Who Is at Risk for Postdischarge Nausea and Vomiting after Ambulatory Surgery?

BACKGROUND:: About one in four patients suffers from postoperative nausea and vomiting. Fortunately, risk scores have been developed to better manage this outcome in hospitalized patients, but there is currently no risk score for postdischarge nausea and vomiting (PDNV) in ambulatory surgical patients. METHODS:: We conducted a prospective multicenter study of 2,170 adults undergoing general anesthesia at ambulatory surgery centers in the United States from 2007 to 2008. PDNV was assessed from discharge until the end of the second postoperative day. Logistic regression analysis was applied to a development dataset and the area under the receiver operating characteristic curve was calculated in a validation dataset. RESULTS:: The overall incidence of PDNV was 37%. Logistic regression analysis of the development dataset (n = 1,913) identified five independent predictors (odds ratio; 95% CI): female gender (1.54; 1.22 to 1.94), age less than 50 yr (2.17; 1.75 to 2.69), history of nausea and/or vomiting after previous anesthesia (1.50; 1.19 to 1.88), opioid administration in the postanesthesia care unit (1.93; 1.53 to 2.43), and nausea in the postanesthesia care unit (3.14; 2.44-4.04). In the validation dataset (n = 257), zero, one, two, three, four, and five of these factors were associated with a PDNV incidence of 7%, 20%, 28%, 53%, 60%, and 89%, respectively, and an area under the receiver operating characteristic curve of 0.72 (0.69 to 0.73). CONCLUSIONS:: PDNV affects a substantial number of patients after ambulatory surgery. We developed and validated a simplified risk score to identify patients who would benefit from long-acting prophylactic antiemetics at discharge from the ambulatory care center.     

Paravertebral Blocks in Breast Cancer Surgery: Is There a Difference in Postoperative Pain,Nausea, and Vomiting?

Background  

The purpose of this study was to evaluate postoperative pain and postoperative nausea and vomiting (PONV) in patients with paravertebral blocks (PVB) undergoing breast cancer surgery with or without axillary staging.     

Ondansetron for the Prevention of Postoperative Nausea and Vomiting: Which is the Best Dosage for Aesthetic Plastic Surgery?

Background Ondansetron has been used widely in plastic surgery to prevent postoperative nausea and vomiting. A literature search showed controversial dosages of this drug, and because of its short half-life, its use only before anesthetic induction could have a limited effect. The purpose of this study was to assess the efficacy of intravenous (IV) ondansetron (4 mg) for aesthetic plastic surgery performed with the patient under general anesthesia and the prophylaxis of postoperative nausea and vomiting (PONV) in two situations: (a) only before anesthetic induction and (b) before anesthetic induction and immediately before extubation.Methods Of the 60 patients who had general anesthesia for aesthetic plastic surgery, 30 received 4 mg of IV ondansetron before anesthetic induction (control group) and 30 received 4 mg of IV ondansetron before anesthetic induction plus 4 mg IV immediately before extubation (experimental group). The PONV was recorded in the postanesthetic care unit and in the hospital room.Results The total occurrence of PONV (n = 60) was 6.7%. In the postanesthetic care unit, one patient in the experimental group (3.3%) manifested this symptom. In the hospital room, two patients in the control group (6.7%) and one patient in the experimental group (3.3%) manifested PONV.Conclusion According to the findings, there was no statistical difference between the groups. However, the dosage used in the control group was effective and less expensive.     

Aprepitant’s Prophylactic Efficacy in Decreasing Postoperative Nausea and Vomiting in Morbidly Obese Patients Undergoing Bariatric Surgery

Background

Postoperative nausea and vomiting is a major cause of patient dissatisfaction towards surgery. For bariatric surgery, increased vomiting/retching is detrimental to surgical anastomosis. The present study evaluated the efficacy of aprepitant (neurokinin-1 inhibitor) as a prophylactic antiemetic in morbidly obese patients for laparoscopic bariatric surgery.

Methods

After institutional review board approval, 125 morbidly obese patients were recruited into this double-blind placebo-controlled trial. On random division, the patients received a tablet of aprepitant (80 mg) in group A, or a similar-appearing placebo in group P, an hour prior to surgery. All patients received intravenous ondansetron (4 mg) intraoperatively. Postoperatively, the patients were evaluated for nausea and vomiting by a blinded evaluator at 30 min, 1, 2, 6, 24, 48, and 72 h.

