Postoperative Nausea Or Vomiting Research Articles

Effects of Systemic Lidocaine Versus Dexmedetomidine on the Recovery Quality and Analgesia After Thyroid Cancer Surgery: A Randomized Controlled Trial.

Surgical management is commonly used for thyroid cancer. We evaluated the effects of systemic lidocaine versus dexmedetomidine on the recovery quality and analgesia after thyroid cancer surgery. A total of 120 patients with thyroid cancer were randomly allocated to groupL (received lidocaine 1.5mg/kg loading, continuously infused 1.5mg/kg per hour), groupD (received dexmedetomidine 0.5µg/kg loading, continuously infused 0.5µg/kg per hour) and groupC (received normal saline), with 40 cases in each group. Anaesthesia induction and maintenance were performed using target-controlled infusions (TCIs) of propofol and remifentanil. The primary outcome of the quality of recovery-15 (QoR-15) score was recorded on the day before surgery and postoperative day1 (POD1). Secondary outcomes included the consumption of remifentanil during surgery, time to first required rescue analgesia, number of patients requiring rescue analgesia, postoperative cumulative consumption of tramadol, visual analogue scale (VAS) pain score, incidence of postoperative nausea or vomiting (PONV) and side effects. The total score of the QoR-15 at POD1 (median, IQR) was higher in groupL (128.0, 122.0-132.8) and groupD (127.5, 122.5-132.5) compared to groupC (118.5, 113.0-123.5) (P = 0.000). Compared to groupC, systemic lidocaine and dexmedetomidine reduced cumulative consumption of remifentanil and VAS pain score (P = 0.000). The time to first required rescue analgesia (mean, SD) was longer in groupL (8.1h, 1.2h) and groupD (8.5h, 1.9h) than groupC (5.9h, 0.9h) (P = 0.000). The number of patients requiring rescue analgesia was lower in groupL (8/40, 20%) and groupD (6/40, 15%) than groupC (16/40, 40%) (P = 0.029), and cumulative consumption of tramadol (mean, SD) was lower in groupL (44.0mg, 17.1mg) and groupD (51.7mg, 14.1mg) than groupC (73.9mg, 18.4mg) (P = 0.000). The incidence of PONV in groupL (7/40, 17.5%) and groupD (9/40, 22.5%) was lower than groupC (18/40, 45.0%) (P = 0.016). Bradycardia (heart rate less than 50beats/min or lower) was noted in 25 patients (25/40, 62.5%), which was reversed by intravenous administration of atropine 0.5mg. Systemic lidocaine and dexmedetomidine had similar effects on enhancing the quality of recovery, alleviating the intensity of pain and reducing the incidence of PONV after thyroid cancer surgery. However, dexmedetomidine may result in bradycardia. Therefore, lidocaine was superior to dexmedetomidine. ChiCTR.org.cn (ChiCTR2000038442). Registered on September 22, 2020.

Opioid-sparing effects of ultrasound-guided erector spinae plane block for adult patients undergoing surgery: A systematic review and meta-analysis.

Erector spinae plane block (ESPB) is a new method of administering analgesics to patients perioperatively. The aim of this meta-analysis was to evaluate the opioid-sparing effects of erector spinae plane block in patients during the perioperative period compared to conventional analgesia and identify its role in the development of opioid-free anesthesia. Relevant study articles were retrieved from PubMed, the Web of Science, Medline via Ovid, Embase via Ovid, and the Cochrane Central Register of Controlled Trials (CENTRAL) on June 11, 2020. We included randomized controlled trials (RCTs) comparing the use of ESPB with control (no/sham block). The primary outcome was opioid consumption at 24h after surgery and intraoperative opioid consumption. A random-effects model was used to calculate the standardized mean difference (SMD) and odds ratio (OR) with 95% confidence interval (CI) if there was significant heterogeneity in the data; otherwise, the fixed-effect model was used. A total of 25 randomized controlled trials involving 1461 patients were included. The use of ultrasound-guided ESPB was associated with reduced opioid consumption at 24h after surgery [SMD: -2.14, 95% CI: -2.61 to -1.67, p<0.001] and during the intraoperative period [SMD: -2.30, 95% CI: -3.21 to -1.40, p<0.001]. In addition, it took a longer time to administer the first rescue analgesia in the ESPB group [SMD: 3.60, 95% CI: 2.23-4.97, p<0.001] and the group was associated with lower incidences of postoperative nausea or vomiting (PONV) [OR: 0.50, 95% CI: 0.34-0.72, p<0.001]. Ultrasound-guided ESPB could provide an opioid-sparing effect and effective analgesia in adults undergoing surgeries with general anesthesia, and then promote opioid-free anesthesia development.

