[Comparison of different prediction models for the occurrence of nausea and vomiting in the postoperative phase : A systematic qualitative comparison based on prospectively defined quality indicators]. / Vergleich verschiedener Vorhersagemodelle für das Auftreten von Übelkeit und Erbrechen in der postoperativen Phase : Ein systematischer qualitativer Vergleich anhand prospektiv definierter Qualitätsindikatoren.

BACKGROUND: Various prognostic prediction models exist for evaluating the risk of nausea and vomiting in the postoperative period (PONV). So far, no systematic comparison of these prognostic scores is available. METHOD: A systematic literature search was carried out in seven medical databases to find publications on prognostic PONV models. Identified scores were assessed against prospectively defined quality criteria, including generalizability, validation and clinical relevance of the models. RESULTS: The literature search revealed 62 relevant publications with a total of 81,834 patients which could be assigned to 8 prognostic models. The simplified Apfel score performed best, primarily because it was extensively validated. The Van den Bosch score and Sinclair score tied for second place. The simplified Koivuranta score was in third place. CONCLUSION: The qualitative analysis highlights the strengths and weaknesses of each prediction system based on predetermined standardized quality criteria.

Pharmacokinetic Characterisation and Comparison of Bioavailability of Intranasal Fentanyl, Transmucosal, and Intravenous Administration through a Three-Way Crossover Study in 24 Healthy Volunteers.

BACKGROUND: For more than 60 years, the synthetic opioid fentanyl has been widely used in anaesthesia and analgesia. While the intravenous formulation is primarily used for general anaesthesia and intensive care settings, the drug's high lipophilic properties also allow various noninvasive routes of administration. Published data suggest that intranasal administration is also attractive for use as intranasal patient-controlled analgesia (PCA). A newly developed intranasal fentanyl formulation containing 47 µg fentanyl, intravenous fentanyl, and oral transmucosal fentanyl citrate were characterised, and bioavailability was compared to assess the suitability of the intranasal formulation for an intranasal PCA product. METHODS: 27 healthy volunteers were enrolled in a single-centre, open-label, randomised (order of treatments), single-dose study in a three-period crossover design. The pharmacokinetics of one intranasal puff of fentanyl formulation (47 µg, 140 mL per puff), one short intravenous infusion of 50 µg fentanyl, and one lozenge with an integrated applicator (200 µg fentanyl) were studied, and bioavailability was calculated. Blood samples were collected over 12 hours, and plasma concentrations of fentanyl were determined by HPLC with MS/MS detection. RESULTS: 24 volunteers completed the study. The geometric mean of AUC0-tlast was the highest with oral transmucosal administration (1106 h ∗ pg/ml, CV% = 32.86), followed by intravenous (672 h ∗ pg/ml, CV% = 32.18) and intranasal administration (515 h ∗ pg/ml, CV% = 30.10). C max was 886 pg/ml (CV% = 59.38) for intravenous, 338 pg/ml (CV% = 45.61) for intranasal, and 310 pg/ml (CV% = 29.58) for oral transmucosal administration. t max was shortest for intravenous administration (0.06 h, SD = 0.056), followed by intranasal (0.21 h, SD = 0.078) and oral transmucosal administration (1.20 h, SD = 0.763). Dose-adjusted absolute bioavailability was determined to be 74.70% for the intranasal formulation and 41.25% for the oral transmucosal product. In total, 38 adverse events (AEs) occurred. Fourteen AEs were potentially related to the investigational items. No serious AE occurred. CONCLUSION: Pharmacokinetic parameters and bioavailability of the investigated intranasal fentanyl indicated suitability for its intended use as an intranasal PCA option.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta-analysis.

Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine3 , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.

Quo Vadis PCA? A Review on Current Concepts, Economic Considerations, Patient-Related Aspects, and Future Development with respect to Patient-Controlled Analgesia.

This review assesses four interrelating aspects of patient-controlled analgesia (PCA), a long-standing and still widely used concept for postoperative pain management. Over the years, anaesthesiologists and patients have appreciated the benefits of PCA alike. The market has seen new technologies leveraging noninvasive routes of administration and, thus, further increasing patient and staff satisfaction as well as promoting safety aspects. Pharmaceutical research focuses on the reduction or avoidance of opioids, side effects, and adverse events although influence of these aspects appears to be minor. The importance of education is still eminent, and new educational formats are tested to train healthcare professionals and patients likewise. New PCA technology can support the implementation of efficient processes to reduce workload and human errors; however, these new products come with a cost, which is not necessarily reflected through beneficial budget impact or significant improvements in patient outcome. Although first steps have been taken to better recognize the importance of postoperative pain management through the introduction of value-based reimbursement, in most western countries, PCA is not specifically compensated. PCA is still an effective and valued technique for postoperative pain management. Although there is identifiable potential for future developments in various aspects, this potential has not materialized in new products.

Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review.

We aimed to assess the effectiveness of remifentanil used as intravenous patient-controlled analgesia for the pain of labour. We performed a systematic literature search in December 2015 (updated in December 2016). We included randomised, controlled and cluster-randomised trials of women in labour with planned vaginal delivery receiving patient-controlled remifentanil compared principally with other parenteral and patient-controlled opioids, epidural analgesia and continuous remifentanil infusion or placebo. The primary outcomes were patient satisfaction with pain relief and the occurrence of adverse events for mothers and newborns. We assessed risk of bias for each included study and applied the GRADE approach for the quality of evidence. We included total zero event trials, using a constant continuity correction of 0.01 and a random-effect meta-analysis. Twenty studies were included in the qualitative analysis; within these, 3713 participants were randomised and 3569 analysed. Most of our pre-specified outcomes were not studied in the included trials. However, we found evidence that women using patient-controlled remifentanil were more satisfied with pain relief than women receiving parenteral opioids (four trials, 216 patients, very low quality evidence) with a standardised mean difference ([SMD] 95%CI) of 2.11 (0.72-3.49), but were less satisfied than women receiving epidural analgesia (seven trials, 2135 patients, very low quality evidence), -0.22 (-0.40 to -0.04). Data on adverse events were sparse. However, the relative risk (95%CI) for maternal respiratory depression for patient-controlled remifentanil compared with epidural analgesia (three trials, 687 patients, low-quality evidence) was 0.91 (0.51-1.62). Compared with continuous intravenous infusion of remifentanil (two trials, 135 patients, low-quality evidence) no conclusion could be reached as all study arms showed zero events. The relative risk (95%CI) of Apgar scores less than 7 at 5 min after birth compared with epidural analgesia (five trials, 1322 participants, low-quality evidence) was 1.26 (0.62-2.57).

[PONV after strabismus surgery : Risk adapted prophylaxis?]. / PONV nach Strabismus-OP : Risikoadaptierte Prophylaxe?

BACKGROUND: Following strabismus surgery, patients frequently develop variable degrees of postoperative nausea and vomiting (PONV). These symptoms cause discomfort and result in serious complications such as intramuscular bleeding and subconjunctival hemorrhage. In children long lasting PONV can lead to and electrolyte imbalance and dehydration. A prolonged course of recovery is the consequence. For the hospital, PONV can also involve negative economic impacts because of a damaged public reputation of the institution. There is still an ongoing debate on wether prophylaxis of PONV is necessary and how the prophylaxis of PONV should be performed. On one hand, there are proponents of a liberal prophylaxis. These intend to treat almost all patients regardless of their individual risk for PONV. On the other hand, opponents point out that every medication has to be indicated individually. In their view, risk scores should be the base of a risk-adapted approach. OBJECTIVES: The aim of the study was to reduce the frequency of PONV by using an anesthetic technique adapted to the individual risk for PONV. Until now, all trials studying the efficiency of a score-based antiemetic prophylaxis were performed on adult patients. In this study, a risk-adapted approach was evaluated on children for the first time. PATIENTS AND METHODS: In 92 patients, the incidence of PONV was analyzed after strabismus surgery. Before surgery we evaluated the risk factors for PONV according to the POVOC score in children (n = 45, 49 %) and the Apfel's score in adults (n = 47, 51 %). Patients with 0-2 risk factors received a balanced anesthesia (n = 47, 51 %). Those with 3-4 risk factors were operated in total IV anesthesia (TIVA) with propofol (n = 45, 49 %). In addition, as an antiemetic prophylaxis, 0.15 mg/kg dexamethason and 0.1 mg/kg ondansetron were applied in the latter patients. we documented the symptoms and severity of PONV 2, 6 and 24 h after surgery by means of a standardized questionnaire for PONV (Wengritzky-Score). RESULTS: The incidence of PONV was 17 % (n = 16) in all of the patients. The incidence in low-risk patients receiving a BA without prophylaxis were 21 % in adults and 38 % in children. Of the patients at high risk for PONV receiving the multimodal antiemetic approach 8 % (adults) and 9 % (children) suffered from PONV. The combination of TIVA and antiemetics could reduce the incidence of PONV compared to the predicted values in a clinically relevant manner (OR = 0.26, KI: 0.76-0.87). CONCLUSION: The overall incidence could be reduced to a level below 20 %. Particularly in patients with a high risk of PONV, TIVA could clearly reduce the incidence. However, the incidence in patients with 2 risk factors is still high (30-39 %). Therefore, it is important to reconsider the effort involved with risk screening and individually adapting anesthesia. Risk stratification means a pre- and perioperative effort. Therefore, we advocate a more liberal approach for PONV prophylaxis.

Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis.

BACKGROUND: Improvement of postoperative pain and other perioperative outcomes remain a significant challenge and a matter of debate among perioperative clinicians. This systematic review aims to evaluate the effects of perioperative i.v. lidocaine infusion on postoperative pain and recovery in patients undergoing various surgical procedures. METHODS: CENTRAL, MEDLINE, EMBASE, and CINAHL databases and ClinicalTrials.gov, and congress proceedings were searched for randomized controlled trials until May 2014, that compared patients who did or did not receive continuous perioperative i.v. lidocaine infusion. RESULTS: Forty-five trials (2802 participants) were included. Meta-analysis suggested that lidocaine reduced postoperative pain (visual analogue scale, 0 to 10 cm) at 1-4 h (MD -0.84, 95% CI -1.10 to -0.59) and at 24 h (MD -0.34, 95% CI -0.57 to -0.11) after surgery, but not at 48 h (MD -0.22, 95% CI -0.47 to 0.03). Subgroup analysis and trial sequential analysis suggested pain reduction for patients undergoing laparoscopic abdominal surgery or open abdominal surgery, but not for patients undergoing other surgeries. There was limited evidence of positive effects of lidocaine on postoperative gastrointestinal recovery, opioid requirements, postoperative nausea and vomiting, and length of hospital stay. There were limited data available on the effect of systemic lidocaine on adverse effects or surgical complications. Quality of evidence was limited as a result of inconsistency (heterogeneity) and indirectness (small studies). CONCLUSIONS: There is limited evidence suggesting that i.v. lidocaine may be a useful adjuvant during general anaesthesia because of its beneficial impact on several outcomes after surgery.

[Hypoxemia after general anesthesia]. / Hypoxämie nach Allgemeinanästhesie.

BACKGROUND: Studies conducted shortly after the implementation of pulse oximetry (PO) into clinical practice 20-25 years ago revealed that many patients breathing room air during transfer from the operating room (OR) to the post-anesthesia care unit (PACU) directly after general anesthesia (GA) had a peripheral oxygen saturation (S(p)O(2)) below 90%. Moreover, it was shown that the detection of hypoxemia by clinical criteria is extremely unreliable. Meanwhile, the use of PO has become part of the obligatory standard monitoring during GA in Germany and many other countries. Likewise, the use of PO is standard care in the PACU although there are no official recommendations. However, for the time period in between, i.e. immediately after GA during transportation of patients from the OR to the PACU, monitoring of the S(p)O(2) in patients breathing room air is neither obligatory in Germany nor are there any official recommendations or guidelines in this respect. Given the introduction of shorter acting anesthetic agents within the last 25 years, the main goal of this study was to explore whether the incidence of hypoxemia in the immediate period after GA is still so high. Additional aims of this study were to examine whether the detection of hypoxemia based on clinical criteria can be confirmed to be very unreliable, what the risk factors for hypoxemia following GA are and how common it is in Germany to transport patients from the OR to the PACU without PO and supplemental oxygen. METHODS: In a prospective observational study 970 patients who underwent a broad spectrum of elective surgery under GA in a university hospital setting were included. The S(p)O(2) was measured at the end of the transfer from the OR to the PACU immediately after the anesthetist who had taken care of the patient during the operation had estimated the S(p)O(2). The association between biometric, surgical and anesthesiological variables on the one hand and hypoxemia as well as a decrease of S(p)O(2) on the other hand were studied using multivariate methods. Finally, a survey including all university hospitals was carried out to find out about the use of PO and oxygen during patient transfer from the OR to the PACU. RESULTS: Of the 959 patients who were eligible for analysis 17% had a S(p)O(2) < 90% and 6.6% a S(p)O(2) < 85%. Hypoxemia was not recognized in 82% of the patients in whom an assessment based on clinical grounds was carried out. Variables with an independent influence on hypoxemia and decrease of S(p)O(2) were as follows: saturation before induction of GA, body mass index, age, American Society of Anesthesiologists (ASA) physical status, difference between maximum and minimum inspiratory pressure, mode of ventilation, the choice of opioid and muscle relaxant as well as the use of nitrous oxide. Patient-dependent risk factors had the strongest impact on hypoxemia. In about 80% of the university hospitals neither PO nor supplemental oxygen is used during transportation of the patient from the OR to the PACU. CONCLUSIONS: The use of opioids and relaxants with short duration of action may have favorable effects on preventing hypoxemia and decreases of S(p)O(2). These measures will, however, not be sufficient to solve this problem because the highest risk factors for hypoxemia are patient-related. Despite knowing risk factors for oxygen desaturation, it is currently not possible to reliably predict which patients will become hypoxemic or have a decrease of S(p)O(2). Therefore, transportation of patients breathing room air from the OR to the PACU directly after GA without use of PO or supplemental oxygen seems to be questionable in terms of patient safety.

