What can be expected from risk scores for predicting postoperative nausea and vomiting?

Several risk scores have been developed to calculate the probabilityof postoperative nausea and vomiting (PONV). However, the powerto discriminate which individual will suffer from PONV is stilllimited. Thus, we wondered how the number of predictors in ascore affects the discriminating power and how the characteristicsof a population—which is needed to measure the power ofa score—may affect the results. For ethical reasons andto be independent from centre specific populations, we developeda computer model to simulate virtual populations. Four populationswere created according to number, frequency, and odds ratioof predictors. Population I: parameters were derived from apreviously published paper to verify whether calculated andreported values are in accordance. Population II: a gynaecologicalpopulation was created to investigate the impact of the studysetting. Populations III and IV: to meet ideal assumptions amodel with up to seven predictors with an odds ratio of 2 and3 was tested, respectively. The discriminating power of a riskscore was measured by the area under a receiver operating characteristiccurve (AUC) and an increase of more than 0.025 per predictorwas considered to be clinically relevant. The AUC of populationI was similar to those reported in clinical investigations (0.72).The study setting had a considerable impact on the discriminatingpower since the AUC decreased to 0.65 in a gynaecological setting.The AUC with the ‘idealized’ populations III andIV was at best in the range of 0.7–0.8. The inclusionof more than five predictors did not lead to a clinically relevantimprovement. The currently available simplified risk scores(with four or five predictors) are useful both as a method toestimate individual risk of PONV and as a method for comparinggroups of patients for antiemetic trials. They are also superiorto single predictor models which are just using the patients’history of PONV or female gender alone. However, our analysissuggests that the power to discriminate which individual willsuffer from PONV will remain imperfect, even when more predictorsare considered. Br J Anaesth 2001; 86: 822–7     

Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 ml kg(-1)

Background. I.V. fluid administration has been shown to reducepostoperative nausea and vomiting (PONV). The optimum dose isunknown. We tested the hypothesis that administration of i.v.crystalloid of 30 ml kg^–1 would reduce the incidence ofPONV compared with 10 ml kg^–1 of the same fluid. Methods. A total of 141 ASA I female patients undergoing electivegynaecological laparoscopy were randomized, in double-blindfashion, to receive either 10 ml kg^–1 (n=71; CSL-10 group)or 30 ml kg^–1 (n=70; CSL-30 group) of i.v. compound sodiumlactate (CSL). Results. In the first 48 h after anaesthesia, the incidenceof vomiting was lower in the CSL-30 group than in the CSL-10group (8.6% vs 25.7%, P=0.01). Anti-emetic use was less in theCSL-30 group at 0.5 h (2.9% vs 14.3%, P=0.04). The incidenceof severe nausea was significantly reduced in the treatmentgroup at awakening (2.9% vs 15.7%, P=0.02), 2 h (0.0% vs 8.6%,P=0.04) and cumulatively (5.7% vs 27.1%, P=0.001). The numbersneeded to treat to prevent vomiting, severe nausea and antiemeticuse in the first 48 h were 6, 5 and 6, respectively. Conclusion. I.V. administration of CSL 30 ml kg^–1 to healthywomen undergoing day-case gynaecological laparoscopy reducedthe incidence of vomiting, nausea and anti-emetic use when comparedwith CSL 10 ml kg^–1.     

Dexamethasone is a cost-effective alternative to ondansetron in preventing PONV after paediatric strabismus repair

This study evaluated the antiemetic efficacy, cost-effectivenessand clinical utility of prophylactic ondansetron and dexamethasonecompared with placebo in the prevention of postoperative nauseaand vomiting (PONV) in 135 children (2–15 yr, ASA I–II)undergoing strabismus repair. After induction with halothaneand nitrous oxide in oxygen or i.v. thiopental, the childrenreceived i.v. dexamethasone 1 mg kg^–1 to a maximumof 25 mg, ondansetron 100 µg kg^–1to a maximum of 4 mg or placebo (n=45). Episodes of PONVwere recorded for the first 24 h after the operation. Trueoutcome measures (parental satisfaction score, duration of stayin the postanaesthesia care unit and fast tracking time), therapeuticoutcome measures (number needed to prevent (NNTP) PONV) andthe cost to benefit a child with each drug were analysed. Theincidence and severity of PONV in the first 24 h were significantlyless in the dexamethasone and ondansetron groups than in theplacebo group (P<0.05). The incidence (P=0.04) and severity(P=0.03) of PONV at the 6–24 h epoch were significantlyless in the dexamethasone group than in the ondansetron group.Recovery time (P=0.07), fast tracking time (P=0.6), parentalsatisfaction scores (P=0.08) and NNTP PONV were comparable (NNTP=2)in both the ondansetron and the dexamethasone group. The costto benefit a child with dexamethasone was approximately 22 timesless than that of ondansetron. Br J Anaesth 2001; 86: 84–9     