Ultrasound-guided bilateral superficial cervical plexus block enhances the quality of recovery of uremia patients with secondary hyperparathyroidism following parathyroidectomy: a randomized controlled trial

BackgroundParathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy.MethodsEighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded.ResultsThe scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 (P = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group (P = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia (P = 0.018), fewer patients requiring rescue analgesia (P = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group (P = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery (P = 0.000).ConclusionUltrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy.Trial registrationChiCTR1900027185. (Prospective registered). Initial registration date was 04/11/2019.

Effect of dexmedetomidine on opioid consumption and pain control after laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials

IntroductionThe clinical evidence on dexmedetomidine (DEX) for postoperative pain scores and opioid consumption remains unclear in laparoscopic cholecystectomy (LC).AimTo evaluate whether DEX could reduce opioid consumption and pain control after LC.Material and methodsA meta-analysis search of EMBASE, PubMed and Cochrane CENTRAL databases was performed and randomized controlled trials (RCTs) comparing DEX with control for adult patients undergoing LC were searched. The primary outcome was opioid consumption in the first 24 h after the operation. The secondary outcomes were the time of first request of analgesia, visual analogue scale (VAS) scores 24 h after the operation, the incidence of patients’ need for rescue analgesics, opioid-related adverse effects, DEX-related adverse effects and other complications.ResultsThere were fourteen aspects of twelve trials and 967 patients included in the analysis. DEX use significantly reduced the opioid consumption in the first 24 h after the operation (weighted mean difference (WMD), –19.17; 95% confidence interval (CI), –30.29 to –8.04; p = 0.0007), lengthened the time of first request of analgesia (WMD = 38.90; 95% CI: 0.88–76.93; p = 0.04) and lowered post-operative nausea or vomiting (PONV) (odds ratio (OR) = 0.49; 95% CI: 0.27–0.89; p = 0.02).ConclusionsIntravenous DEX infusion significantly improved the duration of the analgesic effect and reduced postoperative opioid consumption. Moreover, lower incidence of post-operative nausea or vomiting was found in the DEX group.

Sugammadex versus neostigmine for routine reversal of rocuronium block in adult patients: A cost analysis

Study objectiveThis report analyzes the comparative costs, efficacy and side effects of a newer, more expensive reversal drug, sugammadex, with its generic counterpart, neostigmine combined with glycopyrrolate, or no reversal agent when used routinely to reverse rocuronium-induced neuromuscular blockade in adult patients. DesignCost analysis. MethodsWe constructed a decision model to analyze the costs associated with the choice of reversal drug and differences in reversal time, occurrence of postoperative nausea or vomiting (PONV), and residual blockade requiring unplanned postoperative mechanical ventilation (UPMV). We selected variables that demonstrated meaningful differences in meta-analyses of published studies and/or had significant associated costs. We used data from local hospital system information, meta-analysis of published studies, and the general literature to construct base-case scenarios and sensitivity analyses. We performed the analysis from the perspective of a single hospital system. Costs were in 2019 U.S. dollars. ResultsCost analysis suggested that reversal with sugammadex is preferable to neostigmine or no reversal drug when operating room (OR) time was valued at ≥$8.60/min (base case $32.49/min). Net costs of sugammadex were less than no treatment or neostigmine reversal when the probability of UPMV exceeded 0.019 and 0.036, respectively. Neither sugammadex nor neostigmine reversal was preferable to no treatment in a base-case analysis that considered the effect of the reversal agent on only drug and PONV costs, disregarding costs of OR time or UPMV. ConclusionsRoutine reversal with sugammadex is preferable to choosing neostigmine or no reversal drug when accounting for potential savings in OR time. Sugammadex might also be a reasonable choice for patients at high risk of UPMV. If the cost of OR time is not considered, the analysis does not support the routine use of sugammadex in patients with perceived increased risk or solely to reduce PONV.

