Palonosetron versus ondansetron for prevention of nausea and vomiting after total abdominal hysterectomy under spinal anesthesia with intrathecal morphine: a double-blind, randomized controlled trial.

BACKGROUND: Hysterectomy is a widely performed surgery and neuraxial anesthesia with intrathecal morphine provides superior quality of recovery. Postoperative nausea and vomiting (PONV) is a frequent problem with intrathecal morphine use. Although palonosetron is effective for prevention of PONV after general anesthesia, its efficacy after neuraxial anesthesia has not been established. This study was conducted to compare the use of palonosetron with ondansetron for PONV prophylaxis in patients at a high risk of PONV during total abdominal hysterectomy (TAH) under spinal anesthesia with intrathecal morphine. METHODS: This prospective, randomized double-blind study conducted at São Rafael Hospital involved 140 American Society of Anesthesiologists physical status I or II women who underwent TAH under spinal anesthesia with intrathecal morphine and who had at least 3 risk factors for PONV based on Apfel's simplified score. The patients were randomized into two groups: one received palonosetron whereas the other received ondansetron. All patients received spinal anesthesia with intrathecal morphine, as well as dexamethasone plus palonosetron or ondansetron for PONV prophylaxis. The overall incidence of PONV, incidence of early- and late-onset nausea and vomiting, severity of nausea, and use of rescue antiemetics were recorded. RESULTS: The overall incidence of PONV was 42.9% in the palonosetron group and 52.9% in the ondansetron group (p > 0.05). No significant differences existed in the incidence of early- and late-onset nausea or early-onset vomiting between the two groups. The incidence of late-onset vomiting was significantly lower in the palonosetron group. CONCLUSIONS: Palonosetron exhibited efficacy similar to that of ondansetron for reducing the overall incidence of PONV after TAH under spinal anesthesia with intrathecal morphine; however, palonosetron reduced the incidence of late-onset vomiting significantly better than ondansetron. TRIAL REGISTRATION: RBR-4gnm8n ( ensaiosclinicos.gov.br ), date of registration: August 18, 2014.

Total Spinal Anesthesia Failure: Have You Assessed the Sensory Anesthesia in Sacral Dermatomes?

Intrathecal local anesthetic maldistribution is a well-known cause of spinal anesthesia failure (SAF). This could potentially result in sensory blockade restricted to the sacral dermatomes. We sought to determine the overall incidence of SAF and the role of sacral dermatomes in differentiating between total and partial failures. Of the 3111 spinals prospectively examined, 194 (6.2%) were classified as failures. Of the 72 presumed total failures based on the initial assessment, evaluation of the sacral dermatomes revealed sensory blockade in 32 (44%; 95% confidence interval, 32.7%-56.6%). Sacral dermatome assessment after SAF may be important in safely guiding subsequent anesthetic management.

Efficacy and safety of blood transfusion in obstetric patients: systematic review of the literature.

OBJECTIVES: To evaluate the efficacy of blood transfusion compared to no intervention in obstetric patients. MATERIAL AND METHODS: A systematic review was performed with Cochrane Database of Clinical Trials, PubMed, EMBASE and LILACS databases searched as of September, 2016. Two authors independently selected relevant clinical trials, assessed their methodological quality and extracted data, using the GRADE approach. RESULTS: Five studies within a total of 6,297 met the inclusion criteria, with women generally aged 20-40 years. Three included studies allocated women to receive blood transfusion or no intervention. Two other studies allocated women with either restricted or full blood supplies. The major issue regarding risk of bias was the extent of concealment of randomization and blinding. There was no statistically significant difference between blood transfusion versus no transfusion or restricted blood supply on mortality (relative risk 0.82 [95% confidential interval 0.32 to 2.09], p = 0.68; two studies; I2 = not applicable). CONCLUSIONS: Very low-quality evidence suggests no significant difference between blood transfusion and no intervention in obstetric patients, underlining the need for more robust clinical trials evaluating this area.

