A randomized comparison of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting

A multimodal management strategy for the prevention of postoperative nausea and vomiting (PONV) appears to be superior to single-drug prophylaxis. We tested the hypothesis that a multimodal PONV prophylaxis regimen incorporating total IV anesthesia (TIVA) with propofol and a combination of ondansetron and droperidol is more effective than a combination of these antiemetics in the presence of an inhaled anesthetic. Ninety patients undergoing laparoscopic cholecystectomy were randomized to one of three groups. Group 1 (multimodal group) received TIVA with propofol, droperidol, and ondansetron. Group 2 (combination group) received droperidol and ondansetron with isoflurane and nitrous oxide for the maintenance of anesthesia. Group 3 (TIVA group) received propofol for the induction and maintenance of anesthesia. The complete response rate (no PONV and no rescue antiemetic) at 2 h after surgery was 90%, 63%, and 66% in Groups 1, 2, and 3, respectively (P < 0.05, Group 1 versus Group 2). At 24 h, the complete response rate was 80%, 63%, and 43% in Groups 1, 2, and 3, respectively (P < 0.05, Group 1 versus Group 3). Patient satisfaction was also greater in the multimodal group than in the other two groups in the postanesthesia care unit (P < 0.05). In conclusion, the multimodal management strategy for PONV was associated with a higher complete response rate and greater patient satisfaction when compared with similar antiemetic prophylaxis with inhaled anesthesia or TIVA with propofol.     

Prophylaxis of postoperative nausea and vomiting in elective breast surgery

Study Objective

To evaluate strategies to treat postoperative nausea and vomiting (PONV) in patients undergoing elective breast surgery.

Design

Prospective, randomized, double-blinded, placebo-controlled trial.

Setting

University-affiliated hospital.

Patients

480 patients with risk factors for PONV.

Interventions

Patients were randomized to three groups to receive an antiemetic prophylactic combination of haloperidol and tropisetron (Group HT), dimenhydrinate and dexamethasone (Group DD), or no prophylaxis (Group P). Anesthesia was maintained with volatile anesthesia (desflurane or sevoflurane) and fentanyl or total intravenous anesthesia (TIVA).

Measurements

Incidence of nausea, emesis, or both in the early (0 - 2 hrs) and late (2 - 24 hrs) postoperative periods were recorded, as were the number of episodes and the time of each occurrence; and patient assessment of the PONV experience on a scale comparable to a numeric rating scale (NRS).

Main Results

Both antiemetic combinations significantly reduced PONV incidence. In patients who received no prophylaxis, PONV incidence was 48.2% in patients given volatile anesthetics and 43.8% in those who received TIVA. PONV incidence was 17.5% in the Group HT patients who received volatile anesthetics, and 25% in the Group HT patients who received TIVA. PONV incidence was 11.4% in Group DD patients given volatile anesthetics, and 15% in Group DD patients receiving TIVA. TIVA reduced the incidence of PONV in the early postoperative period (0-2 hrs), but increased PONV incidence in the late period (2-24 hrs). Patients given TIVA with propofol and remifentanil intraoperatively required more opioids postoperatively than patients given volatile anesthetics.

Conclusion

The frequency of PONV was reduced significantly with both antiemetic combinations.     

The effect of anaesthetic technique on postoperative nausea and vomiting after day-case gynaecological laparoscopy

Gynaecological surgery is of high emetogenic potential and both total intravenous anaesthesia (TIVA) and prophylactic antiemetic therapy may reduce the incidence of postoperative nausea and vomiting (PONV). We studied 144 patients scheduled for day-case gynaecological laparoscopy in a randomized trial comparing balanced inhalational anaesthesia and prophylactic dolasetron (group I+D) with propofol TIVA and dolasetron (group T+D) or TIVA alone (group T). The primary outcome of "complete response" (no vomiting, no treatment for PONV) was not significantly different among groups (34%, 51%, 32%; groups I+D vs T+D vs T, P=0.12). During the first hour after surgery, group I+D had nausea of greater severity (P<0.03). During hospital admission, group T had more vomiting (P<0.03). From discharge until 24 hours postoperatively, 55% of group I+D experience nausea and 38% vomited. The incidence and severity of nausea were significantly lower in the TIVA groups (P<0.04 and <0.05 respectively). There were no significant differences between groups T+D and T, although comparing all groups the complete response rate was highest and the post-discharge incidence and severity of nausea lowest in group T+D. In conclusion, propofol TIVA, with or without dolasetron, reduced postoperative nausea, but not perioperative vomiting or antiemetic requirement, when compared with inhalational anaesthesia plus dolasetron.     