Intranasal dexmedetomidine versus oral midazolam premedication to prevent emergence delirium in children undergoing strabismus surgery: A randomised controlled trial.

Dexmedetomidine is being used increasingly as a premedicant in the paediatric population. However, the effectiveness of pre-operative intranasal dexmedetomidine premedication, compared with oral midazolam, for emergence delirium is not well characterised. To identify the effectiveness of pre-operative intranasal dexmedetomidine for emergence delirium in the paediatric patient population following general anaesthesia. A prospective, randomised, double-blind, parallel-group, placebo-controlled trial. Single university teaching hospital, from September 2013 to August 2014. One hundred and fifty-six patients undergoing anaesthesia for strabismus surgery were included in the study. Patients were randomised in a 1 : 1 : 1 ratio to receive premedication with intranasal dexmedetomidine 2 μg kg (the dexmedetomidine group), oral midazolam 0.5 mg kg (the midazolam group), or 0.9% saline (the placebo group). The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included the quality of the inhalational induction, emergence time, postoperative pain intensity, length of stay in the postanaesthesia care unit, the incidence of postoperative nausea or vomiting (PONV) and parents' satisfaction. The incidence of emergence delirium was lower in patients given dexmedetomidine compared with that in patients given midazolam (11.5 versus 44%, relative risk = 0.262, 95% confidence interval 0.116 to 0.592) or 0.9% saline (11.5 versus 49%, relative risk = 0.235, 95% confidence interval 0.105 to 0.525). Likewise, the incidence of PONV was lower in the dexmedetomidine group (3.8%) than that in the midazolam (22%; P = 0.006) or placebo (29.4%; P < 0.001) groups. However, there was no difference among the groups concerning postoperative pain scores and length of postanaesthesia care unit stay. In paediatric patients undergoing strabismus surgery intranasal dexmedetomidine 2 μg kg premedication decreases the incidence of emergence delirium and PONV, and improves parents' satisfaction compared with oral midazolam. ClinicalTrials.gov (identifier: NCT01895023).

Post-operative Nausea and Analgesia Following Total Mastectomy is Improved After Implementation of an Enhanced Recovery Protocol.

Enhanced Recovery Protocols (ERPs) provide a multimodal approach to perioperative care, with the aims of improving patient outcomes while decreasing perioperative antiemetic and narcotic requirements. With high rates of post-operative nausea or vomiting (PONV) following total mastectomy (TM), we hypothesized that our institutional designed ERP would reduce PONV while improving pain control and decrease opioid use. An ERP was implemented at a single institution for patients undergoing TM with or without implant-based reconstruction. Patients from the first two months of implementation (ERP group, N = 72) were compared with a retrospective usual-care cohort from a three-month period before implementation (UC group, N = 83). Outcomes included PONV incidence, measured with antiemetic use; patient-reported pain scores; perioperative opioid consumption, measured by oral morphine equivalents (OME); and length of stay (LOS). The characteristics of the two groups were similar. PONV incidence and perioperative opioid consumption were lower in the ERP than the UC group (21% vs. 40%, p 0.011 and mean 44.1 OME vs. 104.3 OME, p < 0.001), respectively. These differences in opioid consumption were observed in the operating room and post-anesthesia care unit (PACU); opioid consumption on the floor was similar between the two groups. Patient-reported pain scores were lower in the ERP than the UC group (mean highest pain score 6.4 vs. 7.4, p 0.003). PACU and hospital LOS were similar between the two groups. ERP implementation was successful in decreasing PONV following TM with and without reconstruction, while simultaneously decreasing overall opioid consumption without compromising patient comfort.

