Náuseas y vómitos postoperatorios en cirugía mayor traumatológica

ObjectivePostoperative nausea and vomiting (PONV) are common complications during the postoperative period, causing important discomfort to the patient and also can increase morbidity. The objective of our article is to predict the prevalence of postoperative nausea and vomiting, the factors that have an influence on its appearance, and to obtain a predictive model based on prognostic factors.MethodA prospective observational study was conducted on 201 patients who underwent major Orthopaedic and Trauma surgery during the year 2008.A questionnaire was designed to collect the required data as established previously by a standardized protocol, in which was requested, patient demographics, intraoperative and postoperative data, as well as details on any antiemetic treatment that was needed in the recovery ward.ResultsA total of 39.8% patients suffered PONV. Of the females, 46.6% suffered PONV, and 75% had previous history of PONV. A higher prevalence was observed in patients who were subjected to more aggressive surgery.There was a concentration of cases between 5 pm and 7 pm, and also at 8 am.The predictive model was obtained from this formula:Y =  ?1,334 + 0,753*S + 1,5602*NVP + 0,769*IQaConclusionsThe prevalence of PONV in this study has been high, as more a third of the studied population suffered from it.The predictive model should help determine the specific risk of each patient of suffering from PONV, thus being able to define a therapeutic strategy during the preoperative period as well as during the postoperative period. Being female, a previous history of PONV, and undergoing an aggressive surgical procedure are risk factors. Patient mobilization and family visits increase the number of PONV episodes.     

Predictors for Early Physical Recovery for General and Orthopedic Patients after Major Surgery: Structural Equational Model Analyses

BackgroundAttention to factors that may affect patients’ ability to experience enhanced recovery after surgery is essential in planning for postoperative care.AimsTo create models of predefined pre,- peri-, and postoperative variables in order to analyze their impact on patients’ physical recovery on postoperative days 1 and 2 after major orthopedic and general surgery.DesignAn exploratory design with repeated measures was used, including 479 patients who had undergone orthopedic (289) or general surgery (190) at three hospitals.MethodsPain, nausea, and level of physical ability were measured preoperatively and on postoperative days 1 and 2 by using the Numerical Rating Scale and items from the Postoperative Recovery Profile. Structural equation modeling was used to explore the impact of the predefined variables on patients’ physical recovery.ResultsThe orthopedic group contained significantly more women and significantly more patients with pain and opioid use. Although the models showed good fit, “traditional” preoperative (pain, nausea, physical abilities, chronic pain, opioid use) and perioperative variables (anesthesia, length of surgery) constituted few (orthopedic) or no (general surgery) predictive properties for physical recovery. Postoperative average pain intensity, average nausea intensity, and physical ability explained physical recovery on day 1, and physical recovery on day 1 predicted physical recovery on day 2.Conclusions“Traditional” predictors had little effect on patients’ postoperative physical recovery, while associations with common postoperative symptoms were shown. Further research is needed to explore additional variables affecting early physical recovery and to understand how soon patients are physically ready to return home.     

Predictors of Postoperative Nausea and Vomiting After Same-day Surgery: A Retrospective Study

PurposePostoperative nausea and vomiting (PONV) are main issues after same-day surgery. This study aimed to retrospectively evaluate the electronic medical records of patients who underwent same-day operations under general anesthesia to identify the potential risk factors for PONV.MethodsRecords of 7759 adult patients who received general anesthesia with remifentanil were reviewed. The patients were assessed for the incidence and severity of PONV. Multiple logistic regression was used to identify risk factors for PONV. A nomogram was established to predict PONV after same-day operations.FindingsOf 7759 patients, 2317 (29.9%) experienced PONV. In multiple logistic regression analysis, female sex, nonsmoker status, history of motion sickness or nausea, high body mass index (BMI), long surgical duration, laparoscopic procedure, and preoperative analgesic intake within 30 days were independent risk factors for PONV. No correlation was found between the severity of PONV and remifentanil exposure (odds ratio = 1.018; 95% CI, 0.861–1.204; P = 0.834) or remifentanil dose (odds ratio = 1.294; 95% CI, 0.760–2.205; P = 0.343). For the nomogram, which involved sex, laparoscopic procedure, BMI, history of nausea or motion sickness, and analgesic intake within 30 days, the receiver operating characteristic analysis revealed that the AUC values in the training and validation cohorts were 0.81 and 0.83, respectively.ImplicationsPredictors for PONV in same-day surgery include female sex, nonsmoker, history of motion sickness or nausea, high BMI, surgical duration >1 hour, laparoscopic procedure, and preoperative analgesic intake within 30 days. A new predictive model is feasible for predicting the incidence of PONV based on the preoperative and intraoperative predictors.     