The use of droperidol decreases postoperative nausea and vomiting after gynecological laparoscopy

We evaluated whether or not routine prophylaxis with 2.5 mg of droperidol would efficiently prevent postoperative nausea and vomiting (PONV). Fifty-two patients scheduled for elective gynecological laparoscopic surgery were eligible for this study. Anesthesia was induced using propofol, fentanyl, and vecuronium, and maintained with sevoflurane in nitrous oxide, fentanyl, and vecuronium. Patients were randomized to one of two groups: group 1 patients (n = 23) received 2.5 mg droperidol intravenously when the surgery was started, while group 2 patients (n = 29) did not receive any droperidol. At the conclusion of the surgery, the patient was extubated on satisfactory emergence from general anesthesia. Any episodes of nausea and vomiting, rescue medications, and adverse effects were recorded until the next morning after the surgery. There were no differences in the duration of anesthesia on surgery between the groups, but the total fentanyl dose in group 1 was higher than that in group 2. Episodes of nausea and vomiting and the need for metoclopramide in group 1 were lower than in group 2, though the total fentanyl dose in group 1 was higher than in group 2. There were no differences in the need for analgesics between the groups. The use of 2.5 mg droperidol safely decreased PONV after gynecological laparoscopy.     

A comparison of three antiemetic combinations for the prevention of postoperative nausea and vomiting

In this study we compared the efficacy and safety of three antiemetic combinations in the prevention of postoperative nausea and vomiting (PONV). Ninety ASA status I-II women, aged 18-65 yr, undergoing general anesthesia for major gynecological surgery, were included in a prospective, randomized, double-blinded study. A standardized anesthetic technique and postoperative analgesia (intrathecal morphine plus IV patient-controlled analgesia (PCA) with morphine) were used in all patients. Patients were randomly assigned to receive ondansetron 4 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 1, n = 30), dexamethasone 8 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 2, n = 30), or ondansetron 4 mg plus dexamethasone 8 mg after the induction of anesthesia and placebo 12 h later (Group 3, n = 30). A complete response, defined as no PONV in 48 h, occurred in 80% of patients in Group 1, 70% in Group 3, and 40% in Group 2 (P = 0.004 versus Groups 1 and 3). The incidences of side effects and other variables that could modify the incidence of PONV were similar among groups. In conclusion, ondansetron, in combination with droperidol or dexamethasone, is more effective than dexamethasone in combination with droperidol in women undergoing general anesthesia for major gynecological surgery with intrathecal morphine plus IV PCA with morphine for postoperative analgesia. IMPLICATIONS: The combination of ondansetron plus dexamethasone or droperidol was significantly better than the combination of dexamethasone plus droperidol in the prophylaxis of postoperative nausea and vomiting in women undergoing general anesthesia for major gynecological surgery, with intrathecal and IV morphine (patient-controlled analgesia) for management of postoperative pain.     

Minidose lidocaine-fentanyl spinal anesthesia in ambulatory surgery: prophylactic nalbuphine versus nalbuphine plus droperidol

