Preventing Nausea and Vomiting After Bariatric Surgery: Is the Apfel Risk Prediction Score Enough to Guide Prophylaxis?

Postoperative nausea and vomiting (PONV) is a frequent side effect in patients undergoing bariatric procedures. The simplified Apfel score is an attractive and frequently used tool to assess PONV risk in the general surgical population. Despite applying the recommendations based on the Apfel risk prediction score, several studies show that up to 82% of patients undergoing metabolic and bariatric surgery suffer from PONV in the PACU. A combination of multiple antiemetic drugs of different pharmacologic classes targeting a variety of receptors in addition to an intraoperative opioid-free TIVA technique should be considered in high-risk patients.

Different regimens of intravenous sedatives or hypnotics for electroconvulsive therapy (ECT) in adult patients with depression.

BACKGROUND: Depression is a common mental disorder. It affects millions of people worldwide and is considered by the World Health Organization (WHO) to be one of the leading causes of disability. Electroconvulsive therapy (ECT) is a well-established treatment for severe depression. Intravenous anaesthetic medication is used to minimize subjective unpleasantness and adverse side effects of the induced tonic-clonic seizure. The influence of different anaesthetic medications on the successful reduction of depressive symptoms and adverse effects is unclear. OBJECTIVES: This review evaluated the effects of different regimens of intravenous sedatives and hypnotics on anti-depression efficacy, recovery and seizure duration in depressed adults undergoing ECT. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12); MEDLINE via Ovid SP (from 1966 to 31 December 2012); and EMBASE via Ovid SP (from 1966 to 31 December 2012). We handsearched related journals and applied no language restrictions. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and cross-over trials evaluating the effects of different intravenous sedatives and hypnotics for ECT. We excluded studies and trials using placebo or inhalational anaesthetics and studies that used no anaesthetic. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. When possible, data were pooled and risk ratios (RRs) and mean differences (MDs), each with 95% confidence intervals (CIs), were computed using the Cochrane Review Manager statistical package (RevMan). MAIN RESULTS: We included in the review 18 RCTs (599 participants; published between 1994 and 2012). Most of the included trials were at high risk of bias.We analysed the results of studies comparing six different intravenous anaesthetics.Only a few studies comparing propofol with methohexital (four studies) and with thiopental (three studies) could be pooled.No difference was noted in the reduction of depression scores observed in participants treated with propofol compared with methohexital (low-quality evidence). These four studies were not designed to detect differences in depression scores.The duration of electroencephalograph (EEG) and of motor seizures was shorter in the propofol group compared with the methohexital group (low-quality evidence). No difference was seen in EEG seizure duration when propofol was compared with thiopental (low-quality evidence).Time to recovery (following commands) was longer among participants after anaesthesia with thiopental compared with propofol (low-quality evidence).For the remaining comparisons of anaesthetics, only single studies or insufficient data were available. Adverse events were inadequately reported in eligible trials, and none of the included trials reported anaesthesia-related mortality. AUTHORS' CONCLUSIONS: Most of the included studies were at high risk of bias, and the quality of evidence was generally low. The studies were not designed to detect clinically relevant differences in depression scores. Anaesthetic agents should be chosen on the basis of adverse effect profile, emergence and how these medications affect seizure duration. If it is difficult to elicit an adequately long seizure, methohexital may be superior to propofol (low-quality evidence). If a patient is slow to recover from anaesthesia, propofol may allow a faster time to follow commands than thiopental (low-quality evidence). A factor of clinical concern that was not addressed by any study was adrenal suppression from etomidate. Optimal dosages of intravenous sedatives or hypnotics have not yet been determined.Larger well-designed randomized studies are needed to determine which intravenous anaesthetic medication leads to the greatest improvement in depression scores with minimal adverse effects.

Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery.

BACKGROUND: After bariatric surgery, patients are at risk for narcotic-related side effects. Multimodal pain management strategies should be used when possible to reduce the consumption of narcotic medication. The purpose of this study was to investigate whether multimodal analgesia reduces narcotic consumption and may have an influence on opioid-related side effects in patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). METHODS: In this retrospective data analysis, we examined the data of a total of 181 consecutive patients undergoing LRYGB. In January 2011, i.v. acetaminophen became clinically available. Hydromorphone patient controlled analgesia (PCA) was replaced by i.v. acetaminophen and i.v. ketorolac (TNT-Tylenol and Toradol). The first 89 patients received postoperative hydromorphone PCA (PCA group). The next 92 patients received i.v. acetaminophen and i.v. ketorolac every 6 hours for the first 24 hours (TNT group). In the TNT group, 8 patients were excluded in the analysis. RESULTS: There were no differences in clinical characteristics between the groups except for smoking history. Patients treated with PCA required 4.2 mg hydromorphone in the postoperative period. Patients in the TNT group required 1.1 mg hydromorphone. This was a statistically significant reduction of opioids by 73.8%. After discharge from postanesthesia care unit, 34.8% of patients required antiemetic rescue medication (AERM) compared with 20.2% in the TNT group (P<.001). The relative risk (AERM/no AERM) in the postoperative period after postanesthesia care unit discharge is 1.75 (95% CI, 1.05-2.92). CONCLUSION: This study suggests that a multimodal analgesic regimen (TNT) can reduce postoperative narcotic consumption, which may lead to a reduction in the number of patients requiring AERM.

Increased carboxyhemoglobin in a patient with a large retroperitoneal hematoma.

In humans, the sole endogenous source of carbon monoxide is heme degradation. We report the development of prolonged carboxyhemoglobinemia in a critically ill mechanically ventilated patient who required massive transfusion because of retroperitoneal hemorrhage secondary to pheochromocytoma. After the transfusion of 27 U of packed red blood cells, the maximum carboxyhemoglobin level was 6.4%. Although ventilation was controlled with a fraction of inspired oxygen of 0.35-0.5 and external drainage of blood occurred, the concentration of carboxyhemoglobin remained at 1.7%-5.6% for days. Red blood cells for transfusion may be contaminated with carbon monoxide and may have carboxyhemoglobin levels of up to 12%; this may also have contributed to carboxyhemoglobinemia in our patient. If significantly increased concentrations of carboxyhemoglobin develop, therapy to decrease the concentration of carboxyhemoglobin (such as fraction of inspired oxygen of 1.0 and/or minute ventilation or hyperbaric oxygen) or removal of the source should be considered.

Treatment of life-threatening hyperkalemia using hemoconcentration in parallel to venovenous bypass during orthotopic liver transplantation.

IMPLICATIONS: The elimination of potassium in patients with end-stage kidney failure is limited. An increase in potassium concentrations can lead to lethal arrhythmias. In the described case, a large potassium concentration was treated during a liver transplantation using a new technical approach.