[Cardioprotection by thoracic epidural anesthesia? : meta-analysis]. / Kardioprotektion durch thorakale Periduralanästhesie? : Metaanalyse.

BACKGROUND: Thoracic epidural analgesia (EDA) is thought to provide cardioprotective effects in patients undergoing noncardiac surgery. The results of two previous meta-analysis showed controversial conclusions regarding the impact of EDA on perioperative survival. The purpose of the present meta-analysis was to evaluate, whether thoracic EDA has the potential to reduce perioperative cardiac morbidity or mortality on the basis of available randomized controlled trials. PATIENTS AND METHODS: A systematic literature search was conducted in medical databases (Med-Line, EBM-Reviews, Embase, Biosis and Biological Abstracts) and relevant clinical trials including patients undergoing noncardiac surgery were evaluated by two independent investigators. All randomized controlled trials investigating the effects of thoracic EDA on perioperative outcome, published from 1980 up to the end of 2008 were included into this quantitative systematic review. Calculations were performed using the statistics program Review Manager 4.1 using a fixed-effects model. RESULTS: Nine studies with a total of 2,768 patients were included in the meta-analysis. Thoracic EDA did not reduce perioperative mortality [odds ratio (Peto OR): 1.08; 95% confidence interval (CI) 0.74-1.58]. Patients receiving thoracic EDA demonstrated a tendency to a lower rate of perioperative myocardial infarction. However, this effect of thoracic EDA did not reach statistical significance (Peto OR: 0.65; 95% CI 0.4-1.05). CONCLUSIONS: The present meta-analysis did not prove any positive influence of thoracic EDA on perioperative in-hospital mortality in patients undergoing noncardiac surgery. Furthermore, it remains questionable if thoracic EDA has the potential to reduce the rate of perioperative myocardial infarction.

Stability-indicating HPLC assays for the determination of piritramide and droperidol in PCA solution.

WHAT IS KNOWN AND OBJECTIVE: A mixture of morphine and droperidol is a well-established antiemetic for reducing the risk of postoperative nausea and vomiting. A mixture of piritramide and droperidol has not yet been evaluated in this context. Our objectives were to develop a high-performance liquid chromatographic assay for piritramide and droperidol in 0·9% saline, and to establish their stability under defined storage conditions. METHODS: The separation and assay of both drugs were attempted by high performance liquid chromatography (HPLC) using a RP-select B column and a mobile phase of 57:43% v/v methanol-monosodium phosphate solution 0·05 M at a flow rate of 1·2 mL/min. UV detection at 205 and 246 nm for piritramide and droperidol were used, respectively. RESULTS AND DISCUSSION: The HPLC method was successful. Linearity was shown for piritramide from 0·075 to 0·013 mg/mL and for droperidol from 0·8 to 0·2 mg/mL. The intra- and inter-day relative standard deviation (RSD, %) was 0·27% and 0·54% for piritramide and droperidol, respectively. The two drugs were stable for at least 72 h when stored under ambient light at room temperature. WHAT IS NEW AND CONCLUSION: Seventy-five milligrams piritramide and 2·5 mg droperidol diluted to 50 ml with 0·9% saline should be suitable for clinical use. At this dilution, a Dipidolor(®) and Xomolix(®), mixture, was stable when stored under ambient light exposure at room temperature for at least 72 h.

[Implementation of new standards in anaesthesia. Exemplified by the ad hoc introduction of desflurane in 10 German hospitals]. / Implementierung neuer Standards in der Anästhesie. Beispiel der Ad-hoc-Einführung von Desfluran an 10 deutschen Krankenhäusern.