Minidose lidocaine-fentanyl spinal anesthesia (SAB(MLF)) is a safe, effective, and efficient anesthetic for ambulatory surgery. Unfortunately, it has a frequent incidence of pruritus and a substantial incidence of nausea and vomiting. Nalbuphine is effective in treating or preventing pruritus after intrathecal or epidural morphine but may or may not have a beneficial effect on nausea and vomiting. Droperidol has demonstrated antiemetic efficacy with neuraxial opiates. In this study, we examined the prophylactic use of nalbuphine alone compared with nalbuphine with droperidol after SAB(MLF). One-hundred-twenty-four patients having outpatient knee arthroscopy under SAB(MLF) with 20 mg of lidocaine 0.5% and 20 micro g of fentanyl were randomized to receive IV at the end of surgery either 4 mg of nalbuphine (Group N) or droperidol 0.625 mg plus nalbuphine 4 mg (Group ND). The incidences of early (before discharge) and late onset nausea were, respectively, 18% versus 5% and 32% versus 13%. The postoperative incidences of pruritus were 61% versus 40%, whereas 19% of patients in Group N compared with 2% of patients in Group ND requested treatment for this. Group ND had lower pain scores and had a longer delay until first use of analgesic. There were no differences in average times to discharge. The only side effect of the medications was an increased drowsiness in Group ND. In conclusion, as prophylactic medication for use in conjunction with SAB(MLF), the addition of droperidol 0.625 mg to nalbuphine 4 mg was superior to nalbuphine alone. The combination provided for reduced postoperative nausea, pruritus, and pain-benefits that persisted after discharge home. The combination also avoided isolated cases of extreme delay in discharge. IMPLICATIONS: Droperidol in combination with nalbuphine enhances analgesia and is more effective than nalbuphine alone in preventing pruritus, nausea, and vomiting after minidose lidocaine-fentanyl spinal anesthesia.     

Dexamethasone is as effective as ondansetron for the prevention of postoperative nausea and vomiting following breast surgery

INTRODUCTION: Postoperative nausea and vomiting remain a common problem following breast surgery. This study assesses whether dexamethasone is as effective as ondansetron in the control of postoperative nausea and vomiting (PONV). METHODS: Eighty ASA I-III patients undergoing breast surgery for carcinoma of the breast were included in the study. Following premedication with diazepam 5-10 mg, patients were induced with fentanyl 50 micro g and propofol 2-2.5 mg kg-1. A larynx mask was inserted and anesthesia maintained with sevoflurane in oxygen and nitrous oxide. Patients were then randomly divided into two groups: Group D (dexamethasone) was given 4 mg dexamethasone i.v. after induction and Group O (ondansetron) was given 4 mg ondansetron at the same time point. Postoperatively, nausea, vomiting and pain were recorded at 1-h intervals during 4 h, and thereafter every 4 h during 24 h. RESULTS: The incidence of PONV during 24 h was 37% and 33% in Group D and Group O, respectively (NS). No differences were found between the groups in the incidence of postoperative nausea, vomiting or pain at the different time intervals. No differences were found in the incidence of PONV in smokers vs. non-smokers. No side-effects of these drugs were observed. CONCLUSIONS: Ondansetron 4 mg or dexamethasone 4 mg are equally effective in the prevention of postoperative nausea and vomiting following breast surgery. Other factors being similar, the difference in cost between these drugs would favor the use of dexamethasone instead of ondansetron when monotherapy against PONV is used.     

全凭静脉麻醉妇科腹腔镜术后恶心呕吐的临床观察

目的观察妇科腹腔镜手术患者丙泊酚全凭静脉麻醉（TIVA）术后恶心呕吐的发生率。方法138例妇科腹腔镜手术随机分为七氟烷（Sev）组、七氟烷-恩丹西酮（Sev-O）组及丙泊酚TIVA组,每组46例。Sev组和Sev-O组：术中以持续吸入50%N2O和七氟烷维持麻醉,Sev-O组手术结束前30min静脉给予恩丹西酮8mg;TIVA组：术中以丙泊酚、瑞芬太尼靶控输注维持麻醉。记录术后24h内发生恶心呕吐及额外需要止吐药情况。结果TIVA组术后0～2h恶心呕吐发生率[22%（10/46）]低于Sev组[54%（25/46）,χ^2=10.376,P=0.001]和Sev-O组[50%（23/46）,χ^2=7.986,P=0.005]。Sev-O组术后2～6h恶心呕吐发生率低于Sev组[22%（10/46）vs46%（21/46）,χ^2=5.887,P=0.015]。TIVA组术后0～24h恶心呕吐发生率低于Sev组[57%（26/46）vs80%（37/46）,χ^2=6.093,P=0.014）。3组分别有13例（28%）、6例（13%）、6例（13%）术后需要额外止吐药。结论与七氟烷吸入麻醉比较,丙泊酚全凭静脉麻醉可降低妇科腹腔镜手术后恶心呕吐的发生率。     

