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

BACKGROUND: Pain and post-operative nausea and vomiting are the main factors that impair the quality of recovery after surgery. Very few reports have analyzed patient-reported outcomes to investigate the efficacy of an enhanced recovery after surgery protocol to alleviate these symptoms after head and neck surgeries with free tissue transfer reconstruction. METHODS: We investigated post-operative pain and post-operative nausea and vomiting in 47 patients who underwent head and neck surgeries with free tissue transfer reconstruction with enhanced recovery after surgery support between February 2021 and August 2022. Patient-reported outcomes were assessed using the visual analog scale and Japanese version of the Quality of Recovery-40. RESULTS: Significant increases in the mean visual analog scale scores for pain and post-operative nausea and vomiting were observed only on post-operative Day 1 compared with preoperative values (pain: 3.19 ± 2.78 vs. 1.96 ± 2.42, P = 0.0408; post-operative nausea and vomiting: 1.52 ± 2.09 vs. 0.54 ± 1.37, P = 0.0194). From post-operative Day 2, there were no significant differences between the pre- and post-operative visual analog scale scores, and no significant increases in the incidences of moderate or severe pain and post-operative nausea and vomiting compared with preoperatively. The Japanese version of the Quality of Recovery-40 score for post-operative pain showed no significant deterioration compared with preoperatively, while the Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting showed significant deterioration compared with the preoperative value on post-operative Days 2, 4 and 7. CONCLUSIONS: The visual analog scale and Japanese version of the Quality of Recovery-40 scores for post-operative pain and visual analog scale score for post-operative nausea and vomiting suggested that the enhanced recovery after surgery strategy favorably controlled pain and post-operative nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction. However, as the post-operative Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting was lower than the preoperative value, there is still a need for further improvement of the enhanced recovery after surgery pathway.

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

BACKGROUND: The incidence of post-operative nausea and vomiting (PONV) remains at about 30% despite all therapeutic efforts to reduce it. The clinical risk factors guiding the prophylactic treatment are well established, but genetic factors associated with PONV remain poorly known. The aim of this study was to explore clinical and genetic factors impacting PONV by performing a genome-wide association study (GWAS) together with relevant clinical factors as covariates, and systematically attempt to replicate previously reported PONV associations. Relevant clinical factors are explored with logistic regression model. METHODS: This was an observational case control study in Helsinki University Hospital between 1 August 2006 and 31 December 2010. One thousand consenting women with elevated risk for PONV, undergoing breast cancer surgery with standardised propofol anaesthesia and antiemetics. After exclusions for clinical reasons and failed genotyping, 815 patients were included with 187 PONV cases and 628 controls. Emergence of PONV up to 7th post-operative day was recorded. PONV at 2-24 h after surgery was selected to be the primary outcome. The GWAS explored associations between PONV and 653 034 genetic variants. Replication attempts included 31 variants in 16 genes. RESULTS: The overall incidence of PONV up to 7th post-operative day was 35%, where 3% had PONV at 0-2 h and 23% at 2-24 h after surgery. Age, American Society of Anaesthesiologists status, the amount of oxycodone used in the post-anaesthesia care unit, smoking status, previous PONV, and history of motion sickness were statistically significant predictive factors in the logistic model. The receiver operating characteristic-area under the curve of 0.75 (95% CI 0.71-0.79) was calculated for the model. The GWAS identified six variants with suggestive association to PONV (p < 1 × 10-5 ). Of the previously reported variants, association with the DRD2 variant rs18004972 (TaqIA) was replicated (p = .028). CONCLUSIONS: Our GWAS approach did not identify any high-impact PONV susceptibility variants. The results provide some support for a role of dopamine D2 receptors in PONV.

Post-operative vomiting and enhanced recovery after congenital cardiac surgery.

BACKGROUND: Post-operative nausea and vomiting is frequent after congenital cardiac surgery. AIMS: We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes. METHODS: Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis. RESULTS: From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2-12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89). CONCLUSIONS: Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.