BACKGROUND: According to numerous pharmacoeconomic studies new anaesthesia techniques can improve recovery times and thus can have a positive economic impact on patient turnover. However, artificial study protocols do not always match real world situations and thus the practical impact of such studies remains unclear. MATERIAL AND METHODS: At 10 hospitals exclusively using sevoflurane as a volatile anaesthetic, the ad hoc implementation of desflurane was studied with respect to post-anaesthetic recovery times (primary endpoint) and postoperative outcome measured by the Quality of Recovery Score- (QoR-)40, on the first postoperative day was investigated. Randomization of patients undergoing elective surgical procedures under general anaesthesia with sevoflurane (n=186) or desflurane (n=176) was started immediately after a period of a few days after introducing the new drug to all participants. Except for the volatile anaesthetic the anaesthetic procedure was performed according to local standing operating procedures. RESULTS: All parameters indicating the immediate postanaesthetic recovery were superior in the patients receiving desflurane (mean±SD). Time to extubation was accelerated from 8.7±9.7 to 6.2±6.8 min. Times to recalling name and date of birth were accelerated by 2.6 and 3.8 min, respectively. Transferring the patients from the operating theatre to the post-anaesthetic recovery unit was 17.3±11.5 min after sevoflurane and 13.7±7.8 min after anaesthesia with desflurane. Eligibility for discharge according to a modified Aldrete score (White and Song 1999) was reached after 103±98 and 79±76 min, respectively. The postoperative recovery (QoR 40 questionnaire) did not differ 24 h later. DISCUSSION: The implementation of a new drug (here: desflurane to substitute sevoflurane) can improve speed of recovery immediately after termination of anaesthesia even after a very short period of introducing the new technique but has no positive long term effects. Thus, the results of this trial performed under a real world scenario (health service research) without tight standardization by an artificial study protocol supports the results originating from randomized controlled clinical trials.

[Prophylaxis of nausea and vomiting in the postoperative phase: relative effectiveness of droperidol and metoclopramide]. / Prophylaxe von Übelkeit und Erbrechen in der postoperativen Phase : Relative Effektivität von Droperidol und Metoclopramid.

OBJECTIVE: The aim of the present study was to conduct a meta-analysis of the results from randomized controlled trials investigating the relative efficacy of droperidol versus metoclopramide for the prevention of postoperative nausea and vomiting (PONV). METHODS: A systematic literature search for randomized controlled trials comparing droperidol and metoclopramide for the prevention of PONV was performed according to the PRISMA recommendations. The incidence of PONV within the early (0-6 h) and cumulative postoperative periods (0-48 h) was collated and the pooled relative risk (RR) with the corresponding 95% confidence interval (CI) was calculated. Results from a subgroup analysis are presented excluding the data of a Japanese group (Fujii et al.) which are given in parentheses. RESULTS: A total of 41 (30) trials with a total number of 3,491 (2,721) patients were included and of these 12 (8) trials with 1,403 (1,083) patients reported data of the early period and 32 (21) studies with 2,656 (1,836) patients comprised data of the cumulative period. A total of 1,797 (1,309) patients were treated with droperidol (0.25-5 mg) and 1,694 (1,412) with metoclopramide (5-50 mg). In the early period the risk for PONV after metoclopramide was 35% (95%-CI: 17-57%) higher than after prophylaxis with droperidol (without Fujii data: 46%; 23-73%). During the cumulative period the risk for PONV after metoclopramide was increased by 20% (95%-CI: 7-37%) compared to droperidol (without Fujii data: 25%; 4-50%). Due to heterogenous dosing of both drugs subgroup analyses with distinct dose intervals were performed with increments of 0.75 mg for droperidol and 7 mg for metoclopramide. Droperidol was superior in 17 (12) out of 19 (14) subgroup analyses. Comparing recommended doses of droperidol (0.75-1.5 mg) with low doses of metoclopramide (7-14 mg) and medium metoclopramide doses (14-21 mg) PONV was increased by 12% (95%-CI: -11% to 42%) and 32% (95%-CI: 4%-66%), respectively when metoclopramide instead of droperidol was used. When higher doses of metoclopramide (>20 mg) were used the superiority of droperidol was less pronounced and did not reach statistical significance due to the limited numbers of trials included in this analysis (3 studies, 662 patients). The risk for PONV after high-dose metoclopramide was increased by 13% (95%-CI: -21% to +61%) for the early period and by 19% (95%-CI: -11% to +57%) for the cumulative observation period. CONCLUSION: For the prevention of postoperative nausea and vomiting droperidol is significantly superior to metoclopramide doses below 20 mg. There was no obvious positive dose response with respect to increasing doses of metoclopramide. There was also a trend towards higher efficacy of droperidol compared to higher doses of metoclopramide (≥20 mg). However, there were not enough comparative studies to show a statistically significant result in this subgroup analysis. These data support the notion that droperidol in low doses may represent the more effective D(2)-antagonist for a pharmacological armamentarium to cope with PONV.