Prophylactic antiemetics for laparoscopic cholecystectomy: droperidol, metoclopramide, and droperidol plus metoclopramide

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most significant problems in laparoscopic surgery. The antiemetic effects of metoclopramide and droperidol used alone or in combination for prevention of PONV after laparoscopic cholecystectomy (LC) were assessed in this prospective, double blind, placebo controlled randomized study. PATIENTS AND METHODS: A series of 140 patients, ASA physical status I or II, were included in the study. Patients were randomized to one of the following groups: 1, placebo; 2, metoclopramide 10 mg after the induction of anesthesia and placebo at 12 h postoperatively; 3, droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg at 12 h postoperatively; and 4, droperidol 1.25 mg plus metoclopramide 10 mg after the induction of anesthesia and droperidol 1.25 mg at 12 h postoperatively. Patients were observed for 24 hours for PONV, pain, need for rescue analgesics, and adverse events. RESULTS: Data were analyzed using the Student's t-test and chi-square test, with P < 0.05 considered statistically significant. The mean incidence of PONV was 54% with placebo, 42% with metoclopramide, 14% with two doses of droperidol alone, and 11% with a combination of metoclopramide plus droperidol. The patients receiving a combination of metoclopramide and droperidol had a significantly lower rate of PONV than those administered metoclopramide alone (P < 0.05) or placebo (P < 0.001). Those receiving two-dose droperidol alone also had a significantly lower incidence of PONV compared with metoclopramide (P < 0.05) and placebo (P < 0.001). There was no statistically significant difference between the metoclopramide and placebo groups. Sedation was significantly greater in patients administered droperidol 12 h postoperatively. CONCLUSION: The combination of metoclopramide and droperidol, and two-dose droperidol alone, were found to significantly decrease the incidence of PONV after LC, whereas metoclopramide alone proved inefficient.     

Comparison of analgesics used during balanced anesthesia on the incidence of PONV

BACKGROUND: When we make reference to the quality of anesthesia, we consider three points, early emergence, postoperative pain relief, and postoperative nausea and vomiting (PONV). Among these, PONV is comparatively neglected. Many analgesics used during anesthesia may cause PONV. METHODS: The incidence of PONV was assessed in 100 surgical patients who had received balanced anesthesia. Anesthesia was induced with propofol, ketamine, midazolam and buprenorphine (Group P), or butorphanol (Group T), and vecuronium was given to facilitate tracheal intubation. The patients received balanced anesthesia with infusion of propofol, ketamine, vecuronium, and either buprenorphine (Group P) or butorphanol (Group T), with nitrous oxide. PONV was recorded for 24 hours postoperatively. RESULTS: Incidences of nausea were 27.1% in Group P and 15.8% in Group T (NS). Incidences of vomiting were 12.5% in Group P and 5.3% in Group T (NS). However, a high incidence of PONV was found in female (42.2%) vs. male (6.2%) (P < 0.01) and in over 25 BMI group (34.5%) vs. under 25 BMI group (15.5%) (P < 0.05). CONCLUSIONS: The type of analgesics used during balanced anesthesia is not important for development of PONV, but patient's factors, such as gender and BMI, are more closely associated with PONV.     

Postoperative nausea and vomiting in children and adolescents undergoing radiofrequency catheter ablation: a randomized comparison of propofol- and isoflurane-based anesthetics

In children, radiofrequency catheter ablation (RFCA) is typically performed under general anesthesia. With the use of volatile anesthetics, postoperative nausea and vomiting (PONV) are common, with an incidence of emesis as frequent as 60%. We tested the hypothesis that a propofol (PRO)-based anesthetic would have a less frequent incidence of PONV than an isoflurane (ISO)-based anesthetic. Patients were randomly assigned to receive either an ISO- or PRO-based anesthetic. Prophylactic ondansetron was given to all patients and droperidol was used as a rescue antiemetic postoperatively while PONV was monitored postoperatively for 18 h. The incidence of nausea, vomiting, use of rescue antiemetic drugs, and sedation scores were recorded. The cost for the anesthetic was also calculated. Fifty-six subjects were included in this study. The cumulative incidence of PONV was significantly more frequent in group ISO (63% nausea/55% emesis) compared with group PRO (21% nausea/6% emesis). After the administration of droperidol, further vomiting occurred in 70% of the patients in group ISO versus 0% of the patients in group PRO. We conclude that RFCA using ISO has a high PONV risk and the prophylactic use of ondansetron as well as antiemetic therapy with droperidol are ineffective. In contrast, a PRO-based anesthetic is highly effective in preventing PONV in children undergoing RFCA. IMPLICATIONS: In children undergoing radiofrequency catheter ablation and receiving prophylactic ondansetron, a frequent incidence (60%) of postoperative vomiting was observed under an isoflurane-based anesthetic, whereas the incidence was significantly reduced to a very low level (5%) under a propofol-based anesthetic.     