Antiemetics and Apfel Scores in Orthopedic Surgery.

Background: Postoperative nausea and vomiting (PONV) is a common complication following surgery. Only a few risk factors have consistently been reported to be independent predictors for PONV. Aim: To report Apfel scores for orthopedic patients then correlate these scores to the number of antiemetics prescribed and subsequently administered in both the perioperative and post operative setting and determine if screening for Apfel scores is beneficial to predict PONV. Methods: A retrospective analysis of patients admitted under orthopedic units between 1st July 2020 and 31st July 2020 was conducted at a tertiary teaching hospital in Australia. Patients were screened and allocated an Apfel score and antiemetics agents prescribed and subsequently administered were recorded. Results: A total of 115 patients were screened for inclusion. Of these 4 patients met this exclusion criteria, resulting in a total sample size of 111 patients. An Apfel score of 2 was reported in 45.0% of patients, followed by 28.8% of patients scoring 3, with 12.6% scoring one. Only 5.4% of patients scored the highest risk of 4, with 8.2% of patients with no Apfel score documented. Conclusion: Orthopedic patients tend to score 2 or more in their Apfel score placing them at higher risk of postoperative nausea and/or vomiting according to the collectively validated Apfel's simplified risk score. There was no statistically significant relationship between the Apfel score and the number of antiemetic agents prescribed or administered from both the perioperative and post-operative setting following orthopedic surgery in this cohort of adult patients.

A randomised clinical trial to study postoperative abdominal and shoulder tip pain following low and standard pressure laparoscopic cholecystectomy.

Background: Laparoscopic cholecystectomy (LC) has become the gold standard for the management of symptomatic gallstone disease. The complications related to different pressure ranges of pneumoperitoneum have been studied widely with no definite conclusion till date. The current study was planned to determine the effect of standard versus low pressure laparoscopic cholecystectomy (LPLC) on postoperative abdominal and shoulder tip pain (STP). Methods: The present randomised clinical trial included 84 patients divided into two groups: standard pressure laparoscopic cholecystectomy (SPLC) (13 mmHg) and LPLC (9 mmHg). The variables tested were abdominal pain at 3, 6, 12 and 24 h (by verbal rating scale), the incidence and intensity of STP, post-operative nausea and vomiting (PONV) and surgeon's comfort for the two techniques. Results: The demographic characteristics of patients were similar in both groups. In LPP group, the postoperative abdominal pain at 6, 12 and 24 h was significantly less than SPLC; p = 0.02. Incidence of shoulder pain was significantly less in low pressure group (7.14%) compared with standard pressure (28.57%). Conclusions: Low-pressure pneumoperitoneum (LPP) is safe and feasible surgery with reduced abdominal and STP.

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

Background and Aims: Post-operative nausea and vomiting (PONV) is common, undesirable, and stressful following surgery. By focusing attention and resources on those groups of patients most likely to develop PONV, the quality of care provided to the patients can be improved. The primary objective was to compare the incidence of PONV after implementation of the Apfel scoring system with the control group receiving prophylaxis for every surgery. The secondary objective was to identify the effect on the patient's expenditure/savings with respect to management of PONV. Material and Methods: This prospective randomized controlled double-blinded study enrolled 70 patients undergoing surgeries under general anesthesia. Patients were randomized to group A (control group - all received PONV prophylaxis) and group B (Apfel stratification performed for PONV prophylaxis). Based on the Apfel system, the risk of PONV was classified as the grades low, moderate, and high risk. Patients at moderate and high risk received PONV prophylaxis in group B. Patients were monitored for PONV during 24 h after surgery and rescue medication given as required. The effect of implementing Apfel risk stratification on the incidence of PONV (primary outcome measure) and on patient expenditure was compared. Results: Compared to administering prophylaxis for all patients, the incidence of PONV [group A-5 patients (14.3%)] did not increase (P = 0.428) after implementing the Apfel scoring system [group B-2 patients (5.7%)]. The number of patients spending on prophylaxis for PONV in group A [35 (100%)] was higher than that in group B [17 (48%)], without increasing expenditure on PONV treatment. Conclusion: Withholding prophylaxis on the basis of the Apfel scoring system did not increase the incidence of PONV compared to providing prophylaxis for all the patients. The overall cost of prevention and treatment of PONV is less when the Apfel scoring system is used.