The Effect of Intraoperative Body Temperature on Postoperative Nausea and Vomiting in Pediatric Patients

PurposePediatric patients are at greater risk for both perioperative hypothermia and postoperative nausea and vomiting (PONV). The primary aim of this study was to investigate whether there is a relationship between intraoperative body temperature and PONV in children undergoing anesthesia. The secondary aim was to investigate the relationship between PONV and intraoperative fentanyl use, age and duration of operation.DesignA prospective cohort studyMethodsThe study included 80 children who were undergoing lower abdominal surgery. Body temperature was monitored after routine preoperative preparation and standard induction. Analgesic and antiemetic requirements and the presence of nausea and vomiting were assessed postoperatively on the 30th minute and the 6th, 12th and 24th hour.FindingsThe children with or without PONV were compared. At the postoperative 6th hour, the incidence of nausea was statistically significant in the children with a mean body temperature below 36°C (P = 0.044; P < 0.05). The mean duration of the surgery was statistically significant longer in the children with PONV (P = 0.001; P = 0.004; P <0.05). Mean body temperature was not statistically significant when comparing children with and without vomiting(P > 0.05).ConclusionWhile a body temperature below 36°C increases the incidence of postoperative nausea, it does not cause an increase in the incidence of vomiting. A long operation time in pediatric patients causes an increase in the incidence of PONV. Although not statistically significant, PONV is encountered more than twice as much in patients receiving intraoperative fentanyl administration.     

E MERGENCY P REPAREDNESS FOR C HILDREN WITH S PECIAL H EALTH C ARE N EEDS

Objective. To evaluate the change in nausea scales andincidence of vomiting with the use of ondansetron in the treatment of nausea andvomiting in the prehospital setting. Methods. Data were prospectively collected on all emergency medical service patients who received ondansetron for undifferentiated nausea andvomiting during a 6-month study period. Added outcome measures for this study were verbal quantitative (scale of 1–10) andqualitative “nausea scales,” incidence of vomiting prior to andafter administration of ondansetron, andadverse events. Patients who had this additional data collected andones who did not were compared. Changes in the “nausea scales” andincidence of vomiting before andafter administration andcorrelation among these measures were also compared. There was no control or placebo group. Results. Ondansetron was administered to 952 patients of 20,054 patients transported during this time period (5%); of these 472 had at least some of the outcome measures documented. There were minimal differences in the two cohorts; 198 patients had paired before andafter quantitative “nausea scales” documented: 7.6 ± 2.4 and4.6 ± 3.1, respectively (Δ = 2.9, 95% CI: 2.5–3.4); 447 patients had a qualitative change in nausea level documented: 0.4% “a lot worse,” 1.3% “a little worse,” 34% “unchanged,” 40% “a little better,” and25% “a lot better”; 187 patients had all three measures documented with a Pearson correlation coefficient of 0.63 between the change in the quantitative scale andthe qualitative scale (95% CI: 0.14–0.20, R 0.39). In 462 patients, vomiting decreased from 60% to 30% (Wilcoxon signed ranks test p < 0.001). The Pearson correlation coefficients for the change in vomiting incidence with the qualitative andquantitative “nausea scales” were poor: 0.012 (95% CI: ?0.015 to 0.039, R 0.00014) and0.051 (95% CI: ?0.032 to 0.118, R 0.00026), respectively. There were no reported adverse events. Conclusions. Ondansetron appears to be moderately effective in decreasing nausea andvomiting in undifferentiated prehospital patients. Additional controlled trials may be needed to compare it with other antiemetics.     