Superior prolonged antiemetic prophylaxis with a four-drug multimodal regimen - comparison with propofol or placebo

BACKGROUND: The purpose of this study was to compare the effects of a low-dose propofol infusion with a four-drug multimodal regimen for prophylaxis of postoperative nausea and vomiting (PONV). METHODS: : PONV was studied in two patient groups with a known high incidence. Through a stratified randomization, 60 patients undergoing breast surgery and 120 patients undergoing abdominal surgery were randomized to three groups of equal size: the propofol group (P), the multidrug group (M) and the control group (C). All patients received general anesthesia, induction with propofol and maintenance with sevoflurane. After induction, patients in the P group received a continuous infusion of propofol 1 mg/kg/h during the operation and the first 4 postoperative h. Patients in the M group received dexamethasone 4 mg and three antiemetics, ondansetron 4 mg, droperidol 1.25 mg and metoclopramide 10 mg i.v. In the control group no prophylaxis was given. Nausea and pain were evaluated by incidence and a visual analog scale (0-10 cm). All emetic episodes were noted by the staff during the first 4 h and by the patients during the next 20 h. RESULTS: The overall incidence of PONV during the first 24 h postoperatively was significantly lower in the M group (24%) than in the P group (49%) (P<0.01) or the C group (70%) (P<0.001). The incidence of PONV increased significantly both in patients undergoing breast surgery and abdominal surgery after termination of propofol. The number of patients who vomited was significantly lower in the M group, both in breast surgery patients (5%) and abdominal surgery patients (3%) compared to patients in the propofol groups (breast 16% NS; abdominal 29%, P<0.05) and in the control groups (breast 37%, P<0.01; abdominal 29%, P<0.01). CONCLUSION: The incidence of PONV is very high in patients undergoing breast and abdominal surgery. In the present study antiemetic prophylaxis with a combination of droperidol, ondansetron, metoclopramide and dexamethasone was more effective in preventing PONV, especially vomiting, than a postoperative low-dose infusion of propofol, which had a short lasting effect.     

Use of propofol for office-based anesthesia: effect of nitrous oxide on recovery profile.

STUDY OBJECTIVE: To evaluate the effect of nitrous oxide (N2O) on the recovery profile and the incidence of postoperative nausea and vomiting (PONV) after office-based surgery performed under propofol anesthesia. DESIGN: Prospective, randomized, single-blind study. SETTING: Office-based surgical center. PATIENTS: 69 ASA physical status I, II, and III healthy, consenting outpatients undergoing superficial surgical procedures lasting 15 to 45 minutes. INTERVENTIONS: After a standard propofol induction (1.5 mg.kg-1 i.v.), anesthesia was initially maintained with propofol, 100 micrograms.kg-1.min-1 i.v., in combination with either air or N2O 65% in oxygen. The propofol infusion rate was subsequently varied to maintain an adequate depth of anesthesia. All patients received local anesthetic infiltration prior to the surgical incision, as well as during the operation. No prophylactic antiemetics were administered. MEASUREMENTS AND MAIN RESULTS: Recovery times and the incidences of PONV were recorded during the first 24 hours after surgery. Early and late recovery variables were similar in the two treatment groups; however, 65% N2O produced a 19% decrease in the propofol maintenance dosage requirement. One patient (3%) experienced nausea prior to discharge in the propofol-N2O group, and two patients (6%) experienced nausea at home in the propofol alone group. None of the patients vomited or received antiemetic medication during the 24 hours postdischarge period. Ninety-seven percent of patients receiving propofol alone and all of the patients in the propofol-N2O group were "very satisfied" with their anesthetic experience. CONCLUSIONS: In outpatients undergoing office-based surgical procedures with propofol anesthesia, administration of 65% N2O decreased the anesthetic requirement without increasing PONV. Therefore, use of a propofol-N2O combination may be a cost-effective alternative to propofol alone for office-based anesthesia.     