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

BACKGROUND: Intraperitoneal local anaesthetic has shown benefit in operative laparoscopy; however, no randomised controlled trial has been reported with patients having diagnostic laparoscopy. AIMS: To determine the effect of intraperitoneal ropivacaine on post-operative analgesic requirements, pain, nausea scores and recovery following gynaecological diagnostic laparoscopy and hysteroscopy. MATERIALS AND METHODS: Randomised double-blind placebo-controlled trial. Well women aged 18-50 years, undergoing day case hysteroscopy and diagnostic laparoscopy for gynaecological indications were randomised to 20 mL of 150 mg intraperitoneal ropivacaine diluted in saline, or 20 mL normal saline instillation (placebo) at the end of the procedure. Women were followed up until eight hours post-discharge. RESULTS: Slower than anticipated recruitment meant that the study was finished before the sample size of 100 patients was achieved. Fifty-nine patients were included for analysis. Thirty-one patients were randomised to ropivacaine and 28 patients to control. Sixty-one percent of patients in both arms required opioid medication in recovery. The total median equivalent morphine dose was significantly higher in the patients randomised to control (11.7 mg) vs ropivacaine (6.7 mg), P = 0.03. Time to discharge was 20 min faster in patients randomised to ropivacaine, but this finding did not reach significance. Overall pain and nausea scores in the first eight hours showed no significant differences. CONCLUSION: There was significantly reduced opioid use in recovery when using intraperitoneal ropivacaine compared to placebo, in this randomised placebo-controlled trial on women undergoing day case diagnostic laparoscopy and hysteroscopy.

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

BACKGROUND: The overall risk of post-operative nausea and vomiting (PONV) after general anaesthesia is reportedly 20%-40%. The first episode of PONV may occur early in the post-anaesthesia care unit (PACU) or later at the ward or after discharge at home in an ambulatory setting. This study aimed to investigate and describe the risk of early PONV in a PACU, and we hypothesised that patients and perioperative factors were associated with early PONV. METHODS: This single-centre retrospective observational study was conducted in a Swedish county hospital from January to June 2017 and included adult patients who underwent surgical procedures under general anaesthesia. Perioperative data were obtained by reviewing the local registry for surgical procedures, medical records and anaesthesia and post-operative charts. Early PONV was defined as PONV occurring up to 4 hours post-operatively at the PACU. Any notification in the medical records, perioperative charts or the registry regarding nausea, vomiting or PONV treatment was regarded as PONV. Univariate and multivariate analyses were performed for factors associated with early PONV. RESULTS: A total of 2030 patients were included in the study, of which 9.6% (n = 194) experienced early PONV. Factors associated with a high risk of early PONV were suboptimal PONV prophylaxis, need for opioids, female sex, body mass index >35 kg m-2 and major surgery and anaesthesia time ≥60 minutes. CONCLUSION: We found that every 10th patient under general anaesthesia experienced early PONV. Suboptimal PONV prophylaxis and previously acknowledged risk factors for PONV were associated with early PONV.

The impact of nausea on post-operative outcomes in bariatric surgery patients.

