Presence Of Postoperative Nausea And Vomiting Research Articles

The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial

Objectives: The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required. Design: In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia). Participants: All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled. Setting: The study was conducted to the University of Campus Bio-Medico Hospital of Rome. Methods: Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed. Limitations: The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks. Results: A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p p p Conclusions: US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients’ post-operative recovery.

Using Clinical-Based Discharge Criteria to Discharge Patients After Ophthalmic Ambulatory Surgery Under General Anesthesia: An Observational Study

PurposeTo verify the feasibility of the clinical-based discharge (CBD) criteria and identify the reasons of long postanesthesia care unit length of stay (PACU-LOS) for ophthalmic ambulatory surgical patients under general anesthesia. DesignA prospectively observational study conducted at a tertiary eye center in China. MethodsMedical records were collected from patients admitted for strabismus ambulatory surgery under general anesthesia from September 2018 to March 2019. The patients were discharged home once met the CBD criteria based on a combination of the modified Aldrete's scoring system and Chung's Post-Anesthetic Discharge Scoring System. Postoperative complications were recorded in the PACU and within 24 hours after discharge. Multivariate logistic regression was applied to identify the factors relating to late discharges. FindingsAll patients (N = 400) were safely and successfully same-day discharged home as none of the patients informed severe emergency events or unanticipated readmission. Nine displayed discharge delays mainly because of mild postoperative nausea and vomiting (PONV) although met the discharge criteria. About 85.5% of patients were discharged within a PACU-LOS of 150 minutes, 379 (94.8%) were within 180 minutes, and the cutoff time in PACU-LOS was 150 minutes. Multivariable analysis indicated that sevoflurane anesthesia and the presence of PONV were related to late discharges (PACU-LOS of greater than 150 minutes, all P < .05). ConclusionsThe CBD criteria can efficiently and safely guide the ophthalmic ambulatory surgical patients to discharge home on the same-surgery day, whereas sevoflurane anesthesia and the presence of PONV are associated with a relatively long PACU-LOS.

Cumulative incidence and risks factors for postoperative nausea and vomiting in adult patients undergoing cholecystectomy under balanced general anesthesia

Introduction: Postoperative nausea and vomiting (PONV) are common issues arising after general anesthesia, for which several independent risk factors have been described.Objective: To determine the accumulated incidence of PONV during the first 24hours of the postoperative period.Methods: A cohort observational, prospective study was conducted that included all the adults undergoing cholecystectomy under balanced general anesthesia at the EsSalud Talara Hospital from October 2014 until December 2016. The presence of PONV during the first 24hours after surgery was assessed, and univariate, bivariate, and logistic regression analyses were conducted.Results: 244 patients were included, most of them with two risk factors in the Apfel scale, that represented an accumulated incidence of PONV of 0.51 (95% CI 0.45–0.57) during the observation period, notwithstanding the fact that 85.25% received antiemetic prophylaxis. The logistic regression analysis identified that being a female (OR 3.30, 95% CI 1.66–6.55, p=0.0007) and previous PONV or motion sickness (OR 2.67, 95% CI 1.25–5.68, p= 0.011) were independent risk factors for PONV. The administration of antiemetic prophylaxis and the presence of PONV (p=0.92) were found to be independent.Conclusions: The high cumulative incidence of PONV could be the result of the type of surgery, the use of volatile anesthetic agents, and errors in the antiemetic pharmacological prophylaxis.

Postoperative Nausea and Vomiting and Phase I Post-anesthesia Recovery After Strabismus Operations.