Comparison of ondansetron and droperidol in the prevention of postoperative nausea and vomiting after laparoscopic surgery in women

Background : Women undergoing laparoscopic surgery are susceptible to postoperative nausea and vomiting (PONV). Ondansetron and droperidol are useful antiemetics. This study was designed to ascertain primarily the relative difference in efficacy of ondansetron and droperidol and secondarily between these drugs and placebo in the prevention of PONV after laparoscopic surgery. Methods : The prophylactic antiemetic efficacy of ondansetron and droperidol was compared in a prospective, randomised, double–blind, placebo–controlled trial of 439 female inpatients scheduled for laparoscopic surgery. During induction of standardised general anaesthesia the patients received intravenously either ondansetron 8 mg (n=195), droperidol 1.25 mg (n=193) or placebo (n=51). The occurrence of nausea, vomiting, sideeffects and the need for rescue antiemetic medication were recorded for 24 h postoperatively. Results : The proportion of patients with nausea was 48%, 50% and 67% in the ondansetron, droperidol and placebo groups, respectively; with a significant difference when both ondansetron (P=0.02) and droperidol (P=0.04) were compared with placebo. Vomiting occurred in 18%, 26% and 37% of the patients in the three groups, respectively (P=0.05 between ondansetron and droperidol, P=0.004 between ondansetron and placebo, P=0.16 between droperidol and placebo). The proportion of patients given rescue medication was 34%, 28% and 49%, respectively (P=0.23 for ondansetron and droperidol, P=0.07 for ondansetron and placebo, P=0.007 for droperidol and placebo). During early recovery the patients treated with ondansetron were significantly more alert than after droperidol. Serious side–effects were not observed. Headache was significantly more common after ondansetron than after droperidol treatment. Conclusions : The efficacy of prophylactic ondansetron and droperidol in reducing postoperative nausea associated with laparoscopic surgery in female inpatients was similar, but ondansetron appeared to be slightly more efficient than droperidol in preventing vomiting. Ondansetron and droperidol were both significantly better than placebo in the prophylaxis of PONV.     

全麻诱导中地塞米松联合氟哌啶预防腹腔镜胆囊切除术后的恶心呕吐

目的：探讨全麻诱导中地塞米松联合氟哌啶预防腹腔镜胆囊切除术后恶心、呕吐的效果。方法：随机将240例ASAⅠ～Ⅱ腹腔镜胆囊切除术患者分为3组（各80例）。Ⅰ组（对照组）全麻诱导中不用地塞米松、氟哌啶;Ⅱ组全麻诱导中用地塞米松10mg;Ⅲ组全麻诱导中用地塞米松10mg和氟哌啶40μg/kg,观察术后48h患者的恶心、呕吐情况。结果：Ⅰ组患者恶心、呕吐的发生率为72.5%;Ⅱ、Ⅲ组恶心、呕吐的发生率分别为32.5%和7.5%,组间比较差异有统计学意义（P〈0.05）。结论：全麻诱导中用地塞米松联合小剂量氟哌啶能预防腹腔镜胆囊切除术后的恶心、呕吐。     

Pitfalls of anesthesiologic management in paediatric strabismus surgery

Strabismus surgery is one of the most common paediatric operation procedures. As associated with congenital syndrome, congenital heart disease and neuromuscular disorder, the anesthesiologic management has to be planned carefully. Considering high incidences of oculocardiac reflex (OCR) and postoperative nausea and vomiting (PONV) anesthesia can be performed to decrease both. Induction of anesthesia with ketamine or midzolam reduces risk of oculocardiac reflex, whereas propofol or remifentanil lead to higher incidences of OCR. A combination anti-emetic therapy from different drug classes is recommend to patients at high risk for nausea and vomiting like patients undergoing strabismus surgery. A combination therapy of ondansetron and dexamethasone lead to a risk reduction of PONV to at least 10 %. Further, the incidence of OCR and PONV is significantly reduced in children receiving peribulbar block on top of general anaesthesia.     