INTRODUCTION: The evaluation and treatment of post-operative nausea in bariatric surgery patients has not been standardized. In this patient population, nausea can have a significant impact on quality outcomes. The primary objective of this study was to determine the impact of nausea on post-operative outcomes in bariatric surgery patients. METHODS: A retrospective chart review was conducted of adult patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2014 and 2017 at a single institution. Patients with post-operative nausea were identified. Post-operative nausea was defined as patients who had nausea that was documented by multiple providers, and which interfered with their oral intake. Demographic variables were identified for patients with and without documented nausea. Univariate analyses were performed to determine the impact of post-operative nausea on patients' length of stay, readmissions, reoperations, and overall complications. RESULTS: There were 449 primary bariatric surgery patients in the study period, 197 (43.9%) LRYGB and 252 (56.1%) LSG. Of these patients, 160 (35.6%) had documented post-operative nausea. Demographic factors that contributed to post-operative nausea included African-American race and undergoing a LSG (p = 0.004 and p = 0.01, respectively). Patients who underwent a LSG had a 2.0 times increased risk of post-operative nausea compared to LRYGB (p = 0.01). Patients with documented nausea had a statistically significant increased length of stay (2.4 ± 1.9 days vs. 1.6 ± 1.0 days; p ≤ 0.01). Documented nausea patients had an increased incidence of Emergency Department visits within 30 days post-operatively (p = 0.02). CONCLUSIONS: Post-operative nausea was more likely in patients who underwent a sleeve gastrectomy. Gastric bypass and sleeve gastrectomy patients with documented nausea had an increased length of stay and Emergency Department visits. These results highlight the need for a metric to more accurately measure post-operative nausea, as well as a standardized anti-emetic treatment pathway to improve quality outcomes.

A study evaluating the effects of throat packs during nasal surgery: a randomised controlled trial.

The aims of this study were to identify differences in post-operative nausea and vomiting (PONV) and throat pain between throat packed and non-packed patient groups in nasal surgery. This was a prospective, double blind, randomised controlled trial. A water-soaked throat pack gauze was inserted in the mouth to occlude the oropharynx was used in the throat pack group. The second group received no throat pack. A validated PONV questionnaire was completed 6 h post-operatively. Visual analogue scores (VAS) for throat pain were completed in recovery, 2, and 6 h post-operatively. 80 patients were enrolled (40 into each group based on power calculation). With regard to the primary outcome measure, mean PONV score for the throat pack group was 2.75 [median 0, standard deviation (SD 10.86)] and the mean PONV score for the non-packed group was 0.36 (median 0, SD 1.39). The difference in PONV was not statistically significant [P value 0.375, 95% confidence interval (CI) -1.19 to 3.32]. With regard to throat pain VAS scores (our secondary outcome measure), in recovery, the mean throat pain VAS score for the throat packed group was 2.5 (median 1, SD 2.8) and the mean throat pain VAS score for the non-throat packed group was 1.3 (median 0, SD 2.5). Statistical analysis showed a significant difference between the two groups with the throat pack group experiencing more throat pain in recovery (P value 0.018 (95% CI 1.13-2.52). At 2 and 6 h post-operatively, the mean throat pain VAS scores for the throat packed group were 2.1 and 2.3, respectively, and the mean throat pain VAS score for the non-throat packed group was 2.3 and 1.4, respectively. Statistical analysis showed non-significant difference between the two groups at 2 and 6 h post-operatively. The use of throat packs in nasal surgery does not confer PONV reduction benefit. The use of throat pack, however, is associated with a small but statistically significant more throat pain in the initial recovery period from nasal operations.

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

AIMS: This study characterized the pharmacokinetics of ramosetron and compared prophylactic anti-emetic efficacy with that of ondansetron in a large population. METHODS: Fifty-eight patients consented to the pharmacokinetic analysis and were assigned randomly to receive 0.3, 0.45 or 0.6 mg ramosetron after induction of anaesthesia. Blood samples were acquired at preset intervals. Non-compartmental and population pharmacokinetic analyses were performed. In total, 1102 patients consented to the evaluation of prophylactic anti-emetic efficacy and were allocated randomly to receive 0.3 mg ramosetron or 4 mg ondansetron at the end of surgery. An additional 16 mg ondansetron were mixed in the intravenous patient-controlled analgesia pump of the ondansetron group. Post-operative nausea and vomiting (PONV) were evaluated 6, 24 and 48 h post-operatively using the Rhodes index of nausea, vomiting and retching (RINVR). Administration of rescue anti-emetics and adverse events were evaluated. RESULTS: The pharmacokinetic parameter estimates were V1 (l) = 5.12, V2 (l) = 108, CL (l⋅min(-1) ) = 0.08 + (59⋅age(-1) ) × 0.09, Q (l⋅min(-1) ) = 1.42. The incidences of PONV in the ramosetron and ondansetron groups were 77 (13.9%) and 113 (20.6%) and 44 (7.9%) and 66 (12.0%) at 24 and 48 h post-operatively, respectively (P = 0.004, 0.030). RINVR was significantly lower in the ramosetron than the ondansetron group 24 and 48 h post-operatively (P = 0.003, 0.025). Use of rescue anti-emetics and incidence of adverse events were comparable. CONCLUSIONS: A two compartment mammillary model was used to describe ramosetron pharmacokinetics. Prophylactic anti-emetic efficacy of ramosetron was significantly better 24 and 48 h post-operatively than that of ondansetron, particularly when the Apfel score was ≥ 3.