Dolasetron prophylaxis reduces nausea and postanaesthesia recovery time after remifentanil infusion during monitored anaesthesia care for extracorporeal shock wave lithotripsy

Background. Remifentanil is used as an analgesic for differentprocedures performed during monitored anaesthesia care. Opioid-inducednausea and vomiting can be troublesome. Methods. This prospective, randomized, double-blind study wasperformed to evaluate the efficacy of prophylaxis with dolasetronin reducing the frequency of postoperative nausea and durationof discharge time. Forty urological patients, undergoing electiveambulatory extracorporeal shock wave lithotripsy (ESWL) receivedrandomly either dolasetron 12.5 mg i.v. (Group 1) or placebo(Group 2) 10 min before a patient-adapted continuous infusionof remifentanil 0.15–0.4 µg kg^–1 min^–1was administered. Frequency and intensity (VAS 0–100 mm)of nausea, retching, and vomiting were assessed by patientsand blinded investigators during and after the procedure. Results. Patient characteristics, baseline values, durationof ESWL, and total dose of remifentanil did not differ betweengroups. The frequency (Group 1/Group 2; 20/55%; P<0.05) andmean (SD) maximal intensity [15 (9)/45 (14) mm; P<0.05] ofnausea during 24 h was significantly reduced after dolasetronand discharge times in Group 1 were less than Group 2[22 (14)/45 (28) min; P<0.05]. Br J Anaesth 2003; 90: 194–8     

Inspired oxygen fraction of 0.8 compared with 0.4 does not further reduce postoperative nausea and vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy

Background. Postoperative nausea and vomiting (PONV) is oneof the most frequent complications after general anaesthesia.Single-dose antiemetic prophylaxis has limited efficacy in high-riskpatients. Adding a simple potential antiemetic approach, suchas increasing the inspired oxygen fraction, to the antiemeticportfolio would preserve pharmacological interventions for treatmentof symptoms in the postoperative period. However, the antiemeticeffect of a high inspired oxygen fraction is still discussedcontroversially. The aim of the study was to evaluate whetheran inspired oxygen fraction of 0.8 decreases PONV in patientsreceiving the 5-HT₃-antagonist dolasetron. Methods. In a randomized, placebo-controlled, double-blindedtrial we studied 377 patients (ASA I–III) undergoing electivelaparoscopic cholecystectomy. Induction of anaesthesia was standardized,including thiopental fentanyl and cis-atracurium. For all patientsthe individual risk for PONV was calculated using the Koivurantascore and all patients received 12.5 mg dolasetron i.v. beforesurgery. Patients were allocated randomly to one of three groups:Group A (n=125) received 80% oxygen in air, Group B (n=125)40% oxygen in air and Group C (n=127) 40% oxygen in nitrousoxide. Postoperative nausea, postoperative vomiting (PV), ornausea, vomiting, or both (PONV) was assessed in the early (0–4h) and overall postoperative period (0–24 h) by an anaesthesiologistunaware of patient allocation. Results. There was a significantly lower incidence of PONV andPV in Groups A (PONV: 11.2%; PV: 3.2%) and B (PONV: 10.4%; PV:3.2%) compared with Group C (PONV: 26.7%; PV: 13.3%), but therewere no significant differences between Groups A and B. Conclusions. An inspired oxygen fraction of 0.8 does not furtherdecrease PONV or vomiting in dolasetron-treated patients undergoinglaparoscopic cholecystectomy. The lower incidence of PONV inGroups A and B compared with Group C is most likely caused bythe omission of nitrous oxide.      