Impact of ultrasound-guided erector spinae plane block on postoperative quality of recovery in video-assisted thoracic surgery: A prospective, randomized, controlled trial

Study objectiveRegional anesthesia improves postoperative analgesia and enhances the quality of recovery (QoR) after surgery. We examine the efficacy of ultrasound-guided erector spinae plane block (ESPB) on QoR after video-assisted thoracic surgery (VATS). DesignProspective, randomized, double-blinded, placebo-controlled trial. SettingSingle institution, tertiary university hospital. PatientsAdult patients who scheduled for VATS under general anesthesia were enrolled in the study. InterventionsWe randomly allocated patients to receive preoperative ultrasound-guided ESPB with 25 ml of either 0.5% ropivacaine (ESPB group) or normal saline (Control group). MeasurementsThe primary outcome was QoR as measured by the 40-item QoR questionnaire (QoR-40) score at postoperative day 1. Secondary results were post-anesthesia care unit (PACU) discharge time, acute postoperative pain, cumulative opioid consumption, the incidence of postoperative nausea or vomiting (PONV), and patient satisfaction. Main resultsThe global QoR-40 score at postoperative day 1 (median, interquartile range) was significantly higher in the ESPB group (174, 170 to 177) than the control group (161.5, 160 to 165), estimated median difference 11 (95% CI 9 to 13, P < 0.001). Compared with the control group, single-injection of ESPB reduced PACU discharge time, acute postoperative pain, and cumulative opioid consumption. Correspondingly, the median patient satisfaction scores were higher in the ESPB group than the control group (9 versus 7, P < 0.001). ConclusionPreoperative single-injection thoracic ESPB with ropivacaine improves QoR, postoperative analgesia, and patient satisfaction after VATS.

Ultrasound-guided Anterior Quadratus Lumborum Block for Postoperative Pain after Laparoscopic Pyeloplasty: A Randomized Controlled Trial.

Background:Quadratus lumborum block (QLB) has provided adequate analgesia and lowered postoperative opioid requirement in comparison to controls for some urological surgeries.Aims:The aim of this study was to assess the efficacy of postprocedure ultrasound-guided QLB in comparison to port-site infiltrations with local anesthetics (as control) in lowering postoperative pain after laparoscopic pyeloplasty.Settings and Design:This was a prospective, single-blinded, randomized controlled trial.Materials and Methods:Fifty-three adults undergoing laparoscopic pyeloplasty were randomly allocated to either anterior QLB group (n = 27) or port-site infiltration Group P (n = 26) with 20 mL of 0.5% ropivacaine. The primary outcomes were static and dynamic pain on the Visual Analog Scale (VAS) of 0–100 at the 30th min, 2nd, 6th, 12th, and 24th hour after surgery. The secondary outcomes were number of patients requiring rescue analgesics and having postoperative nausea or vomiting (PONV) in 24 hours after surgery.Statistical Analysis:Intergroup comparison of VAS was done with Student's t-test. Categorical data were analyzed using the Chi-square test.Results:The static VAS scores were found to be significantly lower in QLB group at the 2nd, 6th, and 12th hour, and the dynamic VAS was lower at all time points after the 30th min in the QLB group. The number of patients requiring rescue analgesics were significantly lower in the QLB group (13 as compared to 21 in Group P; P = 0.015). The incidence of PONV was comparable. No other side effects were seen.Conclusion:Ultrasound-guided anterior QLB is more effective in comparison to traditional technique of port-site local anesthetic infiltration for providing analgesia after laparoscopic pyeloplasty.