Comparative Analysis of the Modified Aldrete Score and Fast-Track Criteria for Post-general Anaesthesia Recovery: A Narrative Review.

There are two commonly used scoring systems to evaluate recovery from general anaesthesia (GA): the Modified Aldrete Score (MAS) and the Fast-Track Criteria (FTC). Recently, concerns have been expressed about the safety and effectiveness of the Aldrete scoring system due to its exclusion of an assessment for pain or nausea, which can exacerbate recovery from surgery and anaesthesia and cause many patients to experience these side effects. FTC was created to evaluate post-operative nausea vomiting, and pain in order to assess recovery from GA. More data are needed to compare these scoring criteria in low-income countries like India. Understanding how these scores can be effectively utilised in our settings is crucial for ensuring the timely transfer of patients from the operating theatre to the Post-anaesthesia Care Unit and, subsequently, to the ward. This review aims to evaluate the available literature on MAS and FTC and compare their effectiveness. It was found that FTC is more appropriate for outpatient or day surgery procedures where rapid throughput and patient comfort are a priority. MAS, in itself, is very good for a low-income country like India. However, the addition of FTC can only enhance patient care if resources are made available. MAS can ensure consistency and efficiency in the discharge process, while using FTC can address broader recovery-related indicators and improve patient care. More research and modifications are further necessary.

The Effect of Opioid-Free Anesthesia with Transversus Abdominis Plane Block on Patients Undergoing Laparoscopic Sleeve Gastrectomy: Randomized Controlled Study.

Purpose: Anesthesia for metabolic-bariatric surgery is challenging due to the increased risk of opioid-related adverse events. The purpose of the investigation was to assess the feasibility and efficacy of multimodal opioid-free general anesthesia with transversus abdominis plane (TAP) block for laparoscopic sleeve gastrectomy in contrast with conventional opioid-based general anesthesia. Patients and Methods: Eighty patients who underwent laparoscopic sleeve gastrectomy and eventually 71 patients included in the analysis. They were randomly divided into an opioid-based anesthesia group (control group) with sufentanil or opioid-free anesthesia (OFA) group. Esketamine, dexmedetomidine, and TAP were as part of the OFA. Sevoflurane, dexamethasone, and muscle relaxants were administered intraoperatively to all patients. The primary outcome was antiemetic rescue within 24 hours after surgery. The secondary outcomes included pain scores, analgesic needs, extubation time, complications, the hemodynamic changes, and duration of hospital stay. Results: In contrast with the control group, the need for antiemetic rescue was significantly reduced (p= 0.035). Furthermore, the visual Analog Scale (VAS) for postoperative pain was considerably lower in the OFA group (p <0.01) than it was in the control group. There was no significant difference in the need for analgesic rescue in both groups (p= 0.155). Extubation time and post-anesthesia care unit (PACU) stay duration were equal between the two groups (p =0.328 and p =0.54). At the end of the surgery and after extubation, hemodynamic changes was more pronounced in the OFA group (p =0.027) than the control group. The length of the hospital stay was significantly shorter compared with the control group (p =0.002). Conclusion: OFA with TAP results in a significant decrease in the need for antiemetic rescue, a lower level of pain after the surgery, and a shorter hospital stay in contrast with anesthesia based on opioids.