Effects of dexmedetomidine in morbidly obese patients undergoing laparoscopic gastric bypass

BACKGROUND: Obese patients may be sensitive to the respiratory depressant effect of opioid analgesics. Alternative methods for analgesia may be beneficial for management of bariatric surgery. We evaluated the effect of dexmedetomidine on anesthetic requirements during surgery, hemodynamic, recovery profile and morphine use in the postoperative period. METHODS: Eighty adult patients scheduled for elective laparoscopic Roux-en-Y gastric bypass surgery were randomly assigned to one of two study groups; Group D (40 patients) received dexmedetomidine (0.8-microg/kg bolus, 0,4 microg kg(-1) h) and Group P (40 patients) received normal saline (placebo) in the same volume and rate. Intraoperative and postoperative mean blood pressure and heart rate were recorded. The total amount of intraoperative fentanyl and propofol required to maintain anesthesia were measured. Recovery profile, pain score and total amount of morphine used via patient controlled analgesia (PCA) were assessed. RESULTS: During surgery, dexmedetomidine decreased the total amount of intraoperative fentanyl and propofol required for maintenance of anesthesia compared to placebo. Patients who received dexmedetomidine showed significant decrease of intraoperative and postoperative mean blood pressure, heart rate. In the postoperative period, dexmedetomidine decreased pain scores and PCA morphine use significantly and showed better recovery profile as compared to the placebo Group. There was no difference in the incidence of postoperative nausea and vomiting (PONV) between both groups. CONCLUSION: The intraoperative infusion of dexmedetomidine decreased the total amount of propofol and fentanyl required to maintain anesthesia, offered better control of intraoperative and postoperative hemodynamics, decreased postoperative pain level, decreased the total amount of morphine used and showed better recovery profile compared with placebo.     

地塞米松联合恩丹西酮对手术后病人自控镇痛相关恶心呕吐的影响

目的　观察地塞米松联合恩丹西酮对手术后病人自控镇痛 (PCA)所致恶心呕吐的防治效果。方法　随机将 2 0 0例在连续硬膜外麻醉下行下肢手术的患者分为四组 :对照 (C)组于手术切皮前 (T1)和手术结束时 (T2 )分别静脉注射生理盐水 2ml;地塞米松 (D)组于T1、T2 时分别注射地塞米松 10mg和生理盐水 2ml;恩丹西酮 (O)组于T1、T2 时分别注射生理盐水 2ml和恩丹西酮4mg ;地塞米松 +恩丹西酮 (D +O)组于T1、T2 时分别注射地塞米松 10mg和恩丹西酮 4mg。术毕均行病人自控静脉芬太尼镇痛 (PCIFA)。观察术后 2 4h内病人镇痛效果、镇静评分和恶心呕吐发生情况。结果　 5例患者因故退出此观察。组间镇痛效果、镇静评分无明显差异。C组恶心呕吐发生率为 5 2 1% ,明显高于D组 (33 3% )和O组 (32 7% ) ,P <0 0 5 ;D +O组恶心呕吐发生率为16 0 % ,与C组比较 ,P <0 0 1,与D组和O组比较 ,P <0 0 5 ;各处理组恶心程度均小于对照组 ,P <0 0 5 ;D +O组呕吐程度低于C组 ,P <0 0 5。结论　地塞米松与恩丹西酮单独应用均能有效地减少手术后PCIFA相关的恶心呕吐 ,减轻恶心程度 ;两药联合应用进一步降低患者的恶心呕吐发生率和呕吐的程度     

Postoperative Übelkeit und postoperatives Erbrechen nach Strabismuschirurgie bei Kindern Inhalationsanästhesie mit Sevofluran/Lachgas im Vergleich zu intravenöser Anästhesie mit Propofol/Remifentanil