P206 EVALUATION OF PREEMPTIVE MULTIMODAL ANALGESIA IN IVOR LEWIS ESOPHAGECTOMY

Abstract Aim of the study is the evaluation of preemptive multimodal analgesia vs established technique of single epidural, in Ivor Lewis esophagectomy, perioperatively. Background &amp; Methods In a randomized prospective trial, 25 patients were randomly assigned to two groups (A=12: preemptive multimodal analgesia, and B=13: epidural analgesia) after informed consent. Patients with coagulative disorders, and renal or hepatic impairment were excluded from study. In all patients a thoracic epidural (T5 – T7) was placed before anesthesia induction. Anesthetic protocol was the same, according body weight, in both groups, apart from analgesic drugs. Group A patients received morphine 1.5-3mg and ropivacaine 0.25% 10-12 ml epidurally (ed), and paracetamol 1gr, parecoxib 40mg, clonidine 150mcg, dexamethasone 8mg, lidocaine 1mg/kg, and magnesium sulfate 25% 10 ml iv, at least 20 min before surgical incision, while in group B same doses of ed morphine and ropivacaine were administered post-incision and iv paracetamol and parecoxib were administered 1hr before end of surgery. Surgical incision infiltration in both wounds with ropivacaine 0.375% 20ml was performed jn both groups’ patients. Intraoperative opioid doses were titrated accordingly. Analgesic needs intra- and postoperatively, as well as vital signs stability and side effects such as postoperative nausea or vomiting (PONV), dizziness, sleepiness, and respiratory suppression were recorded. Results Group A patients received significantly lower opioid doses intraoperatively (p&lt;0.001), 2 (17%) of them did not need extra opioids at all, and in 8 (67%), operation was completed with only one low dose of fentanyl (2-3mcg/kg) before abdominal surgical incision. Group A patients had stable heart rate (HR) and blood pressure (BP) during whole operation, while 11 (84.6%) from group B (p&lt;0.001) demonstrated HR and BP raising in certain surgical times. All both groups’ patients were transferred to ICU awake. 5 (38.46%) group B patients (p&gt;0.005) required rescue amalgesic post-awakening. None of both groups’patients demonstrated any drugs’ side effects. Conclusion Preemptive multimodal analgesia seems to be more efficient, reducing needs for opioids intraoperatively, rescue analgesics postoperatively and providing better hemodynamic stability, than single epidural. Further studies are needed to support this conclusion.

Ultrasound-guided bilateral superficial cervical plexus blocks enhance the quality of recovery in patients undergoing thyroid cancer surgery: A randomized controlled trial

Regional anesthesia can improve postoperative analgesia and enhance the quality of recovery (QoR) after surgery. This trial evaluates the effects of ultrasound-guided bilateral superficial cervical plexus block (SCPB) on QoR in patients undergoing thyroid cancer surgery. Prospective, randomized, double-blinded, placebo-controlled trial. Operating room. Seventy-four ASA I-II female patients scheduled for thyroid cancer surgery were included to the study. Patients were randomly allocated to receive pre-operative ultrasound-guided bilateral SCPB with 10 ml of ropivacaine 0.5% or normal saline on each side. The primary endpoint was the quality of recovery, which was assessed using the 15-item quality of recovery questionnaire (QoR-15). Secondary endpoints were acute postoperative pain, time to first rescue analgesia, the number of patients requiring rescue analgesia, length of post-anesthesia care unit (PACU) stay, the incidence of postoperative nausea or vomiting (PONV) and dizziness, and patient satisfaction. The global QoR-15 score at 24 h postoperatively was significantly higher in the SCPB group (Median [IQR], 118 [115-120]) than the control group (110 [106-112]) with a median difference of 8 (95% CI: 6 to 10, P < .001). Compared with the control group, pre-operative ultrasound-guided bilateral SCPB reduced postoperative pain up to 24 h and the incidence of PONV, as well as the length of PACU stay. Additionally, the patient satisfaction scores were improved in the SCPB group (P = .024). Pre-operative ultrasound-guided bilateral SCPB with ropivacaine enhances the quality of recovery, postoperative analgesia and patient satisfaction, alleviates the incidence of PONV, and accelerates the PACU discharge following thyroid cancer surgery.