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

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

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

BACKGROUND: The aim of this prospective, randomized, single-blinded study was to compare the effects of a carbohydrate drink 400 mL given 2 h before the surgery with preoperative overnight fasting on the gastric pH and residual volume, postoperative nausea and vomiting (PONV) and antiemetic consumption in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS: Forty American Society of Anesthesiologists physical status I-II patients who underwent elective laparoscopic cholecystectomy. Randomized, prospective, controlled study, Gulhane Medical Faculty and Guven Hospital Department of Anesthesiology and Reanimation. Patients were randomly assigned into two groups: Pre-operative carbohydrate drink group (group C, n = 20) and preoperative fasting group (group F, n = 20). Group C was given a 400 mL carbohydrate drink 2 h before to the surgery. The patients of group F were fasted 8 h before the surgery. Both groups were operated under general anesthesia with volatile anesthetics. RESULTS: Hemodynamic parameters, demographic data, gastric acidity and residual volumes were similar for both groups. No complications were observed. PONV and antiemetic consumption was lower in group C compared to group F (P = 0.001). Patient's satisfaction was higher in group C (P < 0.001). CONCLUSION: This study showed that pre-operative carbohydrate drink may be used safely and also improves patient's satisfaction and comfort in patients undergoing laparoscopic cholecystectomy.

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

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

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

PURPOSE: Level 1 evidence supports the use of acupuncture/acupressure (A/A) to manage post-operative nausea and vomiting (PONV). This study aimed to survey healthcare professionals' attitudes towards A/A, influencing factors and barriers to implementing this effective non-drug intervention into peri-operative care. METHODS: A validated, anonymous survey with 43 questions was emailed or distributed as a hard copy at meetings to anaesthetists, midwives, nurses, obstetricians, gynaecologists and surgeons at a public hospital in Australia. Descriptive data were presented. Influencing factors were explored using chi-square analysis. Multinomial logistical regression was used to identify the influences of confounding factors. RESULTS: A total of 155 completed surveys were returned, reflecting a response rate of 32%. The majority of participants were female (69%), nurses/midwives (61%) and aged between 20 and 50 years old (76%). Eighty-three percent of respondents considered A/A 'clearly alternative' medicine or 'neither mainstream nor alternative'. Eighty-one percent would encourage patients to use acupressure for PONV if it was offered at the hospital. Previous personal use of A/A was the key factor influencing attitudes and openness to clinical use. The key barriers to implementation were perceived lack of evidence and lack of qualified providers and time. CONCLUSION: Hospital-based healthcare professionals strongly supported the evidence-based use of A/A for PONV despite considering the therapy to be non-mainstream and having limited A/A education or history of personal use, providing a positive context for an acupressure implementation study. Significant gaps in training and a desire to learn were identified.

The Optimal Dose of Intraoperative Dexmedetomidine for Antiemetic Effects of Post-operative Nausea and Vomiting in Patients Undergoing Elective Thoracic Surgery: A Retrospective Cohort Study.