To ascertain postoperative nausea and vomiting (PONV) rates in adult patients after strabismus operations and assess causes for prolonged post-anesthesia recovery. This was a retrospective observational study of consecutive adult patients who underwent strabismus operations at one institution from January 1, 2010, to May 31, 2017. The anesthetic records were abstracted and PONV rates were ascertained. On the basis of the cohort's 75th percentile of anesthesia recovery duration, patients were categorized into goal recovery (lower three quartiles) and prolonged recovery (upper quartile). Multivariable logistic regression analyses were performed to assess associations between clinical characteristics and prolonged recovery. A total of 794 adult patients who underwent strabismus surgery were identified. PONV was present in 31 (3.9%) patients. The median (interquartile range) post-anesthesia recovery was 45 minutes (range: 33 to 63 minutes). Prolonged recovery was associated with long-term benzodiazepine use (odds ratio [OR]: 3.07; 95% CI [confidence interval]: 1.23 to 7.80; P = .02). Patients with prolonged recovery had higher rates of PONV (15 [7.2%] vs 16 [2.7%], P = .007), oversedation (107 [51.4%] vs 226 [38.6%], P = .001), and postoperative analgesic administration (138 [66.4%] vs 222 [37.9%], P < .001). Inverse associations were found between desflurane and oversedation (OR: 0.63; 95% CI: 0.45 to 0.86; P = .004) and between acetaminophen administration and postoperative analgesic administration (OR: 0.57; 95% CI: 0.38 to 0.86; P = .007). Adult patients undergoing general anesthesia for strabismus surgery had a low PONV rate. However, the presence of PONV was associated with delayed recovery room discharge. Other factors associated with prolonged Phase I recovery were long-term benzodiazepine use and longer operations, which likely resulted in an increased need for anesthetic agents and therefore more intense postoperative sedation. [J Pediatr Ophthalmol Strabismus. 2019;56(3):151-156.].

Genetic Factors Associated with Postoperative Nausea and Vomiting: a Systematic Review

BackgroundIn previous studies, there seems to be a relationship between different genetic polymorphisms and postoperative nausea and vomiting (PONV). We perform a systematic review of the current literature about the relationship between genetic polymorphisms and the presence of PONV. MethodsTwo bibliographic searches were carried out in three databases (PubMed, Web of Science, and Scopus) of studies, preferably prospective, about PONV following abdominal surgery. It was completed with a backward citation searching. A total of 73 articles were found of which 6 were selected after their critical lecture using CASPe network criteria. Relative frequency and relative risk were taken in each study according to the polymorphism. ResultsStudies about 5-HT3B gene receptor polymorphisms, ABCB1 transporter, and dopamine D2 receptor showed a significant association with the presence of PONV (p = 0.02, 0.01, and 0.034 respectively). In relation to cytochrome P-450 2D6 (CYP2D6) polymorphisms, two of the three analysed articles showed a significant association with postoperative vomiting (p = 0.007). ConclusionGenetic polymorphisms could play an important role in PONV. The AAG deletion in both alleles of the 5-HT3B receptor gene, the Taq IA polymorphism of the dopamine D2 receptor, and the presence of three or more functional alleles of CYP2D6 seem to be related with a higher incidence of PONV, especially in the first 24 h after surgery. The 2677TT and 3435TT genotypes of the ABCB1 transporter could reduce the PONV due to their association with a greater effectiveness of ondansetron. However, new quality studies are needed to consider this relationship.

Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mammaplasty

BackgroundIn light of data finding that postoperative pain, nausea, and vomiting worsen outcomes, a renewed emphasis has been placed on optimizing the perioperative period. Use of preoperative paravertebral block (PVB) has been shown to reduce opioid administration and postoperative nausea and vomiting (PONV) in many surgical populations, though its role in reduction mammaplasty remains undefined. Therefore, we seek to evaluate PVB as an adjunct to general anesthesia (GA) for reduction mammaplasty. Materials and methodsWe reviewed records for patients who underwent reduction mammaplasty at our institution from 2010 to 2015. Patients were categorized into two groups: GA alone and GA + PVB (GA with PVB adjunct). Demographic information, opioid administration, phase I/II pain scores, presence of PONV, and anesthesia time were analyzed. Analysis was performed using t-tests and Fisher's exact test, with P-values less than 0.05 statistically significant. ResultsWe identified 264 patients meeting criteria: 209 (79%) received GA alone and 55 (21%) received GA + PVB. Intraoperative opioid administration were lower for GA + PVB patients (morphine equivalent of 44 mg versus 35 mg, P = 0.019), though there was no difference in postoperative opioid administration (P = 0.915). Phase I and II pain scores were significantly lower for those receiving PVB (2.9 versus 3.9, P = 0.012, and 3.0 versus 4.2, P = 0.001, respectively). GA + PVB was associated with less PONV (14% versus 33%, P = 0.007) and longer anesthesia times (271 min versus 236 min; P = 0.001). ConclusionsBy improving pain control and reducing PONV, factors known to be associated with poor patient satisfaction and inferior outcomes, PVB is an attractive anesthetic adjunct in elective breast surgery.