[Relevance of five core aspects of the pre-anesthesia visit: results of a patient survey]. / Wertigkeit von 5 Kernaspekten der Prämedikationsvisite : Ergebnisse einer Patientenbefragung.

BACKGROUND: Due to a variety of reasons (e.g. increase in outpatient surgery and legal restrictions related to working hours) it has become increasingly more difficult to have the pre-anesthesia visit and the anesthesia carried out by the same anesthetist. In the light of these organizational changes as well as increasing economical pressure it has become common practice to implement pre-anesthesia assessment clinics. It is unclear, however, if these changes in anesthetic patient care respect patient needs. METHODS: By means of a survey using the willingness to pay method, the relative significance of five quality aspects (location of pre-anesthesia visit, waiting time, patient-physician relationship, use of multimedia and ambience) were studied. Participation during a 12-month study period was on a voluntary basis. RESULTS: Of the 1,058 questionnaires, 1,014 were eligible for analysis. A pre-anesthesia visit performed by the anesthetist who would deliver anesthesia was the most important aspect for almost two thirds (624 out of 1,014) of the patients with on average more than one third of the money available spent on this item. Waiting time was the second most important factor with about one third of the patients rating this item as the most relevant factor and on average approximately one quarter of the total money available spent on it. Location of the pre-anesthesia visit, use of multimedia and ambience were considered least important. The order of these preferences was regardless of age and gender of subjects. However, there was a trend to age and gender-specific differences concerning the amount of money spent on these five items. For instance, with increasing age, patient-physician relationship and location of the pre-anesthesia visit become more important. CONCLUSIONS: These results suggest that the integration of a pre-anesthesia assessment clinic in anesthetic patient care is not favorable from the patients' point of view because getting to know the anesthetist who will deliver anesthesia is of paramount importance to most patients. In cases where a pre-anesthetic assessment clinic is indispensable, other measures to build up confidence compensating for the lack of personal patient-physician relationship should be developed. In this respect, the promotion of a corporate identity of the whole anesthesia department may be beneficial. Furthermore, keeping the waiting time as short as possible should be a high priority as this item was rated the second most important factor.

Postoperative analgesia with parecoxib, acetaminophen, and the combination of both: a randomized, double-blind, placebo-controlled trial in patients undergoing thyroid surgery.

BACKGROUND: We assessed the analgesic efficacy of parecoxib, acetaminophen, and the combination of both compared with placebo in patients undergoing elective thyroid or parathyroid surgery. METHODS: We randomized 140 patients to receive one of the following i.v. treatments using a double-blinded double-dummy technique: placebo, 80 mg 24 h(-1) parecoxib, 5 g 24 h(-1) acetaminophen, or 80 mg parecoxib plus 5 g acetaminophen. We provided rescue analgesia with piritramide delivered by a patient-controlled analgesia device. We measured opioid consumption and pain intensity over 24 h after operation. RESULTS: Patient characteristic data, anaesthetic, and surgical characteristics of the patients in the four groups were similar. Parecoxib, acetaminophen, and the combination significantly reduced opioid requirements during 24 h after surgery [mean (sd) 12.5 (10.9) mg for parecoxib, 14.2 (12.3) mg for acetaminophen, and 11.9 (10.7) mg for combination] compared with placebo [23.5 (15.3) mg, P<0.05]. However, the combination of parecoxib and acetaminophen did not have any advantage over individual drugs in terms of opioid consumption in our trial (P>0.05). CONCLUSIONS: Parecoxib and acetaminophen effectively reduce postoperative opioid requirements after thyroid or parathyroid surgery. The combination of these drugs is not associated with a further reduction in opioid consumption.

[Optimization of perioperative management in laparoscopic hernioplasty]. / Optimierung des perioperativen Managements am Beispiel der laparoskopischen Leistenbruchoperation.

