Opioid-Sparing Anesthesia Versus Opioid-Free Anesthesia for the Prevention of Postoperative Nausea and Vomiting after Laparoscopic Bariatric Surgery: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Patients who undergo laparoscopic bariatric surgery (LBS) are susceptible to postoperative nausea and vomiting (PONV). Opioid-free anesthesia (OFA) or opioid-sparing anesthesia (OSA) protocols have been proposed as solutions; however, differences between the 2 alternative opioid protocols for anesthesia maintenance in obese patients remain uncertain. A network meta-analysis was conducted to compare the impacts of OFA and OSA on PONV. METHODS: Systematic searches were conducted using Embase, PubMed, MEDLINE, and Cochrane Library databases to identify randomized controlled trials (RCTs) comparing OFA and OSA strategies. After screening according to the inclusion and exclusion criteria, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the credibility of the evidence. The main concern of this review was the difference between OFA and OSA in reducing PONV. The primary outcome was any PONV occurrence within 24 hours. Secondary outcomes included postoperative pain intensity, opioid consumption, opioid-related adverse events, and length of hospital stay. RESULTS: Fifteen RCTs involving 1310 patients were identified for a network meta-analysis from 1776 articles that compared OFA, OSA, and traditional opioid-based anesthesia (OBA) strategies in LBS. Twelve RCTs (80%) with 922 participants (70%) were eligible for the occurrence of PONV. These included 199 (22%) patients who received OFA and 476 (52%) and 247 (27%) patients who received OSA and OBA, respectively. OFA was more effective at reducing PONV (relative risks [RR], 0.6, 95% confidence interval [CI], 0.5-0.9, moderate-quality evidence) compared to OSA. No differences were observed in postoperative pain control or opioid consumption between the OFA and OSA strategies (very low-to high-quality evidence). Notably, OFA is associated with a higher risk of bradycardia than OSA (RR, 2.6, 95% CI, 1.2-5.9, moderate-quality evidence). CONCLUSIONS: OFA is more effective than OSA in reducing the occurrence of PONV during the early postoperative period of LBS, although it may associate with an increased risk of bradycardia. Patients who received either opioid-alternative strategy demonstrated similar effects in reducing postoperative opioid consumption and alleviating pain intensity.

Effect of noninvasive respiratory support after extubation on postoperative pulmonary complications in obese patients: A systematic review and network meta-analysis.

STUDY OBJECTIVE: Obesity is associated with an increased risk of sleep-disordered breathing (SDB) and postoperative pulmonary complications (PPCs). Postoperative noninvasive respiratory support (NRS) has been recommended to obese patients despite the controversy about its benefit. The network meta-analysis (NMA) was used in this study to compare the effect of different methods of NRS on preventing PPCs in obese patients. DESIGN: This study is a network meta-analysis. SETTING: Post-anesthesia care unit and inpatient ward. PATIENTS: 20 randomized controlled trials involving 1184 obese patients were included in the final analysis. INTERVENTIONS: One of the four NRS techniques, which include continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), high-flow nasal cannula (HFNC), or conventional oxygen therapy (COT), was performed after general anesthesia. MEASUREMENTS: The primary outcome was the incidence of PPCs, e.g., atelectasis, pneumonia, hypoxemia, and respiratory failure. The secondary outcomes included the incidence of oxygen treatment failure and anastomotic leakage, oxygenation index, and length of hospital stay (LOS). RevMan 5.3 and STATA 16.0 were used to analyze the results and any potential bias. MAIN RESULTS: Compared with COT, BiPAP and HFNC were both effective in reducing the occurrence of postoperative atelectasis. There were no significant differences in the occurrence of other PPCs including pneumonia, hypoxemia and respiratory failure between the four NRS techniques. CPAP and HFNC were superior to other techniques in improving oxygenation and shortening LOS respectively. No differences were found in oxygen treatment failure and anastomotic leakage between the patients with different NRS. HFNC ranked the first in five of the eight outcomes (hypoxemia, respiratory failure, treatment failure, anastomotic leakage, LOS) in this review by the surface under the cumulative ranking curve (SUCRA). CONCLUSION: Among the four postoperative NRS techniques, HFNC seems to be the optimal choice for obese patients which shows certain advantages in reducing the risk of PPCs and shortening LOS.

Effect of lidocaine or dexmedetomidine on postoperative recovery in elder patients undergoing colorectal surgery.

