Chewing Gum for Prevention of Nausea and Vomiting After Elective Caesarean Section: a Pilot Randomised Controlled Trial.

Nausea and vomiting are common complications in patients undergoing caesarean delivery under regional anaesthesia. When experienced after surgery, they may delay recovery, reduce patient satisfaction and affect the bonding between mother and baby. Various pharmacological and non-pharmacological approaches for prophylaxis and treatment of postoperative nausea and vomiting (PONV) have been employed with different degree of efficacy. In this pilot randomised controlled trial, we aimed to determine the possible preventative effects of chewing gum on the rate of PONV in expectant mothers undergoing neuraxial anaesthesia for elective lower segment caesarean section. All participants underwent spinal anaesthesia with administration of 10-11.5 mg of intrathecal heavy Bupivicaine 0.5% according to anaesthetists' preference, Morphine 100 µg and Fentanyl 25 µg. Postoperative analgesia regimen was also standardised. Two hundred ninety-six patients were randomised to an intervention arm to receive chewing gum in addition to standard therapy and to a non-intervention arm to receive standard therapy. After exclusions, 258 patients were followed up 24 h postoperatively. Standard therapy is defined as Ondansetron 4 mg IV intra-operatively. The primary outcomes were the incidences of nausea and vomiting in the first 24 h postoperatively. Secondary outcomes were the number of episodes of nausea or vomiting in the recovery room and on the ward 24 h postoperatively, use of anti-emetics postoperatively, severity of nausea and patient satisfaction with the intervention. Our study revealed no significant differences in rates of postoperative nausea and vomiting between the intervention and standard therapy groups (41.4% v 36.9% p = 0.461). There were no significant differences in secondary outcomes between groups. Chewing gum does not reduce the incidence of PONV after elective LSCS under spinal anaesthesia. Our trial was registered with clinicaltrials.org (NCT04191694).

Urinary biomarkers predict progression and adverse outcomes of acute kidney injury in critical illness.

BACKGROUND: Acute kidney injury (AKI) is common in hospitalized patients and is associated with high morbidity and mortality. The Dublin Acute Biomarker Group Evaluation study is a prospective cohort study of critically ill patients (n = 717). We hypothesized that novel urinary biomarkers would predict progression of AKI and associated outcomes. METHODS: The primary (diagnostic) analysis assessed the ability of biomarkers levels at the time of early Stage 1 or 2 AKI to predict progression to higher AKI stage, renal replacement therapy (RRT) or death within 7 days of intensive care unit admission. In the secondary (prognostic) analysis, we investigated the association between biomarker levels and RRT or death within 30 days. RESULTS: In total, 186 patients had an AKI within 7 days of admission. In the primary (diagnostic) analysis, 8 of the 14 biomarkers were independently associated with progression. The best predictors were cystatin C [adjusted odds ratio (aOR) 5.2; 95% confidence interval (CI) 1.3-23.6], interleukin-18 (IL-18; aOR 5.1; 95% CI 1.8-15.7), albumin (aOR 4.9; 95% CI 1.5-18.3) and neutrophil gelatinase-associated lipocalin (NGAL; aOR 4.6; 95% CI 1.4-17.9). Receiver-operating characteristics and net reclassification index analyses similarly demonstrated improved prediction by these biomarkers. In the secondary (prognostic) analysis of Stages 1-3 AKI cases, IL-18, NGAL, albumin and monocyte chemotactic protein-1 were also independently associated with RRT or death within 30 days. CONCLUSIONS: Among 14 novel urinary biomarkers assessed, cystatin C, IL-18, albumin and NGAL were the best predictors of Stages 1-2 AKI progression. These biomarkers, after further validation, may have utility to inform diagnostic and prognostic assessment and guide management of AKI in critically ill patients.

Managing opioid consumption after caesarean delivery: a quality improvement initiative.

INTRODUCTION: Caesarean delivery is the most common major surgical procedure performed worldwide and pain management after caesarean delivery remains challenging. Finding a balance between sufficient postoperative pain relief and excess sedation secondary to opioids is often difficult in this patient population. This quality improvement project aimed to manage the amount of opioid consumption after caesarean delivery using a new postoperative analgesic regimen. METHODS: The current practice was analysed in 52 patients before introducing the new regimen. Oxycodone consumption, pain scores and quality of recovery were recorded. Following this pre-implementation audit, a new postoperative analgesic protocol was introduced. All patients received standard doses of intrathecal morphine, paracetamol and diclofenac. Regular oxycodone sustained-release (SR) was replaced with oxycodone immediate-release (IR) as needed. These changes also coincided with education to improve midwifery assessment of pain and the delivery of analgesia. RESULTS: The outcome measures were re-audited in 178 patients which showed that oxycodone consumption had reduced median (IQR) 30 mg (20-40) vs 10 mg (5-15) (p < 0.001). There was no significant difference in the pain scores between the before and after groups at rest median (IQR) 2.0 (0-4.8) vs 2.0 (0.8-4.0) or at movement 5.0 (3.0-6.0) vs 5.0 (3.0-6.3) (p = 0.292, p = 0.482 respectively). The quality of recovery scores were also equivalent mean (SD) 78.6 (20.6) vs 77.8 (19.0) (p = 0.792). CONCLUSION: The results of this study suggest that postoperative opioid consumption can be reduced with specific analgesic protocols and allow us to improve patient's quality of recovery.

An ultrasound assessment of gastric emptying following tea with milk in pregnancy: A randomised controlled trial.

BACKGROUND: Peri-operative fasting guidelines allow clear fluids including tea without milk to be consumed up to 2 h before surgery. Recent evidence has shown that a modest amount of milk consumed with clear fluids does not significantly slow gastric emptying. OBJECTIVES: The aim of this study was to compare the gastric emptying of tea with milk versus water using ultrasonography in fasted pregnant patients. DESIGN: A randomised controlled trial quantifying gastric emptying in two groups using ultrasonography by an operator blinded to the group allocation. SETTING: Department of Anaesthesia and Peri-operative Medicine, Coombe Women and Infants University Hospital, Dublin. The study was conducted between October 2018 and June 2019. PARTICIPANTS: Total 50 nonlabouring pregnant women, more than 36 weeks gestation. INTERVENTIONS: After a standard overnight fast, women were randomised to either 250 ml of water or 250 ml of tea with milk. All patients underwent a gastric ultrasound assessment at regular intervals for 2 h after consumption of their drink. MAIN OUTCOME MEASURE: The primary outcome was the difference in gastric antrum cross-sectional area (CSA) at 2 h. RESULTS: A total of 50 women were recruited to the study. There was no significant difference in the median [IQR] gastric antrum CSA in either group at 2 h: 3.2 cm [2.3 to 3.7] vs. 3.1 cm [2.6 to 3.9]; P = 0.720. The gastric antrum CSA had returned to its baseline measurement in both groups by 90 min. CONCLUSION: The change of gastric antrum CSA after 250 ml of tea with milk is similar to a corresponding volume of water in fasted pregnant patients. This study could help inform future peri-operative fasting guidelines regarding the use of a modest volume of milk with clear fluids. TRIAL REGISTRY NUMBER: NCT03694509 ClinicalTrials.gov.