Perioperative Duloxetine to Improve Postoperative Recovery After Abdominal Hysterectomy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study.

BACKGROUND: Postsurgical quality of recovery is worse in female than that in male patients. Duloxetine has been used successfully for the treatment of chronic pain conditions, but its use for preventing acute postoperative pain has been limited to a single previous study. More importantly, the effect of preoperative duloxetine on global postoperative quality of recovery has yet to be evaluated. The main objective of the current investigation was to evaluate the effect of perioperative duloxetine on postoperative quality of recovery in women undergoing abdominal hysterectomy. METHODS: The study was a prospective, randomized, placebo-controlled, double-blinded trial. Female patients undergoing abdominal hysterectomy were randomized to receive duloxetine (60 mg orally 2 hours before surgery and 24 hours after surgery) or an identical placebo pill. The primary outcome was the quality of recovery-40 score at 24 hours. Secondary outcomes included opioid consumption and postoperative pain scores. A P value <0.05 was used to reject type I error. RESULTS: Seventy patients were recruited, and 63 completed the study. The median difference (95% confidence interval) in global recovery scores (quality of recovery-40) at 24 hours after surgery between the duloxetine and the placebo group was 9 (4-20) (P < 0.001). Total opioid consumption was reduced at 24 hours in the duloxetine group compared with the placebo group, median (interquartile range) of 1 (0-5) mg IV morphine compared with 5.5 (0.5-9) mg IV morphine (P = 0.004). Nausea, vomiting, and time to postanesthesia care unit discharge were not significantly reduced in the duloxetine group compared with placebo. CONCLUSIONS: Duloxetine improves postoperative quality of recovery after abdominal hysterectomy. In addition, duloxetine reduces postoperative opioid consumption, even in the presence of a robust multimodal analgesic strategy. Duloxetine seems to be a viable pharmacologic strategy to improve postoperative quality of recovery in female patients undergoing abdominal hysterectomy.

Dry needling, trigger point electroacupuncture and motor point electroacupuncture for the treatment of myofascial pain syndrome involving the trapezius: a randomised clinical trial.

OBJECTIVE: The objective of this study was to compare trigger point (TrP) dry needling, TrP electroacupuncture and motor point electroacupuncture of the trapezius muscle for the treatment of myofascial pain syndrome (MPS). METHODS: This randomised clinical trial included 90 patients divided into three groups. Group 1 was treated with dry needling of TrPs, group 2 with intramuscular electrical stimulation of TrPs, and group 3 with electroacupuncture of motor points and/or the spinal accessory nerve. Each group received seven treatment sessions. The outcomes were the pain score measured by visual analogue scale (VAS) and quality of life evaluated by the 12-item short form (SF-12) health questionnaire. We compared the pain outcome over serial time points using growth curve analysis methods. RESULTS: Participants in the three groups experienced significant improvements in pain scores over time. The average pain level of participants in group 3 across the repeated assessments was 0.98 units lower than in group 1 (mean difference (95% confidence interval (CI) = 1.74-0.23)), p = 0.012). There were no significant differences in pain scores between participants in groups 1 and 2, and there were no significant differences in quality of life across the three groups at the end of the treatment period. CONCLUSION: Our results provide evidence that electrical stimulation of motor points and/or of the spinal accessory nerve may be superior in terms of pain relief (but not quality of life) to dry needling and possibly electrical stimulation of trigger points for the management of MPS involving the trapezius. TRIAL REGISTRATION NUMBER: TRIAL-RBR-43R7RF (Brazilian Clinical Trials Registry).

Children's preoperative stress according to the parental presence evaluated by salivary cortisol and mYPAS: quasi-randomized trial.

