Case Report of Remifentanil Labor Analgesia for a Pregnant Patient With Congenital Methemoglobinemia Type 1.

Congenital methemoglobinemia is a rare disease characterized by cyanosis and a left shifting of the oxyhemoglobin dissociation curve. The disease necessitates avoidance of certain medications commonly used in obstetrics, making labor analgesia and anesthesia challenging. We present a case report of peripartum anesthetic management of a pregnant patient with congenital methemoglobinemia type 1 who received remifentanil labor analgesia and continuous methemoglobin monitoring. Continuous real-time monitoring of methemoglobin concentrations may prove to be a useful monitor in future care settings. A review of literature encompassing various perioperative and obstetric anesthesia and analgesia management considerations is presented.

Aprepitant plus ondansetron compared with ondansetron alone in reducing postoperative nausea and vomiting in ambulatory patients undergoing plastic surgery.

BACKGROUND: Postoperative nausea and vomiting is a major challenge in the perioperative setting. The incidence can be as high as 80 percent, and the majority of the symptoms among outpatients occur after discharge. This study evaluated the efficacy of a neurokinin-1 receptor antagonist (aprepitant) in reducing postoperative symptoms for up to 48 hours in patients undergoing outpatient plastic surgery. METHODS: A prospective, double-blinded, randomized, two-arm evaluation of 150 ambulatory plastic surgery patients receiving a standardized general anesthetic, including postoperative nausea and vomiting prophylaxis with ondansetron and either aprepitant or placebo, was performed. The main outcome measures were the occurrence of vomiting and the severity of nausea for up to 48 hours postoperatively. RESULTS: Overall, 9.3 percent of patients who received aprepitant versus 29.7 percent in group B had vomiting, with the majority of vomiting episodes occurring after hospital discharge. The Kaplan-Meier plot of the hazards of vomiting revealed an increased incidence of emesis in patients receiving ondansetron alone compared with the combination of ondansetron and aprepitant (p = 0.006). The incidence of nausea was not significantly different in the two groups. Severity of nausea, however, was significantly higher in those receiving ondansetron alone compared with those receiving ondansetron and aprepitant, as measured by a peak nausea score (p = 0.014) and by multivariate analysis of variance results comparing repeated verbal rating scale scores over 48 hours after surgery (p = 0.024). CONCLUSION: In patients undergoing plastic surgery, the addition of aprepitant to ondansetron significantly decreases postoperative vomiting rates and nausea severity for up to 48 hours postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Desflurane versus sevoflurane for laparoscopic gastroplasty in morbidly obese patients.

STUDY OBJECTIVE: To determine if desflurane results in a faster emergence as measured by time to eye opening compared to sevoflurane in morbidly obese patients undergoing laparoscopic gastroplasty. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary care hospital. PATIENTS: 70 patients with a body mass index of 35 or higher undergoing laparoscopic gastroplasty. INTERVENTIONS: Patients were randomized into two groups to receive either desflurane or sevoflurane for maintenance of general anesthesia. MEASUREMENTS: Intraoperative measured variables included the time from when the inhalation agent was turned off (no agent delivered) to eye opening and the time from when the inhalation agent was turned off to extubation. Postanesthesia care unit (PACU)-measured variables on admission and at 15 minute intervals until discharge included oxygen saturation (Spo2), blood pressure, heart rate, pain and nausea Visual Analog Scale (VAS) scores, emesis, modified Aldrete score, and Mini-Mental Status (MMS) examination score. MAIN RESULTS: No differences were noted in demographic data, total surgical operative time, times from turning inhalation agent off to eye opening and extubation, or average length of stay in PACU. No differences were noted with respect to pain VAS, treatment for pain, modified Aldrete scores, emesis, or treatment for postoperative nausea or emesis. Differences were noted in PACU nausea VAS at 15 minutes, PACU nausea VAS at discharge, and PACU-MMS score at 45 minutes; however, multivariate analysis of variance revealed no differences between groups over the repeated PACU measured time periods in nausea VAS (P=0.17) or in MMS (P=0.34). Higher heart rates in the desflurane group were observed during PACU admission (82.3+/-9.8 vs 74.4+/-13.4 bpm, P<0.01) and 15 minutes post PACU admission (79.4+/-12.1 vs 71.3+/-13.2 bpm, P=0.01). CONCLUSIONS: In morbidly obese patients undergoing laparoscopic gastroplasty, emergence, as measured by time to eye opening, did not differ between desflurane and sevoflurane, with similar recovery characteristics.