Incidence and risk factors of postoperative nausea and vomiting in lung cancer patients following lobectomy and application of analgesic pumps

ObjectiveTo investigate the occurrence rate and risk factors of postoperative nausea and vomiting (PONV) in lung cancer patients following lobectomy and application of analgesic pumps.MethodsThis retrospective study reviewed clinical data from patients that had undergone lobectomy for lung cancer under general anaesthesia. The risk factors of PONV were analysed using binary logistic regression models.ResultsA total of 203 patients (97 females) were enrolled. The rate of PONV was 29.6% (60 of 203 patients) for all patients, 42.3% (41 of 97 patients) for female patients and 17.9% (19 of 106 patients) for male patients. Female patients undergoing thoracotomy (odds ratio [OR] 7.770, 95% confidence interval [CI] 1.747, 34.568) or having surgery durations ≥120 min (OR 4.493, 95% CI 1.502, 12.851) were significantly more susceptible to PONV. The risk of PONV in female patients that received postoperative dolasetron (100 mg, once a day) was significantly lower (OR 0.075, 95% CI 0.007, 0.834). For male patients, the risk of PONV was significantly lower in those with a body mass index ≥24 kg/m² (OR 0.166; 95% CI 0.035, 0.782).ConclusionFemale and male patients have different risk factors for PONV following lobectomy for lung cancer and application of analgesic pumps.     

Safety and Efficacy of Dexmedetomidine in Breast Surgeries: A Systematic Review and Meta-Analysis

PurposePain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries.DesignSystematic review and meta-analysis.MethodsThe present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019.FindingsTwelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery.ConclusionsThe results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV.     

Intravenous acetaminophen reduces postoperative nausea and vomiting: A systematic review and meta-analysis

Opioids are a key risk factor for postoperative nausea and vomiting (PONV). As intravenous (i.v.) acetaminophen reduces postoperative pain and opioid requirements, one would expect i.v. acetaminophen to be associated with a lower incidence of opioid-induced side effects, including PONV. We conducted a systematic search using Medline and Cochrane databases supplemented with hand search of abstract proceedings to identify randomized-controlled trials of i.v. acetaminophen. Inclusion criteria were (a) randomized for i.v. acetaminophen vs a placebo control, (b) general anesthesia, and (c) reported or obtainable PONV outcomes. Primary outcome was postoperative nausea and secondary outcome was postoperative vomiting. We included 30 studies with 2364 patients (1223 in the acetaminophen group, 1141 in the placebo group). The relative risk (95% confidence interval) was 0.73 (0.60–0.88) for nausea and 0.63 (0.45–0.88) for vomiting. Data showed significant heterogeneity for both nausea (P = 0.02, I² = 38%) and vomiting (P = 0.006, I² = 47%), but were homogeneous when studies were grouped according to timing of first administration: i.v. acetaminophen reduced nausea when given prophylactically either before surgery, 0.54 (0.40–0.74), or before arrival in the postanesthesia care unit, 0.67 (0.55–0.83); but not when given after the onset of pain, 1.12 (0.85–1.48). When i.v. acetaminophen was given prophylactically, the reduction of nausea correlated with the reduction of pain (odds ratio 0.66, 0.47–0.93), but not with reduction in postoperative opioids (odds ratio 0.89, 0.64–1.22). Prophylactically administered i.v. acetaminophen reduced PONV, mainly mediated through superior pain control.     

Influence of postoperative pain therapy on nausea and vomiting

PROBLEM: Postoperative nausea and vomiting remains an important problem. Many risk factors have been identified; however, the importance of postoperative analgesic technique and patient expectation remain poorly defined. METHODS: We prospectively collected data on postoperative nausea and vomiting (PONV) in four groups of randomly selected patients (n=50 per group) who received either simple analgesics, nurse-administered intravenous morphine (NAA), patient-controlled analgesia (PCA) with morphine or epidural analgesia with bupivacaine and fentanyl. Patients were questioned regarding any past history of PONV or motion sickness, their preoperative expectation of suffering PONV and satisfaction with their antiemetic therapy. RESULTS: The incidence of nausea was higher in both morphine groups P<0.05), women (P<0.05), those less than the median age of their group (P<0.05) and those with a past history of PONV (P<0.05) or motion sickness (P<0.05). Most patients did not expect to experience PONV (19.3%). The incidence of nausea was higher in those expecting to experience PONV than in those not expecting to suffer PONV (P<0.01). Of those who received postoperative antiemetic treatment, 23.6% were dissatisfied or very dissatisfied with their therapy. Few patients received a prophylactic antiemetic drug (15%). CONCLUSIONS: Study results show that patient expectation is a potent predictor of postoperative nausea, a risk factor hitherto ignored in the anaesthetic literature, and that, in the provision of analgesia following major surgery, epidural analgesia is associated with less PONV than intravenous morphine.     