OBJECTIVE: The main objective of this study was to compare stress and anxiety levels in children undergoing surgical procedures with or without parental presence at induction of anesthesia by measuring salivary cortisol levels and applying the mYPAS. METHOD: Quasi-randomized trial with children aged 5-12 year, with ASA physical status I, II, or III, undergoing elective surgery. According to parents' willingness, the pair were defined as accompanied or unaccompanied group. Chi-square, Fisher's exact tests, Student's t test, Mann-Whitney, Hodges-Lehman and Spearman's tests were used for statistical analyzes. RESULTS: We included 46 children; 63% were preschool children mostly accompanied by their mothers (80%). The median mYPAS score was 37.5 (quartile range, 23.4-51.6) in unaccompanied children, and 55.0 (quartile range, 27.9-65.0) in accompanied children, with an estimated median difference of +11.8 (95% CI of 0 to 23.4; p = 0.044). There were no significant differences in the mean salivary cortisol levels. CONCLUSION: The level of anxiety was higher in accompanied children. There were no differences in salivary cortisol levels between both groups. Brazilian Registry of Clinical Trials (ReBEC): RBR-9wj4qvy.

An update on the mechanisms and risk factors for anesthesia-related cardiac arrest in children: a narrative review.

The relation between surgery and anesthesia safety in children and a country's Human Development Index (HDI) value has been described previously. The aim of this narrative review was to provide an update on the mechanisms and risk factors of Anesthesia-Related Cardiac Arrest (ARCA) in pediatric surgical patients in countries with different HDI values and over time (pre-2001 vs. 2001‒2024). Electronic databases were searched up to March 2024 for studies reporting ARCA events in children. HDI values range from 0 to 1 (very-high-HDI countries: ≥ 0.800, high-HDI countries: 0.700‒0.799, medium-HDI countries: 0.550‒0.699, and low-HDI countries: < 0.550). Independent of time, the proportion of children who suffered perioperative Cardiac Arrest (CA) attributed to anesthesia-related causes was higher in very-high-HDI countries (50%) than in countries with HDI values less than 0.8 (15‒36%), but ARCA rates were higher in countries with HDI values less than 0.8 than in very-high-HDI countries. Regardless of the HDI value, medication-related factors were the most common mechanism causing ARCA before 2001, while cardiovascular-related factors, mainly hypovolemia, and respiratory-related factors, including difficulty maintaining patent airways and adequate ventilation, were the major mechanisms in the present century. Independent of HDI value and time, a higher number of ARCA events occurred in children with heart disease and/or a history of cardiac surgery, those aged younger than one year, those with ASA physical status III‒V, and those who underwent emergency surgery. Many ARCA events were determined to be preventable. The implementation of specialized pediatric anesthesiology and training programs is crucial for anesthesia safety in children.

Global neonatal perioperative mortality: A systematic review and meta-analysis.

STUDY OBJECTIVE: There are large differences in health care among countries. A higher perioperative mortality rate (POMR) in neonates than in older children and adults has been recognized worldwide. The aim of this study was to provide a systematic review of published 24-h and 30-day POMRs in neonates from 2011 to 2022 in countries with different Human Development Index (HDI) levels. DESIGN AND SETTING: A systematic review with a meta-analysis of studies that reported 24-h and 30-day POMRs in neonates was performed. We searched the databases from January 2011 to July 30, 2022. MEASUREMENTS: The POMRs (per 10,000 procedures under anesthesia) were analyzed according to country HDI. The HDI levels ranged from 0 to 1, representing the lowest and highest levels, respectively (very-high-HDI: ≥ 0.800, high-HDI: 0.700-0.799, medium-HDI: 0.550-0.699, and low-HDI: < 0.550). The magnitude of the POMRs by country HDI was studied using meta-analysis. MAIN RESULTS: Eighteen studies from 45 countries were included. The 24-h (n = 96 deaths) and 30-day (n = 459 deaths) POMRs were analyzed from 33,729 anesthetic procedures. The odds ratios (ORs) of the 24-h POMR in low-HDI countries were higher than those in very-high- (OR 8.4, 95% CI 1.7-40.4; p = 0.008), high- (OR 7.3, 95% CI 2.2-24.4; p = 0.001) and medium-HDI countries (OR 7.7, 95% CI 3.1-18.7; p < 0.0001) but with no odds differences between very-high- and high-HDI countries (p = 0.879), very-high- and medium-HDI countries (p = 0.915) and high- and medium-HDI countries (p = 0.689). The odds of a 30-day POMR in low-HDI countries were higher than those in very-high-HDI countries (OR 6.9, 95% CI 1.9-24.6; p = 0.002) but not in high-HDI countries (OR 1.4, 95% CI 0.6-3.0; p = 0.396). CONCLUSIONS: The review demonstrated very high global POMRs in a surgical population of neonates independent of the country HDI level. We identified differences in 24-h and 30-day POMRs between low-HDI countries and other countries with higher HDI levels.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care.