Automated reminders decrease postoperative nausea and vomiting incidence in a general surgical population

Guidelines to minimize the incidence of postoperative nausea and vomiting (PONV) have been implemented in many hospitals. In previous studies, we have demonstrated that guideline adherence is suboptimal and can be improved using decision support (DS). In this study, we investigate whether DS improves patient outcome through improving physician behaviour. Medical information of surgical patients is routinely entered in our anaesthesia information management system (AIMS), which includes automated reminders for PONV management based on the simplified risk score by Apfel and colleagues. This study included consecutive adult patients undergoing general anaesthesia for elective non-cardiac surgery who were treated according to the normal clinical routine. The presence of PONV was recorded in the AIMS both during the recovery period and at 24 h. Two periods were studied: one without the use of DS (control period) and one with the use of DS (support period). DS consisted of reminders on PONV both in the preoperative screening clinic and at the time of anaesthesia. In the control period, 981 patients, of whom 378 (29%) were high-risk patients, received general anaesthesia. Overall, 264 (27%) patients experienced PONV within 24 h. In the support period, 1681 patients, of whom 525 (32%) had a high risk for PONV, received general anaesthesia. In this period, only 378 (23%) patients experienced PONV within 24 h after operation. This difference is statistically significant (P=0.01). Automated reminders can improve patient outcome by improving guideline adherence.

Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis

ABSTRACTObjective: To report the incidence of postoperative nausea and vomiting (PONV), to describe the use of anti-emetics both for the prophylaxis and treatment of PONV, and to assess resource utilization and duration of post-anesthesia care unit (PACU) stay.Research design and methods: We retrieved data from the Duke Anesthesia Peri-operative database. We included adult patients, who underwent inpatient surgery under general anesthesia with inhaled agents between January 2004 and February 2005, and had two or more risk factors for PONV documented preoperatively (female, previous history of PONV or motion sickness, non-smoker or use of postoperative opioid). Data on the use of prophylactic anti-emetics, the incidence of PONV, nausea scores, pain scores, and the use of rescue anti-emetics in PACU and in the period between PACU discharge and 24 h after surgery were recorded. Resource utilization and cost assessment was performed from the perspective of the hospital and included length and direct cost of PACU stay, as well as the acquisition costs of rescue anti-emetics in PACU. Descriptive statistics were used to summarize the demographic characteristics of patients. For group comparisons, data were analyzed with the t‐test for continuous data, and the Chi-square test for categorical data. Multiple linear regression models were used to evaluate the association between PONV and PACU length of stay adjusting for confounding factors.Results: A total of 3641 patients were included in the analysis. Of those, 2869 (79%) received prophylactic anti-emetics. In the PACU, nausea and vomiting were reported in 16% and 3% of the patients, respectively. Rescue anti-emetics were given to 26% of all patients. The incidence of vomiting was significantly less in patients who received PONV prophylaxis ( p = 0.03). In multiple linear regression models, the duration of PACU stay was longer by a mean of 25 min in patients who experienced PONV or received rescue anti-emetics in PACU ( p < 0.0001) despite the fact that the duration of surgery was shorter by a mean of 24 min in this group of patients ( p < 0.0001). Following PACU discharge, 40% of patients reported nausea, vomiting or needed rescue anti-emetics. PONV was associated with significantly increased resource utilization and costs of PACU stay ( p < 0.0001). Emesis was associated with greater incremental cost ($138) than nausea ($85), mainly from the longer duration of PACU stay.Conclusions: PONV remain a significant problem postoperatively and often persists beyond PACU discharge. The presence of PONV is associated with increased length of PACU stay and greater resource utilization and costs.