Results

Both groups were evenly distributed for age, body mass index, type, and length of surgery. Cumulative incidence of vomiting at 72 h was significantly lower in group A (3 %) compared to group P (15 %; p?=?0.021). Odds ratio for vomiting in group P compared to group A was 5.47 times. On Kaplan–Meier plot, time to first vomiting was also significantly delayed in group A (p?=?0.019). A higher number of patients showed complete absence of nausea or vomiting in group A compared to group P (42.18 vs. 36.67 %). On the other hand, nausea scores were unaffected by aprepitant, and no significant difference between groups was found at any of the measured time points.

Conclusions

In morbidly obese patients undergoing laparoscopic bariatric surgery, addition of aprepitant to ondansetron can significantly delay vomiting episodes simultaneously lowering the incidence of postoperative vomiting.     

Steal Syndrome Complicating Hemodialysis Access Procedures: Can It Be Predicted?

The development of steal syndrome distal to an arteriovenous fistula (AVF) created for hemodialysis access remains a significant clinical problem. This study was undertaken to determine the role of intraoperative noninvasive testing in the prediction and management of steal syndrome following arteriovenous fistula creation. First, in order to determine a threshold digital/brachial index (DBI) for patients at risk for steal syndrome, we performed a retrospective review of patients who had had the DBI measured and who developed symptoms (steal syndrome) following AVF creation. This was followed by a prospective evaluation of the ability of the DBI to predict which patients undergoing AVF surgery would develop steal syndrome. A DBI of <0.6 identifies a patient at risk for steal syndrome. Intraoperative DBI cannot be used to predict which patient will develop steal syndrome; however, if revision is indicated, the DBI should be increased to >0.6. Failure to accomplish this puts the patient at risk for continued steal syndrome.     

Intrathyroid Parathyroid Adenoma in Primary Hyperparathyroidism: Can It Be Predicted Preoperatively?

Introduction The role of cervical ultrasonography (US)-guided surgery for intrathyroid parathyroid adenoma in primary hyperparathyroidism is rarely reported. The aim of this study was to elucidate the role of cervical US in identifying this entity. Methods From 1996 to 2003, cervical explorations were performed in 178 patients (mean age 57 years) with primary hyperparathyroidism. High-resolution cervical US was performed in all of the patients. Patients’ characteristics were reviewed to identify predictive factors for intrathyroid adenoma. Results Cervical US identified abnormal parathyroid glands in 163 of 178 patients, with a positive predictive value (PPV) of 100%. Six patients (3.4%) were found to have intrathyroid parathyroid adenomas (two in the superior parathyroid and four in the inferior parathyroid). Cervical US predicted this anomaly in four of six patients (67%) in whom the thyroid gland was not nodular and allowed total enucleation of the adenoma to be performed in three and subtotal thyroid loboisthmectomy in three; these operations were performed uneventfully and rapidly. The PPV in this anomaly was 80%. Thirteen patients required postoperative calcium supplementation for 2 to 4 months, and all were normocalcemic at the time of the last clinic visit, with follow-up varying from 12 to 96 months. On multivariable analysis, no factor predicted intrathyroid localization of parathyroid adenoma. Conclusions The PPV of high-resolution cervical US for identifying an abnormal parathyroid gland was 100% in this series. It was 80% for predicting intrathyroid localization of the adenoma. This method allows us to shorten the operating time by guiding the exploration immediately toward the thyroid gland.     

Can the Change in Center-edge Angle During Pincer Trimming Be Reliably Predicted?

Background  

Femoroacetabular impingement is recognized as a cause of hip pain in young adults and as a precursor to osteoarthritis although many questions persist regarding its management. One in particular is when to resect a pincer lesion and how much to resect. Instability can result from overresection and persistent impingement can result from underresection.     

Timing of Complications during Carotid Artery Stenting. How Can they Be Predicted ?