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial.

BACKGROUND: Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. METHODS: We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.m-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 µg.mL-1 plus 0.5 µg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. RESULTS: The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0‒0) vs. 0 (0‒0) (p = 0.239) and 1 (0‒1) vs. 3 (1‒4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group ‒ 2 (0‒2) vs. 1 (0‒1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 µg.kg-1.min-1 vs. 195 ± 44 µg.kg-1.min-1 (p = 0.040)). CONCLUSIONS: During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

Minimal fresh gas flow sevoflurane anesthesia and postoperative acute kidney injury in on-pump cardiac surgery: a randomized comparative trial.

BACKGROUND: Compound A is generated by sevoflurane when it reacts with carbon dioxide absorbers with strong bases at minimal fresh gas flow (FGF) and is nephrotoxic in animals. No conclusive data has shown increased risk in humans. The aim of this study was to investigate if minimal FGF promotes an increase in the incidence of acute kidney injury (AKI) when compared to high FGF in patients undergoing on-pump cardiac surgery under sevoflurane anesthesia. METHODS: Two hundred and four adult patients scheduled for on-pump cardiac surgery under sevoflurane anesthesia were randomly allocated to two groups differentiated by FGF: minimal FGF (0.5 L.min-1) or high FGF (2.0 L.min-1). Baseline creatinine measured before surgery was compared daily to values assayed on the first five postoperative days, and 24-hour urinary output was monitored, according to the KDIGO (Kidney Disease Improving Global Outcomes) guideline to define postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). Creatinine measurements were also obtained 20 and 120 days after hospital discharge. RESULTS: Postoperative AKI occurred in 55 patients, 26 patients (29.5%) in the minimal FGF group and 29 patients (31.5%) in the high FGF group (p = 0.774). Twenty days after discharge, 11 patients (6.1%) still had CSA-AKI and 120 days after discharge only 2 patients (1.6%) still had CSA-AKI. CONCLUSIONS: When compared to high FGF, minimal FGF sevoflurane anesthesia during on-pump cardiac surgery is not associated with increased risk of postoperative AKI in this population at high risk for renal injury.

Patient satisfaction in ambulatory anesthesia assessed by the Heidelberg Peri-anaesthetic Questionnaire: a cross-sectional study.

BACKGROUND: Service quality in anesthesiology has been frequently measured by morbidity and mortality. This measure increasingly considers patient satisfaction, which is the result of care from the client's perspective. Therefore, anesthesiologists must be able to build relationships with patients, provide understandable information and involve them in decisions about their anesthesia. This study aimed to evaluate the peri-anesthetic care provided by the anesthesia service in an ambulatory surgery unit using the Heidelberg Peri-anaesthetic Questionnaire. METHODS: This cross-sectional study used the Heidelberg Peri-anaesthetic Questionnaire to evaluate 1211 patients undergoing ambulatory surgery. We selected questions that showed a greater degree of dissatisfaction and correlated them with patient characterization data (age, sex, education, and ASA physical status), anesthesia data (type, time, and prior experience), and surgical specialty. RESULTS: Questions in which patients tended to show dissatisfaction involved fear of anesthesia and surgery, feeling cold, the urgent need to urinate, pain at the surgical site, and the team's level of concern and speed of response in relieving the patient's pain. CONCLUSION: The Heidelberg Peri-anaesthetic Questionnaire proved to be a useful tool in identifying points of dissatisfaction, mainly fear of anesthesia and surgery, feeling cold, the urgent need to urinate, pain at the surgical site, and the team's level of concern and speed of response in relieving the patient's pain in the population studied. These were correlated with patient, anesthesia, and surgical variables. This allows the establishment of priorities at the different points of care, with the ultimate goal of improving patient satisfaction regarding anesthesia care.