Ambulatory Tympanomastoid Surgery in Children

To identify clinical factors associated with postoperative nausea and vomiting (PONV) and failure to discharge from the hospital on the day of surgery in children undergoing tympanomastoid surgery. Records of 144 children undergoing 152 tympanomastoid surgical procedures from July 1, 2001, through June 30, 2002, were retrospectively reviewed and the data analyzed. A tertiary care university-affiliated hospital. The mean +/- SD age of the cases was 11 +/- 3.7 years. Sixty-eight cases (45%) were middle ear procedures, while 84 cases (55%) were mastoid procedures. Forty-three cases (28%) were discharged home from the postanesthesia care unit (PACU), 55 cases (36%) were discharged on the day of surgery, and 142 cases (92%) were discharged home from the day surgery unit (DSU) within 23 hours after surgery. Patients who underwent mastoid procedures were more likely to require intravenous (IV) morphine sulfate in the PACU (75% vs 56%; P = .02) and were less likely to be discharged from PACU (15% vs 44%; P<.001) compared with patients who had middle ear procedures. In patients who underwent mastoid procedures, the presence of cholesteatoma (odds ratio, 1.9; 95% confidence interval, 1.0-3.7; P = .04) was associated with a higher likelihood of PONV. In both groups, the need for IV morphine sulfate to control pain on admission to DSU was associated with a higher occurrence of PONV. Factors that were significantly associated with failure to discharge from the hospital on the day of surgery were a pain score of 5 or greater, the presence of PONV, and the requirement of IV morphine sulfate on admission to DSU. Factors associated with higher risks of PONV and failure to discharge from the hospital on the day of surgery include the presence of cholesteatoma, a pain score of 5 or greater, and the requirement of IV morphine sulfate at the time admission to the DSU.

Ondansetron Versus Droperidol for Postoperative Nausea and Vomiting

In Response: We thank Dr. Phillips for his interest in our manuscript. The article referenced by Dr. Phillips is a meta-analysis of 53 clinical trials that sought the optimal dose of ondansetron based on the outcome variable of presence or absence of postoperative vomiting [1]. Meta-analyses, however, may have there their own set of problems, as noted in the accompanying editorial by Fisher [2]. Among these are the possibility of publication bias, the use of data that have not been collected uniformly, and the dependence on outcome measures that are universal to all the studies. As pointed out by Fisher, the only outcome noted by Tramer et al. [1] was the presence or absence of postoperative nausea and vomiting (PONV). Outcomes such as unplanned hospital admissions and patient satisfaction were not included. A more recent article by Dershwitz et al. [3] reported a dose-response study of 175 women undergoing elective surgery and specifically studied patient satisfaction, as well as the presence of PONV. The results of this study led the authors to conclude that 4 mg of ondansetron remained the recommended dose for PONV prophylaxis and that there was no advantage to larger doses. Interestingly, the article by Tramer et al. [1] also suggested that, when used on a dose/weight basis, further efficacy was not evident when the ondansetron dose was >50 [micro sign]g/kg (approximately 4 mg in an average 75-kg person). We believe that ondansetron 4 mg was the appropriate dose to use in the comparison with droperidol for the prevention of PONV. Jennifer T. Fortney, MD Tong Joo Gan, MD, MBBS, FRCA Peter S. A. Glass, MD Department of Anesthesiology; Duke University Medical Center; Durham, NC 27710