Antiemetic and analgesic-sparing effects of diphenhydramine added to morphine intravenous patient-controlled analgesia

Background. This study was designed to examine the analgesicand dose-related antiemetic efficacy of diphenhydramine–morphinemixture for intravenous patient-controlled analgesia (PCA). Methods. Healthy women, undergoing abdominal total hysterectomywere recruited to this double-blinded randomized placebo-controlledstudy. Patients were randomly allocated to one of three groups(n=40 each). In group 1, patients received saline at inductionand morphine 1 mg ml^–1 alone for postoperative PCA. Patientsin groups 2 and 3 received diphenhydramine 30 mg i.v. at inductionand were given a 1.2:1 or a 4.8:1 ratio, respectively, of diphenhydramine–morphinemixture for postoperative PCA. Results. A total of 112 patients completed the study. The incidenceof postoperative nausea (31.6% vs 67.6%, P<0.01) and vomiting(15.8% vs 40.5%, <0.05) was significantly lower in group3 than in group 1. Furthermore, the incidence of severe nauseawas significantly lower in group 3 than in group1 (2.6% vs 24.3%,P<0.05). The rescue antiemetic requirements were also significantlyless in group 3 than in group 1 (5.3% vs 24.3%, P<0.05).However, there was no significant difference between group 2and group 1 in any of the comparisons. Pain intensity, 24-hmorphine consumption and diphenhydramine-related side-effects,such as sedation or dry mouth, did not differ among the threegroups. Conclusion. An initial bolus of diphenhydramine 30 mg at anaestheticinduction followed by postoperative PCA with a 4.8:1, but not1.2:1, diphenhydramine–morphine mixture provides an effectiveantiemetic efficacy without morphine-sparing effects.     

Analgesic effects of parecoxib following total abdominal hysterectomy

Background. Forty-eight ASA I–II patients undergoing totalabdominal hysterectomy (TAH) were studied in a double blind,randomized placebo controlled trial of parecoxib for postoperativeanalgesia. Methods. All patients were given propofol 2–4 mg kg^–1i.v., a non-depolarizing muscle relaxant, morphine 10 mg i.v.and prochlorperazine 12.5 mg i.m. intraoperatively. Their lungswere ventilated with nitrous oxide and isoflurane 1–1.5%in oxygen. Morphine was self-administered for postoperativeanalgesia via a patient controlled analgesia (PCA) device. Patientswere allocated randomly to receive either parecoxib 40 mg i.v.or normal saline on induction of anaesthesia. Results. Twelve patients did not complete the study. Of theremaining 36 patients, there was no significant difference betweenthe treatment groups in age, weight, ASA status, duration ofsurgery, or intraoperative dose of morphine. However, mean (95%CI) 24 h morphine consumption of 54 (42–65) mg in theparecoxib group was significantly (P=0.04) lower than that of72 (58–86) mg in the placebo group. Pain intensity scoreson sitting up were significantly lower (P=0.02) in the parecoxibgroup compared with placebo. There was no significant differencebetween the treatment groups in pain intensity scores at restand on deep inspiration, or in nausea, total number of vomitingepisodes, median number of rescue antiemetic doses, and sedationscores. Conclusions. Parecoxib 40 mg i.v. may be recommended in patientshaving TAH as it provides morphine-sparing analgesia. Br J Anaesth 2003; 90: 746–9     

Patient preferences for immediate postoperative recovery

Background. Several attempts have been made to evaluate patients’concerns with respect to postoperative recovery. To identifyaspects of postoperative recovery relevant to patients, severalmethodological and statistical approaches have been used. Oneof the first to provide useful information was Fredrick Orkinwho used conjoint analysis. This methodology is usually performedby market researchers to learn about the relative importanceof product attributes. We used conjoint analysis in the presentstudy. Methods. A total of 220 patients undergoing preoperative anaestheticexamination before impending surgery under general anaesthesiawere asked to rate nine scenarios during immediate postoperativerecovery based on four factors (alertness, pain, postoperativenausea and vomiting (PONV), and extra costs) each with threelevels. Using conjoint analysis the relative impact of eachfactor on ranking the scenarios was assessed. Results. The relative importance of the four factors (as a percentageof the preference decision) was PONV (49%), pain (27%), alertness(13%), and additional costs (11%). Conclusion. Avoidance of PONV is a major concern for patientsbefore surgery. Br J Anaesth 2002; 89: 760–1     