Comparison between oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in autism spectrum disorder: double-blind randomized clinical trial.

BACKGROUND: Conventional dental care is often impossible in patients with Autism Spectrum Disorder (ASD). Non-collaborative behaviors, sometimes associated with aggressiveness, are usual justifications for premedication in this population. Thereby, this research focuses on the effects of oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in ASD. METHODS: The sample included 64 persons with ASD, aged 2-59 years, scheduled for dental care under general anesthesia. The primary objective of this study was to compare degrees of sedation between two parallel, double-blinded, equally proportional groups randomized to receive oral midazolam (0.5 mg.kg-1, maximum 15 mg) or oral midazolam (0.5 mg.kg-1) associated with oral S(+)-ketamine (3 mg.kg-1, maximum 300 mg). The secondary outcomes were the need of physical stabilization to obtain intravenous line, awakening time, and occurrence of adverse events. RESULTS: According to the dichotomous analysis of sedation level (Ramsay score 1 and 2 versus Ramsay ≥ 3), oral association of S(+)-ketamine and midazolam improved sedation, with increased probability of Ramsay ≥ 3, Relative Risk (RR) = 3.2 (95% Confidence Interval [95% CI] = 1.32 to 7.76) compared to midazolam alone. Combined treatment also made it easier to obtain venous access without physical stabilization, RR = 2.05 (95% CI = 1.14 to 3.68). There were no differences between groups regarding awakening time and the occurrence of adverse events. CONCLUSION: The association of oral S(+)-ketamine with midazolam provides better preanesthetic sedation rates than midazolam alone and facilitates intravenous line access in patients with autism.

Chronic pain after hospital discharge on patients hospitalized for COVID-19: an observational study.

BACKGROUND: There are few studies related to Coronavirus Disease 2019 (COVID-19) on the prevalence and nature of pain symptoms after hospital discharge, especially in individuals who develop moderate to severe disease forms. Therefore, this study aimed to evaluate the presence of chronic pain in patients discharged after hospitalization for COVID-19, and the relationship between the presence of chronic pain and intensive care stay, demographics, and risk factors for the worst Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outcome. METHODS: A cross-sectional observational study was carried out on patients with COVID-19 who recovered after hospitalization. Patients were recruited at the least 3 months after discharge and their hospital's health files were prospected. The variables evaluated were demographics, the severity of SARS-CoV-2 infection (considering the need for intensive care), and the presence of chronic pain. The results were shown in a descriptive manner, and multivariate analysis expressed as Odds Ratios (ORs) and respective Confidence Intervals (CIs) for the outcomes studied. Statistical significance was set at p < 0.05. RESULTS: Of 242 individuals included, 77 (31.8%) reported chronic pain related to COVID-19, with no correlation with the severity of infection. Female sex and obesity were associated with a higher risk for chronic pain with ORs of 2.69 (Confidence Interval [95% CI 1.4 to 5.0]) and 3.02 (95% CI 1.5 to 5.9). The limbs were the most affected areas of the body. CONCLUSION: Chronic pain is common among COVID-19 survivors treated in hospital environments. Female sex and obesity are risk factors for its occurrence.

The effects of subarachnoid administration of preservative-free S(+)-ketamine on spinal cord and meninges in dogs.