INTRODUCTION: Although about 150,000-200,000 hernia repair procedures are performed every year in Germany alone, fast-track concepts are mainly ignored for this type of surgery. Therefore, this study was designed to analyze the perioperative management of patients undergoing laparoscopic hernia repair, performed as transabdominal preperitoneal patch hernioplasty (TAPP). Based on these results, the clinical management was optimized in order to shorten the length of stay without affecting the quality of treatment or the complication rate, and the effects of the optimization strategies were reanalyzed. METHODS: With ethics committee approval 249 patients undergoing TAPP procedures were investigated. In the first two study sections, problems of the perioperative management were identified first retrospectively (n=129) and then prospectively (n=60). Based on these results, the clinical management was then redesigned and optimized. A TAPP score was developed including the parameters age, ASA physical status, extent and severity of the procedure and postoperative pain level. Patients were scored 24 h after surgery, and clear-cut criteria were defined for discharge home on the second postoperative day. Furthermore, all patients received 10 mg of sodium picosulfate to avoid postoperative constipation. In the third study section (n=60) the impact of the optimization strategies on length of stay, need for pain medication, complication rate and patient satisfaction (based on the PPP33 questionnaire) was evaluated. RESULTS: Patients were on average approximately 60 years old (range 22-92 years), and demographic data were comparable within the study sections. As a result of the optimization process, 72% of the patients could be discharged home on the second postoperative day whereas previously that had only been possible in 5%. Accordingly, the postoperative length of stay (including the day of surgery) was significantly reduced from 4.2+/-0.6 to 3.3+/-0.6 days. By the administration of sodium picosulfate, 92% of all patients reported defecation on the first day after surgery, whereas previously the majority of patients (60%) had complained of constipation at this time. No serious complications were observed. The number of minor complications was very low in total and neither complication rate nor patient satisfaction was affected by earlier discharge. The second day after surgery was judged to be the ideal time point for discharge by 81% of all patients. CONCLUSIONS: This study demonstrates that the length of stay after laparoscopic hernia repair can be reduced by one day by relatively simple means without affecting patient satisfaction or the complication rate. Most important is the introduction of clear-cut criteria that allow an early decision-making for discharge home. Moreover, many patients complain of constipation after laparoscopic surgery, and this may prolong the length of stay. This problem can be solved completely by the standardized use of sodium picosulfate, administered on the evening after surgery.

[Combined analgesics for postoperative pain therapy. Review of effectivity and side-effects]. / Analgetikakombinationen zur postoperativen Schmerztherapie. Ubersicht zu Effektivität und Nebenwirkungen.

BACKGROUND: The supplementation of an opioid by a non-opioid analgesic is a widely accepted technique for the treatment of postoperative pain. However, it is still unclear whether a combination of different non-opioids has an advantage in terms of an improved analgesia and/or a reduction of the opioid-related adverse effects. METHODOLOGY: A systematic analysis of the literature was performed searching for randomized, controlled trials studying the effects of a combination of two non-opioid analgesics in order to reduce postoperative opioid requirements and/or postoperative pain. Significant reduction of the postoperative opioid requirement and/or postoperative pain were defined as main rating criteria. To facilitate comparisons between the trials, the relative (proportional) reduction of postoperative opioid administration and the relative reduction of postoperative pain were calculated on defined pain scales. RESULTS: A total of 25 trials were identified, mainly studies comparing non-steroidal anti-inflammatory drugs (NSAIDs) with paracetamol. Only 3 trials found a statistically improved analgesic efficacy and 15 studies did not show any relevant improvement or the combination group was only significantly superior to one of the groups receiving monotherapy. A further seven studies could not be evaluated due to methodological issues. There was no evidence for a significant reduction of opioid-induced adverse effects. CONCLUSION: A combination of non-opioid analgesics, in particular NSAIDs with paracetamol, cannot be recommended at present due to the lack of data showing improved effectiveness.

Effect of a balanced anaesthetic technique using desflurane and remifentanil on surgical conditions during microscopic and endoscopic sinus surgery.

OBJECTIVES: Controlled hypotension is used to improve surgical conditions during microscopic and endoscopic sinus surgery. Several drug combinations are suitable to provide deep and predictable level of anaesthesia combined with an exact control of intraoperative blood pressure. However, only little is known about the relative importance of the level of hypnosis on the one hand and analgesia on the other hand. STUDY DESIGN: Prospective, randomized, patient and observer-blinded study. METHODS: All 100 consecutive patients received a balanced anaesthesia technique using desflurane and remifentanil. Anaesthesia was desflurane-accentuated with remifentanil-supplementation (DARS-group: 1 MAC desflurane; remifentanil: 0.2 microg x kg(-1) x min(-1)) or remifentanil-accentuated with desflurane-supplementation (RADS-group: desflurane: 0.5 MAC; remifentanil: 0.4 microg x kg(-1) x min(-1)). Administration of anaesthetics performed to maintain a sufficient level of anaesthesia and to keep mean arterial pressure between 60 and 70 mmHg (8-9.3 hPa). The attending ENT-surgeons were unaware of the type of anaesthesia and rated general surgical conditions and the dryness of the operating site on a visual analogue scale (0-10 cm) and on a verbal rating scale immediately after surgery. RESULTS: Blood pressure and heart rate was not different between the two groups. Dryness of the operating site was rated significantly better (p < 0.0001) in the DARS-group (median; 25th/75th-percentile: 2.0; 1.5-3.5 vs. RADS-group: 2.6; 2.0-4.0) but the overall rating of the surgical conditions did not differ between the groups (DARS-group: 2.0; 1.0-2.4 vs. RADS-group: 2.2; 1.5-3.2). Immediate postoperative recovery times were increased in the RADS-group, but there was no difference with respect to fit-for-discharge criteria one hour after surgery. CONCLUSION: Balanced anaesthesia using high dose of desflurane offers small but statistically significant advantages with respect to dryness of the operating site compared to an opioid-accentuated anaesthesia technique. However, since the opioid-accentuated anaesthetic group had a faster immediate recovery both techniques are equally effective for microscopic and endoscopic sinus surgery.