Patient well-being after general anaesthesia: a prospective, randomized, controlled multi-centre trial comparing intravenous and inhalation anaesthesia

Background. The aim of this study was to assess postoperativepatient well-being after total i.v. anaesthesia compared withinhalation anaesthesia by means of validated psychometric tests. Methods. With ethics committee approval, 305 patients undergoingminor elective gynaecologic or orthopaedic interventions wereassigned randomly to total i.v. anaesthesia using propofol orinhalation anaesthesia using sevoflurane. The primary outcomemeasurement was the actual mental state 90 min and 24 h afteranaesthesia assessed by a blinded observer using the AdjectiveMood Scale (AMS) and the State-Trait-Anxiety Inventory (STAI).Incidence of postoperative nausea and vomiting (PONV) and postoperativepain level were determined by Visual Analogue Scale (VAS) 90min and 24 h after anaesthesia (secondary outcome measurements).Patient satisfaction was evaluated using a VAS 24 h after anaesthesia. Results. The AMS and STAI scores were significantly better 90min after total i.v. anaesthesia compared with inhalation anaesthesia(P=0.02, P=0.05, respectively), but equal 24 h after both anaesthetictechniques (P=0.90, P=0.78, respectively); patient satisfactionwas comparable (P=0.26). Postoperative pain was comparable inboth groups 90 min and 24 h after anaesthesia (P=0.11, P=0.12,respectively). The incidence of postoperative nausea was reducedafter total i.v. compared with inhalation anaesthesia at 90min (7 vs 35%, P<0.001), and 24 h (33 vs 52%, P=0.001). Conclusion. Total i.v. anaesthesia improves early postoperativepatient well-being and reduces the incidence of PONV. Br J Anaesth 2003; 91: 631–7     

Supplemental oxygen for prevention of nausea and vomiting after breast surgery

Background. Administration of supplemental oxygen 80% has beenshown to halve the incidence of postoperative nausea and vomiting(PONV). We tested the efficacy of supplemental oxygen 50% indecreasing the incidence of PONV after breast surgery. Methods. One hundred patients receiving standardized sevofluraneanaesthesia were randomly assigned to two groups: oxygen 30%administration (Group 30); and oxygen 50% administration (Group50). Oxygen was administered during surgery and for 2 hfrom the end of surgery. Results. The incidence of PONV over 24 h after surgeryshowed no difference between the groups: 82% in Group 30 and89% in Group 50. However, during the postoperative oxygen administration,eight patients vomited in Group 30, compared with none in Group50 (P<0.05). After oxygen therapy ceased, there was no differencein the incidence of vomiting between the groups. Nausea andneed for rescue antiemetics did not differ between the groups. Conclusion. The incidence of vomiting decreased during the shortpostoperative administration of supplemental oxygen 50%. However,perioperative oxygen 50% administration did not prevent PONVover the 24-h follow-up period in patients undergoing breastsurgery performed under general anaesthesia. Br J Anaesth 2003; 91: 284–7     

Prevention of postoperative nausea and vomiting after spinal morphine for Caesarean section: comparison of cyclizine,dexamethasone and placebo

Background. Low-dose intrathecal (spinal) morphine (0.1–0.2mg) for Caesarean section delivers excellent postoperative analgesiabut is associated with significant nausea and vomiting. We comparedthe antiemetic efficacy of cyclizine, dexamethasone, and placeboin this clinical setting. Methods. Ninety-nine women undergoing elective Caesarean sectionunder spinal anaesthesia were allocated randomly, in a double-blindstudy design, to receive either cyclizine 50 mg, dexamethasone8 mg, or placebo as a single-dose infusion in saline 0.9%, 100ml on completion of surgery. Spinal anaesthesia consisted of:hyperbaric bupivacaine 0.5%, 2.0 ml; fentanyl 10 µg; andspinal morphine 0.2 mg. The primary outcome measure was theincidence of nausea. Results. The incidence of nausea was significantly less in patientsreceiving cyclizine compared with dexamethasone and placebo(33 vs 60 and 67%, respectively, P<0.05). Severity of nauseaand number of vomiting episodes were also less at 3–6h in cyclizine patients. Overall satisfaction with postoperativecare at 24 h, expressed on a 100 mm visual analogue scale, wasgreater in cyclizine [78 (28)] than either dexamethasone [58(31), P=0.03] or placebo [51 (28), P=0.008]. Conclusion. We conclude that following spinal morphine 0.2 mgand fentanyl 10 µg analgesia for Caesarean section, cyclizine50 mg i.v. reduces the incidence of nausea compared with dexamethasone8 mg i.v. or placebo. It also lessens the severity of nauseaand vomiting, and increases maternal satisfaction in the earlypostoperative period. Br J Anaesth 2003; 90: 665–70     

