dimenhydrinate LA versus droperidol alone and the combination for prophylaxis of nausea, vomiting, and retching in outpatient gynecologic laparoscopy. One-hundred-forty-one women were randomized into 3 groups: 1) droperidol (placebo capsule preoperatively and IV droperidol 0.625 mg before induction), 2) dimenhydrinate LA preoperatively and IV placebo before induction, or 3) combination. Information regarding nausea, vomiting, retching, pain, and sedation was recorded in the postanesthesia care unit (PACU) and collected by telephone for the presence of symptoms: on arrival home; at bedtime; upon arising, and at lunchtime the following day. The overall incidence of complete treatment failure (rescue medication in PACU or nausea, vomiting, or retching at any time point) was 28 of 46 (61%), 28 of 48 (58%), and 22 of 47 (47%); and for treatment failure vomiting (rescue medication in PACU or vomiting or retching at any time point) was 16 of 46 (35%), 11 of 48 (23%), and 5 of 47 (11%), for the droperidol, dimenhydrinate, and combination groups, respectively (P = 0.007 for droperidol versus combination). There were no differences in sedation or pain. Preoperative administration of an oral dose of LA dimenhydrinate in combination with droperidol when compared with droperidol alone effectively reduced the incidence of vomiting but not nausea in women undergoing elective outpatient gynecologic laparoscopy.

IMPLICATIONS

Dimenhydrinate is an inexpensive antiemetic with few side effects available as a long-acting oral formulation. Women undergoing outpatient gynecologic laparoscopy were given droperidol, an effective antiemetic, dimenhydrinate alone, or the combination of the two drugs. Dimenhydrinate plus droperidol significantly reduced the overall incidence of vomiting, but not nausea, when compared with droperidol alone.

[Postoperative nausea and vomiting]

Numerous pathophysiological mechanisms are known to cause nausea or vomiting but their role for postoperative nausea and vomiting (PONV) is not quite clear. Volatile anesthetics, nitrous oxide and opioids appear to be the most important causes for PONV. Female gender, non-smoking and a history of motion sickness and PONV are the most important patient specific risk factors. With these risk factors an objective risks assessment is achievable as a good rational basis for a risk dependent antiemetic approach: When the risk is low, moderate, or high, the use of none, a single or a combination of prophylactic antiemetic interventions seems to be justified. Performing a total intravenous anesthesia (Ti.v.A) with propofol is a reasonable prophylactic approach, but does not solve the problem satisfactorily alone if the risk is very high, reducing the risk of PONV only by 30%. This is comparable to the reduction rate of antiemetics, such as serotonin antagonist, dexamethasone and droperidol. It must be stressed that metoclopramide is ineffective. Data from IMPACT indicate that prophylaxis is not very effective if the patients risk is low. At a moderate risk the use of Ti.v.A or an antiemetic is reasonable and only a (very) high risk justifies the combination of several prophylactic antiemetic interventions. For the treatment of PONV an antiemetic should be chosen which has not been used prophylactically. The necessary doses are usually a quarter of those needed for prophylaxis.

Disturbing post-operative symptoms are not reduced by prophylactic antiemetic treatment in patients at high risk of post-operative nausea and vomiting

BACKGROUND

To give prophylactics or timely treatment for post-operative nausea and vomiting (PONV) is the question. We compared the intensity and number of disturbing post-operative symptoms (i.e. pain, PONV, headache, fatigue, etc.) after prophylactic antiemetic treatment in a group of patients with >30% risk for post-operative vomiting.

METHODS

Four hundred and ninety-five patients, from three hospitals, planned for gynaecological surgery were randomized double blind. They were given granisetron 3 mg, droperidol 1.25 mg or no prophylactic antiemetic. Post-operative symptoms were followed for 24 h using a questionnaire. Symptoms were analyzed both according to their intensity and in a dichotomous fashion.

RESULTS

The intensity of different symptoms differed depending on whether droperidol, granisetron or no antiemetic had been given (P = 0.005) but the overall incidence of moderate to very severe symptoms was similar in all groups. No group fared better in general. The total number of symptoms was higher in the groups given prophylactic treatment (P < 0.05). The relative risk reduction for PONV with granisetron or droperidol prophylaxis was 27%[95% confidence interval (CI) 8-43] and 22% (2-38), respectively. The NNT (number needed to treat) for granisetron (0-24 h) was 7 and for droperidol 8. The NNH (number needed to harm) (0-24 h) for headache and visual disturbances was 6 and 13 (NS) for granisteron and, 50 (NS) and 6 for droperidol.

CONCLUSION

The intensity of symptoms or the total number of disturbing symptoms did not decrease after prophylactic antiemetic treatment in a group of patients, but the profile of disturbing symptoms changed. The relevance of post-operative symptoms in terms of patients' well-being needs to be addressed.

Effect of combining naloxone and morphine for intravenous patient-controlled analgesia

BACKGROUND

An early study showed that a naloxone infusion decreased the incidence of morphine-related side effects from intravenous patient-controlled analgesia. The authors tested the hypothesis that a more convenient combination of morphine and naloxone via patient-controlled analgesia would decrease the incidence of side effects compared to morphine alone.