Efficacy of prophylactic dexamethasone in prevention of postoperative nausea and vomiting

ObjectiveMany trials have been conducted with regard to the relative benefits of prophylactic anti-emetic interventions given alone or in combination, yet the results remain unknown. This study reviewed the efficacy of a single prophylactic dose of dexamethasone on postoperative nausea or vomiting (PONV) after abdominal hysterectomy. MethodsIn a prospective study of 100 women undergoing total abdominal hysterectomy (TAH) under general anesthesia, the dexamethasone group (n=50) received a single dose (8mg) immediately after the operation, and the saline group (n=50) received a dose of saline as a placebo, in addition to conventional management. The incidence of nausea, vomiting, the need for an anti-emetic and patient satisfaction with the management of PONV were evaluated during the first 24 postoperative hours. ResultsThe overall frequency of nausea during the initial postoperative 24 in the dexamethasone and saline groups were 12% and 18%, respectively, and vomiting was 10% and 16%, respectively (P=0.001). However, there was a lower need for a rescue anti-emetic drugs in the dexamethasone group (18% vs 24%), but it was not statistically significant (P=0.06). ConclusionThe results of this study indicate that a single prophylactic dose of dexamethasone after an operation can reduce postoperative nausea and vomiting.

Measuring the quality of anaesthesia from a patient’s perspective: development, validation, and implementation of a short questionnaire

The primary aim of this study was to develop and validate a short psychometric instrument to assess the patient's perception of the quality of anaesthesia. In Part 1, the Perception of Quality in Anaesthesia (PQA) questionnaire was developed, pilot tested, and validated. Attributes of high-quality anaesthesia were identified using a process that restricted input to patients and members of the public. In Part 2, patient cohorts completed the PQA before, and after, a 6 month period where anaesthetists were given individualized performance data using questions from the PQA. In Part 1, items in the PQA were identified and ranked by 120 patients and members of the public. Validity and reliability of the PQA was assessed by 714 patients. Principal component analysis showed that the PQA comprised five factors: attention/gentleness; pain management; information/confidence; postoperative nausea or vomiting (PONV); and concerns addressed. In Part 2, there were 2046 patient participants in the pre-feedback cohort, 4251 in the feedback cohort, and 1421 in the post-feedback cohort. Unsatisfactory experience in at least one PQA factor was described by 45.2% [95% confidence interval (CI) 43.1-47.4%] during the pre-feedback period, and 35.0% (95% CI 32.6-37.6%) during the post-feedback period. We developed and validated a patient-derived questionnaire to measure the patient's perception of anaesthesia quality. PONV, postoperative pain management, and communication with the anaesthetist are the most important features of the patient's experience. Feedback of PQA performance scores to anaesthetists can lead to improved patient experience.

Bayesian enhanced meta‐analysis of post‐operative analgesic efficacy of additives for caudal analgesia in children