Prospective randomized, double-blind comparative study of dexamethasone, ondansetron, and ondansetron plus dexamethasone as prophylactic antiemetic therapy in patients undergoing day-case gynaecological surgery

Dexamethasone alone and in combination with selective 5-hydroxytryptaminereceptor antagonists is of benefit in the prophylaxis of post-operativenausea and vomiting. In this study, the effectiveness of sucha combination in comparison to either drug alone is investigatedin day case gynaecological surgery. A total of 177 patientswere randomized to three treatment groups: dexamethasone 8 mg,ondansetron 4 mg, and dexamethasone 8 mg plus ondansetron 4mg. The only significant difference between groups was seenin the first 3 h when failure of prophylaxis was more frequentin patients who had received dexamethasone alone (P=0.0085;Fisher’s exact probability test). Confidence intervalanalysis indicates a modest treatment effect for the combinationand the decision whether to perform a larger study depends uponwhether such an effect is clinically relevant. Br J Anaesth 2001; 87: 588–92     

Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidectomy

Background. Supplemental intra-operative oxygen 80% halves theincidence of nausea and vomiting after open and laparoscopicabdominal surgery, perhaps by ameliorating intestinal ischaemiaassociated with abdominal surgery. It is unlikely that thyroidsurgery compromises intestinal perfusion. We therefore testedthe hypothesis that supplemental perioperative oxygen does notreduce the risk of postoperative nausea and vomiting (PONV)after thyroidectomy. Methods. One hundred and fifty patients undergoing thyroidectomywere given sevoflurane anaesthesia. After induction, patientswere randomly assigned to the following treatments: (i) 30%oxygen, (ii) 80% oxygen, or (iii) 30% oxygen with droperidol0.625 mg. Results. The overall incidence of nausea during the first 24 hafter surgery was 48% in the patients given oxygen 30%, 46%in those given oxygen 80%, and 22% in those given droperidol(P=0.004). There were no significant differences between theoxygen 30% and 80% groups in incidence or severity of PONV,the need for rescue antiemetics, or patient satisfaction. Droperidolsignificantly shortened the time to first meal. Conclusions. Supplemental oxygen was ineffective in preventingnausea and vomiting after thyroidectomy, but droperidol reducedthe incidence. Br J Anaesth 2003; 91: 857–61     

Cost-effectiveness of three combinations of antiemetics in the prevention of postoperative nausea and vomiting

Background. This study compares the cost-effectiveness of threecombinations of antiemetics in the prevention of postoperativenausea and vomiting (PONV). Methods. We conducted a prospective, double-blind study. NinetyASA I–II females, 18–65 yr, undergoing general anaesthesiafor major gynaecological surgery, with standardized postoperativeanalgesia (intrathecal 0.2 mg plus i.v. PCA morphine), wererandomly assigned to receive: ondansetron 4 mg plus droperidol1.25 mg after induction and droperidol 1.25 mg 12 h later (Group1); dexamethasone 8 mg plus droperidol 1.25 mg after inductionand droperidol 1.25 mg 12 h later (Group 2); ondansetron 4 mgplus dexamethasone 8 mg after induction and placebo 12 h later(Group 3). A decision analysis tree was used to divide eachgroup into nine mutually exclusive subgroups, depending on theincidence of PONV, need for rescue therapy, side effects andtheir treatment. Direct cost and probabilities were calculatedfor each subgroup, then a cost-effectiveness analysis was conductedfrom the hospital point of view. Results. Groups 1 and 3 were more effective (80 and 70%) thanGroup 2 (40%, P=0.004) in preventing PONV but also more expensive.Compared with Group 2, the incremental cost per extra patientwithout PONV was €6.99 (95% CI, –1.26 to 36.57) forGroup 1 and €13.55 (95% CI, 0.89–132.90) for Group3. Conclusion. Ondansetron+droperidol is cheaper and at least aseffective as ondansetron+ dexamethasone, and it is more effectivethan dexamethasone+droperidol with a reasonable extra cost. Br J Anaesth 2003; 91: 589–92     