Prevention and control of postoperative nausea and vomiting in post-craniotomy patients.

Postoperative nausea and vomiting (PONV) are the most frequent side-effects in the postoperative period, impairing subjective well-being and having economic impact due to delayed discharge. However, emetic symptoms can also cause major medical complications, and post-craniotomy patients may be at an increased risk. A review and critical appraisal of the existing literature on PONV in post-craniotomy patients, and a comparison of these findings with the current knowledge on PONV in the general surgical population, leads to the following conclusions: (1) Despite the lack of a documented case of harm caused by retching or vomiting in a post-craniotomy patient, the potential risk caused by arterial hypertension and high intra-abdominal/intra-thoracic pressure leading to high intracranial pressure, forces to avoid PONV in these patients. (2) There is unclarity about a specifically increased (or decreased) risk for PONV in post-craniotomy patients compared with other surgical procedures. (3) The decision whether or not to administer an antiemetic should not be based primarily on risk scores for PONV but on the likelihood for potential catastrophic consequences of PONV. If such a risk cannot be ruled out, a multimodal antiemetic approach should be considered regardless of the individual risk. (4) Randomized controlled trials with antiemetics in post-craniotomy patients are limited with respect to sample size and methodological quality. This also impacts upon the meaning of meta-analyses performed with trials that showed marked heterogeneity and inconclusive results. (5) No studies on the treatment of established PONV are available. This highlights the need to transfer knowledge about PONV treatment from other surgical procedures. (6) Despite the possibility that PONV in post-craniotomy patients can be triggered by specific conditions (e.g. surgery near the area postrema at the floor of the fourth ventricle with the vomiting centre located nearby), recommendations based on trials in post-craniotomy patients may be flawed. Thus, general knowledge on prevention and treatment of PONV must adopted for craniotomy settings.

Anti-emetic prophylaxis with oral tropisetron and/or dexamethasone.

BACKGROUND: The corticosteroid dexamethasone and the serotonine3 -antagonist tropisetron are both effective drugs for the prophylaxis of post-operative nausea and vomiting (PONV) when given intravenously. The aim of this trial was to evaluate the oral use of both drugs as part of a routine oral premedication and to compare their single and combined effectiveness. MATERIALS AND METHODS: In this randomized, placebo-controlled, double-blind study, 320 inpatients with a moderate-high risk of PONV (> or = 40% according to two validated risk scores) received an oral premedication 1-2 h pre-operatively with placebo, a fixed dose of tropisetron 5 mg, dexamethasone 8 mg, or a combination of both drugs. A standardized general anaesthesia was performed, including benzodiazepine premedication, propofol, rocuronium, desflurane in air/O2, fentanyl or sufentanil followed by a continuous infusion of remifentanil. Post-operative analgesia and anti-emetic rescue medication were standardized. The main outcome measures were the severity of PONV within the first 24 h (rated by a standardized scoring algorithm). The incidence of PONV was used as the secondary outcome. RESULTS: Data from 310 patients were analyzed. The mean severity score in the placebo-, tropisetron-, dexamethasone- and the combined-groups was 1.37, 0.8, 0.8 and 0.38, respectively. The incidence of PONV of any severity was 59.2%, 37.5%, 40% and 22.8%, respectively. The reduction of the incidence and the severity of PONV were statistically significant with all three interventions. Results from additional analyses suggested that both drugs were equally effective and that there was a simple additive effect of tropisetron and dexamethasone compared with placebo. CONCLUSION: Oral tropisetron and dexamethasone were both equally effective in reducing the severity and incidence of post-operative nausea and vomiting. The latter could be reduced by approximately 35% in a population of moderate-high risk for PONV. Both drugs had an additive effect. However, even in the combination group there still remained an unacceptably high incidence of PONV of more than 20%. This highlighted the need for a multimodal anti-emetic approach in high-risk patients and the importance of treatment of PONV.