BACKGROUND: Opioid sparing techniques have been shown to promote gastrointestinal recovery, shorten length of stay (LOS), and reduce opioid-related complications. We investigated whether intraoperative intravenous lidocaine or dexmedetomidine infusion could improve gastrointestinal recovery in elderly patients undergoing laparoscopic colorectal surgery. METHODS: Ninety-six patients aged 65 years or older who underwent elective laparoscopic colorectal resection were randomly allocated into the following three groups: the control group (N.=32) received an equal volume of saline, the lidocaine group (N.=32) received intraoperative intravenous lidocaine infusion, and the dexmedetomidine group (N.=32) received intraoperative intravenous dexmedetomidine infusion. The primary outcome was time to first feces. Secondary outcomes were time to first flatus, postoperative pain intensity, patient-controlled intravenous analgesia (PCIA) consumption, postoperative inflammatory response, postoperative complications, anesthetic adverse events, and LOS. RESULTS: The lidocaine group had a significantly shorter time to first flatus (24.6 [IQR, 14.4-48.8] hours vs. 48.1 [IQR, 30.0-67.1] hours; adjusted P=0.022) and time to first feces (48.0 [IQR, 19.0-67.8] hours vs. 74.8 [IQR, 40.3-113.3] hours; adjusted P=0.032) than the control group. However, no significant differences were found between dexmedetomidine and control group for first flatus or first feces. Intraoperative sufentanil consumption and postoperative plasma concentrations of IL-6 were significantly lower in lidocaine group and dexmedetomidine group compared with control group. No difference could be observed in postoperative PCIA consumption, pain scores, postoperative complications, anesthetic adverse events, and LOS among the groups. CONCLUSIONS: Intraoperative intravenous lidocaine infusion accelerated return of the bowel function in elderly patients undergoing elective colorectal surgery.

Blood Urea Nitrogen Is Associated with In-Hospital Mortality in Critically Ill Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Propensity Score Matching Analysis.

Background: Elevated blood urea nitrogen (BUN) level is associated with a higher risk of mortality in various diseases; however, the association between BUN level and in-hospital mortality in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) admitted to the intensive care unit (ICU) is not known. This study aimed to investigate the relationship between BUN level and in-hospital mortality in patients with AECOPD admitted to the ICU. Methods: In this retrospective cohort study, AECOPD patients were identified from the Medical Information Mart for Intensive Care (MIMIC-IV) database. Multivariate regression was used to elucidate the relationship between BUN level and in-hospital mortality, and propensity score matching (PSM) was used to adjust confounders. Receiver operating characteristics and Kaplan−Meier curves were used to evaluate the relationship between BUN level and in-hospital mortality. Results: Data from 1201 patients were analyzed. The all-cause in-hospital mortality was 13.7%. BUN levels were significantly higher in non-survivors compared to the survival group before (p < 0.001) and after (p = 0.005) PSM. Multivariate analysis indicated that elevated BUN levels were independently associated with increased risk of in-hospital mortality both before (p = 0.002) and after (p = 0.015) PSM. The optimal BUN cut-off value for in-hospital mortality in critical patients with AECOPD before (>23 mg/dL) and after (>22 mg/dL) PSM was comparable. Compared with the low BUN group, the hazard ratio (HR) of the high BUN group was 1.8987 (before PSM) and 1.7358 (after PSM). Conclusions: Higher BUN levels were significantly associated with an increased risk of in-hospital mortality in critically ill patients with AECOPD. As a widely available and rapidly measured biomarker, BUN may be useful in the risk stratification of critically ill AECOPD patients. The results need to be verified in prospective studies.

Efficacy of preventive use of oxygen therapy after planned extubation in high-risk patients with extubation failure: A network meta-analysis of randomized controlled trials.