Background: Dexmedetomidine (DEX) administration decreases post-operative nausea and vomiting (PONV), but it is a lack of large-scale retrospective cohort study and is unclear whether there is a dose-relationship and optimal dose for antiemetic effects between DEX and PONV. We performed a large-scale retrospective cohort study to explore the optimal dose of intraoperative DEX for antiemetic effects of PONV. Methods: A total of 5,310 patients aged ≥18 who underwent elective thoracic surgery from January 2016 to March 2020 under total intravenous anesthesia (TIVA) or combined intravenous and inhalation anesthesia in Henan Provincial People's Hospital. Patients were divided into two groups, those who received DEX intraoperatively and those who did not receive DEX. Patients who received DEX after surgery were excluded. Our primary outcomes were the association, the dose-response relationship, and the optimal dose for antiemetic effects between intraoperative DEX and PONV. Results: Among the 3,878 patients enrolled, 2,553 patients received DEX and 1,325 patients did not receive DEX. The incidence of PONV in patients who received DEX was 21.3%, and the incidence of PONV in patients who did not receive DEX was 46.5% (P = 0.001). After the matched-pairs cohort consisted of 1,325 patients, the incidence of PONV in patients who received DEX was 23.6%, and the incidence of PONV in patients who did not receive DEX was 46.5% (P = 0.001). We analyzed three different models after propensity matching to validate the stability of the prediction model between intraoperative DEX and PONV. A dose-response relationship between intraoperative DEX and PONV was observed. The optimal dose range of intraoperative DEX for antiemetic effects of PONV is 50-100 µg in elective thoracic surgery. Conclusions: Intraoperative DEX was associated with a decreased incidence of PONV in the large-scale retrospective cohort study. A dose-response relationship between intraoperative DEX and PONV was observed. The optimal dose range of intraoperative DEX for antiemetic effects of PONV is 50-100 µg in elective thoracic surgery.

Practice towards perioperative care of cesarean delivery in Debre Tabor Comprehensive Specialized Hospital, North Central Ethiopia: Cross-sectional study.

Background: Perioperative obstetric care is vital in clinical practice to improve maternal and neonatal outcomes. The standardized practice of perioperative obstetrics care service has a great role in the reduction of both expected and unexpected adverse outcomes. So, the purpose of this study was to assess the implementation of perioperative obstetric care services based on standards of Enhanced Recovery after Cesarean Delivery and the Society of Anesthesiology and Perinatology. Method and materials: A cross-sectional study was conducted on 161 mothers with an elective cesarean delivery from August 10, 2021, to May 15, 2022. The standard of this study was taken from evidence-based practice guidelines of perioperative practice for an elective cesarean delivery. Informed consent was taken from all study participants. The data was collected through direct observation using a standard checklist changed to standardized question forms with two checking components ("Yes", and "No"), and data were entered into SPSS version 20 for analysis and interpretation. Descriptive analysis was done and the results were expressed in numbers and percentages using a table. Results: A total of 161 elective cesarean sections were involved to identify the level of perioperative care. Administration of first-generation antibiotics prophylaxis, aqueous povidone-iodine solution-based skin preparations, and preparation for immediate neonatal resuscitation were fully performed based on the standards. Conclusions: The majority of elective caesarian deliveries were carried out below the recommended level as per the checklists for perioperative practice. So, added interventions are needed to improve perioperative obstetrics care services on those standards which are not totally applied and partially performed.

Prevention and management of postoperative nausea and vomiting after cesarean section: A systematic literature review.

Introduction: Post-operative nausea and vomiting (PONV) are a common post-operative problem in anesthesia. The incidence of PONV in patients undergoing cesarean sections is very high. Post-operative nausea and vomiting have many negative impacts on the patient, baby, family, and health care system. Therefore, appropriate evidence-based knowledge regarding the prevention and management of PONV for those high-risk patients is a timely and very important issue to address to decrease the associated complications. Methods: A comprehensive literature search was conducted in Pubmed/Medline, Cochrane reviews, and google scholar including those studies published in the English language from 2010 up to 2021. The methodological quality of the included studies was appraised by the Cochrane risk of a biased assessment tool for intervention and non-interventional studies. Result: The search strategy identified a total of 10,540 articles from different electronic databases. 33 articles were selected for screening after duplicates were removed; finally, 17 articles were included for critical appraisal and 16 articles were excluded with reasons. The included articles consist of 15 RCT, 1 non-control prospective cohort, and 1 cross-sectional study. Conclusion: Pieces of evidence revealed that all obstetrics patients undergoing cesarean section should be given multimodal PONV prophylaxis. It is shown that a multimodal approach by a combination of different antiemetic agents should be preferred and most effective in preventing intraoperative and postoperative nausea and vomiting for patients undergoing cesarean section because of the complex pathophysiology of nausea and vomiting.