BACKGROUND: The N-methyl-d-aspartate receptor antagonist ketamine and its active enantiomer, S(+)-ketamine, have been injected in the epidural and subarachnoid spaces to treat acute postoperative pain and relieve neuropathic pain syndrome. In this study we evaluated the effects of a single dose of preservative-free S(+)-ketamine, in doses usually used in clinical practice, in the spinal cord and meninges of dogs. METHODS: Under anesthesia (IV etomidate (2 mg/kg) and fentanyl (0.005 mg/kg), 16 dogs (6 to 15 kg) were randomized to receive a lumbar intrathecal injection (L5/6) of saline solution of 0.9% (control group) or S(+)-ketamine 1 mg/kg(-1) (ketamine group). All doses were administered in a volume of 1 mL over a 10-second interval. Accordingly, injection solution ranged from 0.6% to 1.5%. After 21 days of clinical observation, the animals were killed; spinal cord, cauda equina root, and meninges were removed for histological examination with light microscopy. Tissues were examined for demyelination (Masson trichrome), neuronal death (hematoxylin and eosin) and astrocyte activation (glial fibrillary acidic protein). RESULTS: No clinical or histological alterations of spinal tissue or meninges were found in animals from either control or ketamine groups. CONCLUSION: A single intrathecal injection of preservative-free S(+)-ketamine, at 1 mg/kg(-1) dosage, over a concentration range of 6 to 15 mg/mL injected in the subarachnoid space in a single puncture, did not produce histological alterations in this experimental model.

Intraoperative lactate levels and postoperative complications of pediatric cardiac surgery.

OBJECTIVES: Correlate arterial lactate levels during the intraoperative period of children undergoing cardiac surgery and the occurrence of complications in the postoperative period. AIM: Arterial lactate levels can indicate hypoperfusion states, serving as prognostic markers of morbidity and mortality in this population. BACKGROUND: Anesthesia for cardiac pediatric surgery is frequently performed on patients with serious abnormal physiological conditions. During the intraoperative period, there are significant variations of blood volume, body temperature, plasma composition, and tissue blood flow, as well as the activation of inflammation, with important pathophysiological consequences. METHODS/MATERIALS: Chart data relating to the procedures and perioperative conditions of the patients were collected on a standardized form. Comparisons of arterial lactate values at the end of the intraoperative period of the patients that presented, or not, with postoperative complications and frequencies related to perioperative conditions were established by odds ratio and nonparametric univariate analysis. RESULTS: After surgeries without cardiopulmonary bypass (CPB), higher levels of arterial lactate upon ICU admission were observed in patients who had renal complications (2.96 vs 1.31 mm) and those who died (2.93 vs 1.40 mm). For surgeries with CPB, the same association was observed for cardiovascular (2.90 mm × 2.06 mm), renal (3.34 vs 2.33 mm), respiratory (2.98 vs 2.12 mm) and hematological complications (2.99 vs 1.95 mm), and death (3.38 vs 2.40 mm). CONCLUSION: Elevated intraoperative arterial lactate levels are associated with a higher morbidity and mortality in low- and medium-risk procedures, with or without CPB, in pediatric cardiac surgery.

Effects of Preoperative Acupuncture on Prevention of Nausea and Vomiting and Plasma Serotonin Values in the Hysterectomy Postoperative Period: a Randomized Clinical Trial.

Background: Nausea and vomiting are frequent complications of anesthesia in the postoperative period. Acupuncture at the pericardium point 6 (PC6) is known to be effective in preventing postoperative nausea and vomiting (PONV). Objectives: The objective of the present study is to investigate the effects of acupuncture performed at the PC6 point in the prevention of PONV in women undergoing elective open hysterectomy under general inhalational anesthesia and to assess its association with plasma serotonin levels. Methods: 97 patients undergoing elective open hysterectomy were randomly divided into two groups: acupuncture group (bilateral acupuncture at PC6, n = 49), and a control group (no acupuncture, n = 48). All patients prophylactically received ondansetron and dexamethasone and, as rescue medication, metoclopramide in case of occurrence of PONV. The primary outcome evaluated was occurrence of nausea and vomiting within 24 hours after surgery. Serotonin plasma levels were measured before and after acupuncture prior to anesthesia induction. For the control group, the repeat measurement was performed 30 minutes after admission to the preoperative unit. Results: Acupuncture at PC6 significantly reduced the incidence of nausea (29.2% vs. 6.1%; p > 0.003), and the need of rescue medication (metoclopramide) (33.3% vs. 10.2%; p > 0.006), but not vomiting (4.2 vs. 4.1; p > 0.98). The plasma serotonin levels between control and acupuncture groups did not differ. Conclusion: This study shows that acupuncture at PC6 resulted in a lower incidence of postoperative nausea in patients undergoing hysterectomy.