Preemptive analgesia with bupivacaine for segmental mastectomy.

BACKGROUND AND OBJECTIVES: Preemptive analgesia is the concept of providing analgesia before surgical incision, resulting in less postoperative pain. The purpose of this study is to determine if preemptive and/or postoperative local anesthetic infiltration of bupivacaine in patients undergoing segmental mastectomy results in less postoperative pain compared with patients receiving placebo. METHODS: In this prospective, double-blinded study, 120 patients were randomized into 4 groups: group 1, preincisional (10 mL) and postoperative (10 mL) wound infiltration of 0.5% bupivicaine, (+Pre+Post); group 2, preincisional bupivacaine (10 mL) and postoperative infiltration (10 mL) of placebo (normal saline solution), (+Pre-Post); group 3, preincisional placebo (10 mL) and postoperative bupivacaine (10 mL), (-Pre+Post); or group 4, preincisional (10 mL) and postoperative infiltration of placebo (10 mL), (-Pre-Post). All patients received a standardized laryngeal mask general anesthetic. Data were recorded at the following time intervals: preoperative admission, postanesthesia care unit (PACU) admission, PACU stay, stepdown-unit admission, stepdown-unit stay, hospital discharge, and 24 hours post operation. RESULTS: No difference was noted with respect to preoperative pain visual analog scale (VAS, 0-100 mm), surgical duration, PACU stay time, stepdown-unit stay time, incidence of postoperative nausea, or treatment for nausea in all measured time periods. The placebo group (group 4) had significantly higher mean pain VAS scores during the early postoperative period (PACU admission and PACU stay) compared to the other groups (PACU admission: group 1 = 2 +/- 8, group 2 = 4 +/- 11, group 3 = 3 +/- 15, group 4 = 17 +/- 21, P < .01; PACU stay: group 1 = 6 +/- 13, group 2 = 6 +/- 10, group 3 = 10 +/- 21, group 4 = 20 +/- 18, P < .01). Likewise, the number of patients who reported pain (pain frequency) was significantly higher in group 4 (placebo) compared with all other groups at PACU admission, PACU stay, stepdown-unit admission, and stepdown-unit stay (P < or = .01). CONCLUSION: Preincisional and/or postoperative wound bupivacaine infiltration lacks preemptive analgesic effects for segmental mastectomy.

Propofol-ketamine versus propofol-fentanyl for outpatient laparoscopy: comparison of postoperative nausea, emesis, analgesia, and recovery.

STUDY OBJECTIVE: To compare postoperative nausea, emesis, analgesia, and recovery between propofol-ketamine and propofol-fentanyl in outpatient laparoscopic tubal ligations with general anesthesia. STUDY DESIGN: Prospective, randomized, blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: 120 ASA physical status I and II ambulatory patients scheduled for elective laparoscopic tubal ligation. INTERVENTIONS: Patients were randomized to two groups to receive either ketamine (1-1.5 mg/kg) or fentanyl (3-5 microg/kg). MEASUREMENTS: Measured variables included total dose of ketamine, fentanyl, propofol, and operating time. Vital signs, pain visual analog scale scores (VAS), nausea VAS, presence of emesis, treatment for nausea and vomiting, pruritus, sedation, and presence of dreaming were recorded on postanesthesia care unit (PACU) admission, PACU discharge, stepdown unit admission, and hospital discharge. Results are expressed as means +/- SD or medians and analyzed using t-test, Chi-square, or Mann-Whitney (p < 0.05). MAIN RESULTS: No differences were noted with respect to propofol dose, operating times, pain or nausea VAS scores, emesis, treatment for nausea and vomiting, pruritus, and sedation on PACU admission, PACU discharge, stepdown unit admission, and hospital discharge. The ketamine group had a higher heart rate, required more pain medication, and had a higher frequency of dreaming on PACU admission than the fentanyl group. These differences became insignificant on PACU discharge. CONCLUSIONS: For outpatient laparoscopic tubal ligations with general anesthesia, propofol-ketamine does not improve postoperative nausea, emesis, analgesia or recovery compared with the propofol-fentanyl combination.