Predictive models for post-operative nausea and vomiting in patients using patient-controlled analgesia

This study identified predictive factors for post-operative nausea and vomiting (PONV) in patients using patient-controlled analgesia (PCA) and developed five predictive model pathways to calculate the probability of PONV using decision tree analysis. The sample consisted of 1181 patients using PCA. Data were collected using: a specifically designed check-off form to collect patient-, surgery-, anaesthesia- and post-operation-related data; the Beck Anxiety Inventory to measure pre-operative anxiety; and a visual analogue scale, to measure post-operative pain. The incidence of PONV was 27.7%. Nine factors were highly predictive of PONV in our five model pathways: gender, obesity, anxiety, history of previous PONV, history of motion sickness, inhalation of nitrous oxide during operation, use of inhalational agents, starting oral fluid/food intake after operation, and post-operative pain. With these five predictive model pathways, we can predict the probability of PONV in an individual patient according to their individual characteristics.     

Methylprednisolone reduces postoperative nausea in total knee and hip arthroplasty

What is known and objective: Total knee and hip joint replacement has a high risk of postoperative nausea and vomiting (PONV), and steroid cover is used for cases associated with autoimmune diseases. Our aim is to evaluate the antiemetic efficacy of methylprednisolone as steroid cover in patients undergoing the surgery. Methods: A prospective cohort study design was used. Sixty‐eight patients, aged between 20 and 80 years, were scheduled for a standardized general anaesthetic technique. Patients who were given methylprednisolone were assigned as the steroid cover group, and those who were not given methylprednisolone formed the non‐steroid cover group. PONV were assessment by direct questioning or spontaneous complaints by patients 1 week after surgery. Postoperative pain was evaluated using Visual Analog Scale (VAS) 1 and 3 days after surgery. Results and discussion: The incidence of nausea in the steroid cover group was significantly less than that in the non‐steroid cover group (adjusted odds ratio, 0·17, P = 0·021), but there was no significant difference in vomiting between the two groups. Postoperative pain VAS score was not significantly different between groups. What is new and conclusion: In total knee and hip arthroplasty, methylprednisolone is effective in preventing postoperative nausea; however, higher doses of methylprednisolone may be needed to prevent vomiting.     

A randomized placebo-controlled study of aromatherapy for the treatment of postoperative nausea and vomiting

ObjectiveThe purpose of this study was to compare the aromatherapy treatment effects on PONV patients using ginger, lavender and rose oils and a placebo.DesignA randomized 4-armed placebo controlled study.SettingGaziosmanpasa University, School of Medicine, Health Research and Application Center.InterventionThe total of 184 patients were randomized into 4 groups: Aromatherapy with lavender essential oil (Lavender group), with rose essential oil (Rose group), with ginger essential oil (Ginger group) or with pure water (Placebo group).Main outcome measuresPostoperative nausea (0–3 Likert type; 0=no nausea, 1=some, 2=a lot, 3=severe) and vomiting scores (0–3 Likert type; 0=no vomiting, 1 = 1 time, 2 = 2 or 3 time, 3 = 4 times and up) and antiemetic medication requirement.ResultsThe nausea scores at 15 min were statistically significantly different between the groups (p = 0.00). The postoperative nausea scores improved in 20 (43.5%) subjects in the placebo group, 38 (82.6%) subjects in the lavender group, 22 (47.8%) subjects in the rose group and 30 (65.2%) subjects in the ginger group (p = 0.00). There were statistically significant differences between the groups with regard to the vomiting and antiemetic drug requirements (p = 0.00).ConclusionThe aromatherapy can be used as an alternative or complementary method for managing PONV. Specifically, the ginger and lavender essential oils were superior to the rose oil and pure water for the aromatherapy treatments. However, further studies with larger sample sizes are necessary to confirm these results.     