BACKGROUND: Postoperative nausea and vomiting (PONV) is still one of the major problems in strabismus surgery, especially in children. In recent years many studies have been published, suggesting that choosing propofol as the anaesthetic agent may help to reduce the high incidence of PONV in children undergoing strabismus surgery. Experience with remifentanil in children is still very limited and little is known, whether propofol in combination with this new short acting opioid is also superior regarding PONV in squint surgery compared to sevoflurane/N2O. Additionally, little is known, whether the type of operation or the muscle which is operated on has any influence with respect to PONV. METHODS: Following sample size estimation, ethics committee approval and parents informed consent in a prospective, randomised, observer-blind study 105 ASA I and II children aged 3-8 years scheduled for elective strabismus surgery were assigned into one of the following groups: Group TIVA (propofol/remifentanil, n = 53): anaesthesia was induced by remifentanil 0.5 microgram kg-1 min-1 over 2 min (loading phase), followed by 3 mg kg-1 propofol along with 30% O2 in air. After endotracheal intubation anaesthesia was maintained initially with remifentanil 0.25 microgram kg-1 min-1 and propofol 10 mg kg-1 h-1 by constant infusion. In the course of the operation the infusions of the anaesthetics were adjusted to the decreasing need for anaesthesia. Group VOLATIL (sevoflurane/N2O, n = 52): anaesthesia was induced by inhalation of sevoflurane along with 50% O2 in N2O. After endotracheal intubation anaesthesia was maintained with sevoflurane 1.0-1.5 MAC along with 30% O2 in N2O and in the course of the operation the administration of the inhaled anaesthetics was adjusted correspondingly. Preoperatively collected data included gender, age, weight and history of PONV. Intraoperatively collected data consisted of data belonging to routine monitoring (heart rate, blood pressure, peripheral oxygen saturation and temperature) as well as the duration of the operation and anaesthesia and specific data regarding the operation (including the number and type of muscles as well as the kind of operation). Data collected within the first 24 hours postoperatively in the recovery room and on the ward by blinded observers included any PONV events as well as the antiemetics and analgesics applied. RESULTS: Vomiting was observed less frequently in the TIVA-group than in the VOLATIL-group (21 of 53 vs. 32 of 52, p = 0.03) within the first 24 hours postoperatively. Posterior fixation suture ("faden-operation") compared to other operations was followed rather frequently by nausea and vomiting (30 of 44 and 33 of 44, respectively), whereas recessions were rarely associated with nausea and vomiting (12 of 35 and 9 of 35, respectively). CONCLUSIONS: TIVA with propofol/remifentanil proved to be a suitable form of anaesthesia for children in this setting. Propofol showed advantages over sevoflurane/N2O with respect to PONV after squint surgery in children also when applied in the combination with remifentanil. TIVA with propofol/remifentanil may therefore be one way to reduce the high incidence of PONV in this setting, bearing in mind, that PONV is not only influenced by the regimen of the general anaesthesia but rather by the combination of many other factors, in particular the type of operation.     

Tropisetron or droperidol in the prevention of postoperative nausea and vomiting

BACKGROUND: Women undergoing laparoscopic cholecystectomy are susceptible to postoperative nausea and vomiting (PONV). This study was undertaken to evaluate the efficacy of tropisetron or droperidol for preventing PONV after laparoscopic cholecystectomy. METHODS: In a prospective, randomised, double-blind trial, 120 female patients received either tropisetron 5 mg or droperidol 1.25 mg intravenously at the beginning of surgery. A standard general anaesthetic technique and postoperative analgesia were used. Nausea, emetic episodes and the need for rescue medication were recorded for 24 h postoperatively. RESULTS: Nausea was experienced by 55% of the patients in the tropisetron group and by 62% in the droperidol group (ns). The incidence of emetic episodes was 20% and 52% (P=0.001) in the two groups, respectively. Rescue antiemetic medication was needed in 42% and 50% (ns) of the patients, respectively. Patients in the droperidol group were more drowsy in comparison with patients in the tropisetron group, mean sedation score being 6.7 vs 5.7, respectively (P=0.023). No difference in other side-effects was observed. CONCLUSION: Tropisetron, when compared with droperidol, had no better efficacy on the prevention of postoperative nausea but resulted in a significantly lower incidence of vomiting after laparoscopic cholecystectomy.