METHODS

Patients scheduled for hysterectomy under general anaesthesia were enrolled in a double-blind, randomized, placebo-controlled trial. Patients received a standardized general anesthetic and postoperative patient-controlled analgesia. They were randomized to receive 60 mg patient-controlled analgesia morphine in 30 ml saline or 60 mg morphine in 30 ml saline with naloxone 0.8 mg. Parameters for patient-controlled analgesia were a 1-mg bolus of morphine with a 5-min lockout and no background infusion. Patient recall of nausea, vomiting, itching, and pain (at rest and with movement) were assessed at 6 and 24 h postoperatively by verbal rating score. Pain was also assessed by a 0- to 100-mm visual analog score, and sedation was assessed by an observer. The amount of morphine used and the requirements for symptomatic treatment were also recorded.

RESULTS

Ninety-two patients completed the study, with no significant differences in outcomes between groups. At 24 h, the incidence of nausea was 84.8% in each group; the incidence of pruritus was 56.5% in the naloxone group and 58.7% in the placebo group. There were also no differences in symptomatic treatment requirements, pain scores, morphine use, or sedation between groups. The median dose of naloxone received equated to 0.38 microg x kg-1 x h-1 over 24 h.

CONCLUSIONS

There was no benefit from administering naloxone combined with morphine via patient-controlled analgesia.

Antiemetic prophylaxis: pharmacology and therapeutics

Postoperative nausea and vomiting (PONV), a common problem with complex causes, may result in substantial complications. This Journal course discusses the pathogenesis of PONV and reviews antiemetic pharmacology. Corticosteroids, gastrointestinal prokinetics, neuroleptic butyrophenones, phenothiazines, and serotonin receptor antagonists may be prescribed alone or in combination. State-of-the-art anesthetic techniques for prevention of PONV are described. Multimodal therapy with combined low-dose antiemetics affecting multiple receptors is suggested to prevent PONV in high-risk patients such as nonsmokers, females with a previous history of nausea, and patients with high postoperative narcotic requirements.

Prophylactic ip injection of bupivacaine and/or morphine does not improve postoperative analgesia after laparoscopic gynecologic surgery

PURPOSE

To determine the effectiveness of ip bupivacaine and/or morphine for postoperative analgesia after laparoscopic surgery. A controversy exists on the effectiveness and clinical value of ip injection of local anesthetics for postoperative analgesia. A possible peripheral analgesic effect of morphine after ip injection remains debated as well.

METHODS

We conducted a randomized, double-blinded, study to compare the efficacy of prophylactic ip administration of 0.9% saline (n = 16), 0.5% bupivacaine (100 mg, n = 15), morphine (3 mg, n = 16) and a mixture with 0.5% bupivacaine (100 mg) and morphine (3 mg, n = 18) to reduce both postoperative pain scores and analgesic requirements after gynecologic laparoscopic surgery. A multimodal analgesia regimen (acetaminophen, nonsteroidal anti-inflammatory drugs and morphine) was used for postoperative analgesia.

RESULTS

No difference was observed in postoperative pain scores (visual analogue scale at rest and on coughing), or analgesic requirements during the first 24 postoperative hours between the four groups. There was also no significant intergroup difference in sedation scores and incidence of nausea and vomiting.

CONCLUSION

When multimodal postoperative analgesia is used, prophylactic ip administration of 100 mg bupivacaine and/or 3 mg morphine does not significantly improve postoperative analgesia in patients undergoing laparoscopic gynecologic surgery.

[Postoperative nausea and vomiting--pathophysiology, prophylaxis and treatment]

Postoperative nausea and vomiting (PONV) are among the most common complications in operative medicine. Especially patients undergoing middle ear surgery or adenotonsillectomy are frequently associated with PONV (70 %). Furthermore, emesis carries the risk of severe postoperative complications and is associated with additional costs and distress in patient management. If the patient carries a high risk for postoperative emesis, the patient should receive a prophylactic antiemetic therapy. 5-HT 3 receptor antagonists are highly effective in prevention and management of PONV. This review will discuss pathophysiology, prophylaxis and treatment of postoperative nausea and vomiting after E.N.T. surgery.

Postoperative nausea and emesis

Watcha and White [51] have made recommendations for antiemetic therapy and prophylaxis based on published peer-reviewed studies. They range from no prophylaxis for patients at low risk to "multimodal" antiemetic therapy for those at the highest risk (Fig. 1) [10]. Recommendations for rescue therapy of breakthrough PONV are also provided. With this approach, it should be possible [figure: see text] to individualize prophylaxis and rescue therapy to achieve an optimal cost-effective management strategy for this uncomfortable postoperative complication.

Intracerebral hemorrhage after spinal anesthesia

A rare case of intracerebral hematoma after spinal anesthesia is reported along with a review of the literature. The patient demonstrated a remarkable recovery after a timely diagnosis and surgical evacuation.