Impact of colloids or crystalloids in renal function assessed by NGAL and KIM-1 after hysterectomy: randomized controlled trial.

BACKGROUND: Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. METHODS: This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg-1.h-1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. RESULTS: Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p = 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p = 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p = 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. CONCLUSION: HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.

Enzyme biomarkers of renal tubular injury in arterial surgery patients.

OBJECTIVE: The aim of this study was to verify whether preoperative diabetes, hypertension, and renal function had any relationship with postoperative tubule function in patients submitted to anesthesia for arterial surgery. METHODS: Prospective observational study. One hundred and forty-four patients submitted to anesthesia for arterial surgery enrolled consecutively and divided into four groups: G1--diabetes and hypertension; G2--diabetes; G3--hypertension; and G4--without hypertension or diabetes. Urine was obtained for laboratory analysis of urinary creatinine (Ucr), alkaline phosphatase (AP), γ-glutamyltransferase (γGT), and blood for cystatin C and creatinine before the surgery (M1) and 24 h after the surgery (M2). RESULTS: Values of γGT, γGT/Ucr, and AP × Î³GT/Ucr increased at M2 in G4. Patients without renal function compromise (GFR ≥90 mL/min/1.73 m(2)) presented increased γGT/Ucr and AP × Î³GT/Ucr values at M2 and those with slightly compromised renal function (60-89 mL/min/1.73 m(2)) presented increased γGT values at M2. There was no correlation between deltaCystatin C and deltaAP, deltaγGT, deltaγGT/Ucr, deltaAP/Ucr, and deltaAP × Î³GT/Ucr. CONCLUSIONS: Diabetes, hypertension, and preoperative renal function seem to interfere in tubular enzymuria immediately after surgery in arteriopathic patients. However, when these markers do not increase in postoperative period, renal dysfunction cannot be discarded.

Intermittent Fasting before Laparotomy: Effects on Glucose Control and Histopathologic Findings in Diabetic Rats.

(1) Background: Intermittent fasting is a nutrition practice in which individuals fast for several hours in a day, mainly with feeding time during the daylight hours. They seek to improve metabolic performance and cellular resistance to stress. In this study, we tested the fasting protocol to investigate the glycemic effect in a laparotomy perioperative period in diabetic rats and histopathologic findings. (2) Methods: The animals were diabetic-induced with alloxan. Two groups were set according to the feeding protocol: free food and intermittent fasting, whose rats could only eat 8 h in the daylight. Both groups were anesthetized, and a laparotomy was performed. We evaluated the glucose levels during the perioperative period, and we accessed organ histology seeking damage of kidney, bowel and liver after surgical trauma, and we evaluated the wound healing process. (3) Results: Glycemic levels were improved in the intermittent fasting group, especially in the post-operative period after laparotomy. Comparing both groups' tubular damage showed interdependency with mice with worse glycemic level (Z = 2.3; p = 0.0215) and wound-healing parameters showed interdependency with rats with better glycemic status for neovascularization (Z = 2.2; p = 0.0273) and the presence of sebaceous and sweat gland in the healing process (Z = 2.30; p = 0.0215). (4) Conclusions: Intermittent fasting before surgery can be a tool to improve glycemic levels in diabetic rats, with improvement especially in the post-operative period.