Carotid artery stenting (CAS) is becoming increasingly common for the treatment of carotid stenosis. Accumulating data, but not randomised data, suggest that CAS has promising efficacy in preventing stroke with an acceptable rate of procedure-related complications when compared to carotid endarterectomy (CEA). However, CAS procedures can carry a risk of non-negligible complications such as cerebral embolization, cerebral hemorrhage, severe hypotension and bradycardia. These may occur after the first 24 hours. Lessons may be learned from the timing of occurrence of CAS adverse events. The most severe neurological complications are generally due to embolism and occur intraprocedurally especially during catheter, wire or sheath manipulation in the aortic arch and common carotid. These strokes, obviously, cannot be prevented by using cerebral protection devices and enhance the importance of an appropriate learning curve that includes proper material choice, patient selection, good technique and the skill of “know when to quit”.     

Postoperative Trunk Shift in Lenke 1C Scoliosis: What Causes It? How Can It Be Prevented?

STUDY DESIGN.: A risk factor analysis study. OBJECTIVE.: To identify the causative factors for postoperative trunk shift in Lenke 1C scoliosis and investigate how to prevent it. SUMMARY OF BACKGROUND DATA.: When selective thoracic fusion is performed, postoperative trunk shift is a significant problem in the management of Lenke 1C scoliosis. It is often accompanied by unsatisfactory clinical outcomes and a risk of reoperation. METHODS.: We reviewed all the patients with adolescent idiopathic scoliosis (AIS) surgically treated in our institution from 2002 through 2008. Inclusion criteria were as follows: (1) patients with Lenke 1C curves who were treated with selective thoracic fusion using posterior pedicle screw-only constructs; (2) the lowest instrumented vertebra (LIV) ending at L1 level or above; and (3) 2-year radiographical follow-up. Eighteen radiographical parameters were chosen as potential risk factors. The 18 parameters measured (1) amount of correction obtained by surgery; (2) preoperative position of LIV; (3) magnitude of major thoracic and thoracolumbar/lumbar (MT and TL/L) curves and ratio of MT: TL/L curve; and (4) curve flexibility. Both comparative and correlation analyses were performed. Those parameters that had shown highest correlation with the 2-year thoracic apical vertebra-center sacral vertical line (AV-CSVL) distance were selected to form a linear regression model, by which the correlations were quantified. RESULTS.: Of the 278 patients reviewed, 44 met the inclusion criteria. The parameters that measured the preoperative position of LIV and ratio of MT: TL/L curve showed high correlation with the 2-year thoracic AV-CSVL distance. With regard to the parameters that measured the amount of correction obtained by surgery, only the correction of the thoracic AV-T1 distance showed low correlation. Among the 18 parameters, preoperative lowest instrumented vertebra-lower end vertebra (LIV-LEV) difference and ratio of MT: TL/L Cobb angle were selected to form a formula to help predict postoperative trunk shift. The formula was as follows: 2-year thoracic AV-CSVL distance = -26.6 + 22.7 (ratio of MT: TL/L Cobb angle) - 3.9 (preoperative LIV-LEV difference). The model R = 0.55. CONCLUSION.: Both LIV selection and ratio of MT: TL/L curve were found to be highly correlated with the onset of postoperative trunk shift in Lenke 1C scoliosis. Amount of correction obtained by surgery, however, did not seem to be an independent causative factor. Postoperative trunk shift is less likely to occur when selecting LEV as LIV and the ratio of MT: TL/L Cobb angle of 1.2° or more.     

Can Aesthetic Facial Reconstruction Be Judged in Black and White?

Aesthetic considerations of the face need to be evaluated in real-life full color. Staged contouring and insetting of a transferred free flap is sometimes required. This consists of debulking, thinning, and reshaping the flap. If the facial area is involved, however, color mismatch of a free flap represents an aesthetic challenge for the reconstructive surgeon, and often is missed with black and white photos.This article reports on a patient in whom a first dorsal metatarsal cutaneus free flap was used to reconstruct a full-thickness defect in the lateral orbit including upper and lower eyelids and outer canthus. The flap resulted in an unacceptable aesthetic outcome consisting of a bulky, hypopigmented deformity. Revisional surgery consisted of debulking the free flap and resurfacing it with a full-thickness skin graft taken from the postauricular area. This resulted in a pleasant, thin, and better color match reconstruction.The advantages of the first web space of foot free flap to the eyelid are well described. The authors are of the opinion that the flap does not match the color of the eyelid region, and therefore suggest that if used, prefabrication or a second procedure is needed.Evaluation of the postoperative results needs to be in color because black and white can mask the final aesthetic result.