Background: Extubation failure is common in critically ill patients, especially those with high-risk factors, and is associated with poor prognosis. Prophylactic use of oxygen therapy after extubation has been gradually introduced. However, the best respiratory support method is still unclear. Purpose: This study aimed to evaluate the efficacy of four post-extubation respiratory support approaches in reducing reintubation and respiratory failure in patients at high-risk of extubation failure. Methods: A comprehensive search was performed in Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science from inception to June 2022. Randomized controlled trials (RCTs) comparing post-extubation preventive use of respiratory management strategies, including conventional oxygen therapy (COT), non-invasive ventilation (NIV), and high-flow nasal catheter (HFNC) in high-risk patients with extubation failure were reviewed. Primary outcomes were reintubation rate and respiratory failure. Secondary outcomes included intensive care unit (ICU) mortality, ICU stay and length of hospital stay (LOS). Results: Seventeen RCTs comprising 2813 participants were enrolled. Compared with COT, the three respiratory support methods (NIV, HFNC, NIV + HFNC) were all effective in preventing reintubation [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.32-0.67; OR 0.26, 95% CI 0.14-0.48; OR 0.62, 95% CI 0.39-0.97, respectively] and respiratory failure (OR 0.23, 95% CI 0.10-0.52; OR 0.15, 95% CI 0.04-0.60; OR 0.26, 95% CI 0.10-0.72, respectively). NIV and NIV + HFNC also reduced ICU mortality (OR 0.40, 95% CI 0.22-0.74; OR 0.32, 95% CI 0.12-0.85). NIV + HFNC ranked best in terms of reintubation rate, respiratory failure and ICU mortality based on the surface under the cumulative ranking curve (SUCRA) (99.3, 87.1, 88.2, respectively). Although there was no significant difference in shortening ICU stay and LOS among the four methods, HFNC ranked first based on the SUCRA. Conclusion: Preventive use of NIV + HFNC after scheduled extubation is probably the most effective respiratory support method for preventing reintubation, respiratory failure and ICU death in high-risk patients with extubation failure. HFNC alone seems to be the best method to shorten ICU stay and LOS. Systematic review registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022340623].

The Impact of Goal-Directed Fluid Therapy on Postoperative Nausea and Vomiting in High-Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy.

PURPOSE: Patients with laparoscopic sleeve gastrectomy (LSG) are at high risk of postoperative nausea and vomiting (PONV). Goal-directed fluid therapy (GDFT) has been proven effective in improving postoperative gastrointestinal function in patients with obesity, but its effect on prevention of PONV remains controversial. This study aimed to investigate the impact of GDFT on PONV in high-risk patients with LSG. METHODS: In a randomized, single-blinded, two-arm trial, patients with an Apfel score ≥ 3 and scheduled for LSG were included. Patients in the GDFT group received stroke volume-guided fluid therapy. Patients in the control group received conventional fluid therapy. The primary outcome was the incidence of PONV within 48 h after LSG. The second outcome included intensity of PONV, use of rescue therapy, recovery of gastrointestinal function, and postoperative length of stay (LOS). RESULTS: A total of 137 patients were analyzed. The incidence of PONV in the GDFT group was lower than that in the control group (47.1% vs. 71.6%; odds ratio [95%CI], 0.35 [0.17-0.72]; P = 0.004). Fewer patients in the GDFT group received rescue therapy (30% vs. 58.2%; P = 0.001). Patients following GDFT protocol had a faster return of flatus (27.5 (19, 31) vs. 31 (20, 48) hours, P = 0.037) and shorter postoperative LOS (6.1 ± 1.0 vs. 6.6 ± 1.1 days; P = 0.007). CONCLUSION: GDFT is conducive to deceasing PONV occurrence, restoring intestinal function, and shortening postoperative LOS in high-risk patients undergoing LSG.

Effectiveness of Acupuncture Therapy on Postoperative Nausea and Vomiting After Gynecologic Surgery: A Meta-Analysis and Systematic Review.

PURPOSE: The aim of this study was to evaluate the effectiveness and safety of acupuncture therapy (AT) on postoperative nausea and vomiting (PONV) after gynecologic surgery (GS). DESIGN: A meta-analysis using a systematic search strategy was performed. METHODS: A comprehensive literature search of all published randomized controlled trials or prospective cohort studies assessing the effectiveness of AT on PONV in patients undergoing GS was conducted in three databases: PubMed, EMBASE, and Cochrane Library. The incidence of PONV, the use of rescue antiemetics, and side effects of AT were analyzed using the Review Manager 5.3 software. FINDINGS: Nine randomized controlled trials and one prospective cohort study identified in the literature search from database inception (1966) to December 31, 2019, including 1,075 participants were included in the present study. AT significantly reduced the risk of developing postoperative nausea and postoperative vomiting by 48% (relative risk = 0.52; 95% confidence interval, 0.44 to 0.61; P < .00001) and 42% (relative risk = 0.58; 95% confidence interval, 0.49 to 0.68; P < .00001), respectively. No significant differences in the incidence of side effects such as bleeding and needle pain were observed between groups (P = .54). AT was also associated with a lower rate of rescue antiemetic usage (P < .00001) and a higher degree of satisfaction with postoperative recovery (P < .0001). Moreover, the optimal therapeutic effect of AT on preventing PONV was achieved when the treatment time was controlled within 30 minutes and transcutaneous acupoint electrical stimulation was applied. CONCLUSION: AT is an effective and safe physical therapy for the prophylaxis of PONV in patients undergoing GS.