The discriminating power of a risk score for postoperative vomiting in adults undergoing various types of surgery

Background : Recently, we have demonstrated that the probability of postoperative vomiting (PV) following ENT surgery with inhalational anaesthetics can be predicted using a risk score. This score is based on gender, age, smoking status, history of motion sickness or postoperative nausea and vomiting and the duration of anaesthesia. Therefore, it is of interest whether this score is also accurate in predicting PV in patients undergoing different types of surgery.
Methods : Inpatients scheduled for bone, vascular, general or eye surgery were included in a prospective survey for PV over 24 h. Data of 1091 patients were analyzed, of which 542 were used for the validation of the previously constructed risk score (Score I). The data of the remaining 549 patients were used to evaluate the risk factors that contribute to PV in this setting and to develop a new score (Score II). The discriminating power of both scores to predict PV was tested in the validation set (n=542) and compared by calculating the area under the receiver operating characteristic (ROC) curves.
Results : The area under the ROC curve of Score I was 0.77 (SD 0.024). Risk factors for PV in the evaluation set were female gender, young age, history of motion sickness or postoperative nausea and vomiting and the type of surgery. The area under the curve of Score II was 0.75 (SD 0.026) and was not significantly different from Score I ( P =0.57).
Conclusion : Score I was accurate in predicting PV in patients after most types of surgery with volatile anaesthetics, which suggests that this score might be useful for other centres as well.     

Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty

Background. Peripheral neural blockade appears to provide effectiveanalgesia with potentially less morbidity than central neuraxialtechniques. We compared the relative benefits of combined femoral(3-in-1) and sciatic nerve block with epidural blockade forpostoperative knee arthroplasty analgesia. Methods. Sixty patients, ASA I–III, undergoing unilateralknee replacement were prospectively randomized to receive eithera lumbar epidural infusion or combined single-shot femoral (3-in-1)and sciatic blocks (combined blocks). All patients receivedstandard general anaesthesia. Visual analogue pain scores andrescue opioid requirements were recorded at four time pointspostoperatively. Patient satisfaction, morbidity, block insertiontime, perioperative blood loss and rehabilitation indices werealso assessed. Results. In both groups, pain on movement was well controlledat discharge from recovery and 6 h postoperatively but increasedat 24 and 48 h. Median (95% CI) analogue scale scores were 0(0–0), 15 (0–30), 55 (38–75) and 54 (30–67)mm for epidural block and 0.5 (0–22), 21.5 (10–28),40 (20–50) and 34.5 (21–55) mm for combined block.VAS pain scores with the combined blocks were significantlylower at 24 h (P=0.004). Total morphine usage was low in bothgroups: median epidural group 17 mg (8–32) versus combinedblocks 13 mg (7.8–27.5). Patient satisfaction was highin both groups with median (95% CI) scores of 100 (85–100),83 (70–100) and 82 (57–90) mm for epidural and 90(73–100), 100 (77–100) and 97 (80–100) mmfor combined blocks (not significant). Perioperative blood lossand rehabilitation indices were also similar. Conclusions. Combined femoral (3-in-1) and sciatic blocks offera practical alternative to epidural analgesia for unilateralknee replacements.      

Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery

Background. Thoracoscopic surgery can be associated with considerablepostoperative pain. While the benefits of paravertebral blockon pain after thoracotomy have been demonstrated, no investigationson the effects of paravertebral block on pain after thoracoscopyhave been conducted. We tested the hypothesis that a single-injectionthoracic paravertebral block, performed preoperatively, reducespain scores after thoracoscopic surgery. Methods. Of 45 patients recruited, 40 completed the study. Theywere randomly allocated to two groups: the paravertebral groupreceived i.v. patient-controlled analgesia (PCA) with morphineplus single-injection thoracic paravertebral block with bupivacaine0.375% and adrenaline 1:200 000 0.4 ml kg^–1 (n=20). Thecontrol group was treated with a back puncture without injectionand morphine PCA (n=20). Results. The main outcomes recorded during 48 h after surgerywere pain scores using the visual analogue scale (VAS, 0–100).Secondary outcomes were cumulative morphine consumption andpeak expiratory flow rate (PEFR). Half an hour and 24 h aftersurgery, median (25th–75th percentiles) VAS on coughingin the paravertebral group was 31.0 (20.0–55.0) and 30.5(17.5–40.0) respectively and in the control group it was70.0 (30.0–100.0) and 50.0 (25.0–75.0) respectively.The difference between the groups over the whole observationperiod was statistically significant (P<0.05). Twenty-fourand 48 h after surgery, median (25th–75th percentiles)cumulative morphine consumption (mg) was 49.0 (38.3–87.0)and 69.3 (38.8–118.5) respectively in the paravertebralgroup and 51.2 (36.0–84.1) and 78.1 (38.4–93.1)in the control group (statistically not significant). No differenceswere found in PEFR or the incidence of any side-effects betweengroups. Conclusion. We conclude that single-shot preoperative paravertebralblock improves post-operative pain treatment after thoracoscopicsurgery in a clinically significant fashion.      

Nausea and vomiting after fast-track cardiac anaesthesia

Background. The aim of this study was to determine the prevalenceof postoperative nausea and vomiting (PONV) after fast-trackcardiac anaesthesia, risk factors for PONV and its influenceon the length of stay in the intensive care unit (ICU). Methods. A prospective study was performed in the cardiothoracicICU (CTICU) of a university hospital; 1221 consecutive patientsundergoing fast-track anaesthesia (FTCA) in cardiac surgerywere enrolled in the study. Severity of PONV was assessed immediatelyafter extubation and then every hour until discharge from theCTICU. Metoclopramide 10 mg i.v. was used as a first-line rescuemedication and ondansetron 4 mg i.v. as second-line rescue medicationfor PONV. Results. Nausea was reported in 240 (19.7%) patients, and vomitingin 53 (4.3%). A total of 269 (22%) patients were treated withmetoclopramide and 38 (3.1%) with metoclopramide and ondansetron.The latter was effective in all cases. Risk factors for PONVwere age less than 60 yr, female gender and previous historyof PONV. Discharge from the CTICU was delayed for a few hoursbecause of PONV in eight patients, all of whom were dischargedthe same day. Conclusions. The incidence of PONV is relatively low after FTCAand does not prolong ICU stay. Prophylactic administration ofanti-emetic drugs before FTCA is not necessary. Br J Anaesth 2003; 91: 214–17     

Pain on medical wards in a district general hospital

Background. Little attention has been paid to pain on medicalwards, with publications limited to the management of surgicalpatients. We wanted to establish the prevalence and severityof pain in the general medical setting, and how this comparedwith other clinical specialties. Methods. All consenting adult in-patients were assessed dailyfor 5 days. Patients recorded the occurrence and severity ofpain, and whether their pain was bearable. The pain team reviewedpatients with unbearable pain. Results. 1594 questionnaires were completed, representing 54%of the target population. 887 patients reported pain, 17% withpain scores over 6, and 10% with unbearable pain. The distributionof pain was similar for all ward types with 52% of patientson medical wards reporting pain. Of these, 20% reported severepain and 12% unbearable pain. When patients with pain scoresover 6 were analysed by consultant specialty, elderly care,general medicine, and general surgery scored highest. In eachspecialty 20–25% of patients with pain reported a painscore over 6. In patients reviewed by the pain team, reasonsfor poor analgesia included inadequate information, pain assessment,analgesic prescribing, and administration and patient reporting. Conclusion. Patients in all hospital specialities experiencepain. Until the issue of pain management in medical patientsis fully addressed the situation will not improve. Br J Anaesth 2004; 92: 235–7