The authors calculated the effect size for post-operative analgesia of three additives, clonidine, neostigmine, and tramadol to bupivacaine, ropivacaine, or levobupivacaine used for single-dose caudal extradural blockade in children. A meta-analysis was performed for three end points of efficacy: the increase of time until administration of analgesic drugs, the proportion of patients requiring analgesic drugs during the initial 24 post-operative hours, and the amounts of post-operative analgesic drugs. A Bayesian inference supporting direct statements about the probability of the magnitude of an effect was used to compare the effects size. Neostigmine increased the duration of analgesia by 9.96 h (95% confidence interval: 7.75 to 12.16), as compared with 3.68 h (2.65 to 4.7) with clonidine and 4.45 (2.84 to 6.07) with tramadol. There is a 95% probability that neostigmine increases the duration of post-operative analgesia by more than 8 h, clonidine by more than 2.8 h, and tramadol by more than 3.25 h, as compared with local anesthetics alone. The odds ratios for the proportion of patients requiring analgesic drugs were 0.22 [0.13 to 0.37] for clonidine and 0.28 [0.10 to 0.75] for neostigmine. With tramadol, there was no statistically significant difference. All three additives reduced the amounts of post-operative analgesic drugs. Neostigmine and tramadol increase the probability for post-operative nausea or vomiting (PONV). Neostigmine provides the longest post-operative analgesia. With clonidine, the duration of analgesia is shorter and sedation is increased, but the probability for PONV could be decreased.

A randomised controlled trial on the efficacy and side-effect profile (nausea/vomiting/sedation) of morphine-6-glucuronide versus morphine for post-operative pain relief after major abdominal surgery

Morphine is the first choice of treatment of severe post-operative pain, despite the occurrence of often discomforting (post-operative nausea or vomiting (PONV)) and sometimes dangerous (sedation, respiratory depression) side effects. Literature data indicate that morphine’s active metabolite, morphine-6-glucuronide (M6G), is a powerful analgesic with a possibly more favourable side-effect profile. In this multi-centre randomised controlled clinical trial patients undergoing major abdominal surgery were randomised to M6G or morphine treatment. Treatment started 30–60 min prior to the end of surgery and was continued postoperatively, after patients were titrated to comfort, via patient-controlled analgesia (PCA) for 24–48 h. Pain intensity, nausea, vomiting and sedation scores were collected at regular intervals. In the study 268 patients were randomised to M6G and 249 to morphine. Withdrawal due to insufficient pain relief occurred predominantly just after surgery and was higher in the M6G group (16.8%) than in the morphine group (8.8%), suggesting a slower onset of analgesia for M6G compared to morphine. Subjects who continued on PCA remained equi-analgesic throughout the study. During the first 24 h, nausea levels showed a 27% difference in favour of M6G which narrowly failed to reach statistical significance ( P = 0.052). Sub-analysis showed a significant reduction in nausea levels in females on M6G (30% difference, P = 0.034). In all patients, similar reductions of 30–35% were observed in anti-emetic use, vomiting, PONV (a combined measure of nausea and vomiting) in favour of M6G, persisting for the first 24 h postoperatively. Reductions in sedation were observed in the first 4 h post-operative period for M6G patients.

Is There Value in Obtaining a Patient’s Willingness to Pay for a Particular Anesthetic Intervention?

Is There Value in Obtaining a Patient’s Willingness to Pay for a Particular Anesthetic Intervention?

Facial laser resurfacing with the propofol-ketamine technique: room air, spontaneous ventilation (RASV) anesthesia.

Multiple anesthetic approaches exist for full-face laser resurfacing. The propofol-ketamine technique is reviewed as a reasonable alternative to providing adequate anesthesia for full-face laser resurfacing in the office environment. To report outcomes using propofol-ketamine opioid avoidance, room air, spontaneous ventilation monitored anesthesia care (MAC). A retrospective chart review of 95 consenting adult patients receiving propofol-ketamine anesthesia in a private practice, office-based setting. An average of 6 (200 mg) ampules of propofol, including waste, were used per patient. All patients received adequate anesthesia as evidence by a lack of movement during surgery. There were no hallucinations, no postoperative nausea or vomiting (PONV), no cardiovascular instability or seizures (clinical signs of lidocaine toxicity), and no hospital admissions for either PONV or pain. The propofol-ketamine technique appears to be an excellent alternative anesthetic approach to EMLA cream, tranquilizer-opioid regimens, or general inhalational anesthesia for facial laser resurfacing.