Aprepitant vs. Multimodal Prophylaxis in the Prevention of Nausea and Vomiting following Extended‐Release Epidural Morphine

Background: Extended‐release epidural morphine (EREM) is an effective option for postoperative analgesia following major orthopedic surgery; however, postoperative nausea/vomiting (PONV) is a recognized limitation. The incidence of PONV following prophylactic aprepitant, a neurokinin‐1 antagonist, was compared with prophylactic multimodal antiemetic therapy in patients receiving EREM for postoperative analgesia following unilateral primary total knee arthroplasty (TKA). Methods: Prospectively collected quality assurance data were examined with Institutional Review Board approval. A sequential, open‐label, active matched case‐control study compared PONV following EREM in patients receiving ondansetron and dexamethasone, and either metoclopramide, diphenhydramine, or prochlorperazine every 6 hours for the 48‐hour study period, to patients receiving aprepitant 40 mg given as a single oral dose in the preoperative holding area. Cases were matched for procedure (TKA), age, epidural morphine dose, and known major risk factors for PONV (sex, smoking, previous PONV/motion sickness). Results: Twelve consecutive patients (3 male; 9 female) receiving aprepitant prior to EREM were matched to 12 patients of the same sex of similar age (range 51 to 84 years.) and EREM dose (range 5 to 12.5 mg) receiving the multimodal regime. The incidence of PONV was significantly less for the aprepitant group where 3 of 12 (25%) had PONV compared with 9 of 12 (75%) in the multimodal group (P = 0.039, Fisher's Exact Test; odds ratio = 0.11; 95% CI: 0.018 to 0.706, P = 0.03). Conclusion: While aprepitant significantly reduced the incidence of PONV compared with a multimodal antiemetic regime, used alone it did not eliminate PONV.     

Risk factors for acute and chronic postoperative pain in patients with benign and malignant renal disease after nephrectomy

Aims: This longitudinal study was performed in order to analyze the incidence of and perioperative risk factors for the development of chronic postsurgical pain (CPSP) in patients after nephrectomy. Methods: For baseline data acquisition, valid instruments were used for scoring sociodemographic, psychological, psychosocial, pain, pain treatment, and comorbidity factors: the Mainz Pain Staging System (MPSS) for pain chronicity, the Chronic Pain Grading Questionnaire (CPGQ), the Neuropathic Pain Scale (NPS), the Hospital Anxiety and Depression Scale (HADS), the Short Form 12 (SF‐12) for health‐related quality of life, the Habitual Well‐Being Questionnaire (HWBQ), the Symptom Check List (SCL‐8) for detecting psychosomatic dysfunction, and the Weighted Illness Check List (WICL) for evaluation of comorbidities and their impact on activities of daily living. Pain intensities were recorded over the first 6 postoperative days after nephrectomy. A sample of 35 patients was followed up for 3 and 6 months. Results: Patients with more intense postoperative pain during the first 6 days had significantly higher preoperative anxiety scores. The incidence of CPSP 3 and 6 months after nephrectomy was 28.6% and 8.6%, respectively. Preoperatively increased anxiety scores, reduced physical health‐related quality of life (SF‐12), multiple comorbid conditions, and increased comorbidity‐related disability were significantly associated with the occurrence of CPSP after 3 months. These patients also reported more severe pain during the first week after surgery. Preoperative “current pain intensity” was significantly increased in CPSP patients. Conclusions: Our results demonstrate a multifactorial development of CPSP. This process may contribute not only to the occurrence of chronic postsurgical pain but also to the biopsychosocial impairment in these patients as often seen in other chronic pain populations.     

The role of perioperative intravenous low-dose dexamethasone in rapid recovery after total knee arthroplasty: a meta-analysis

PurposeThe purpose of this meta-analysis was to evaluate the overall safety and effectiveness of perioperative intravenous dexamethasone to facilitate postoperative rehabilitation in patients after total knee arthroplasty (TKA).MethodsA comprehensive literature search was performed using the Embase, PubMed, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases for relevant randomized controlled trials (RCTs) from inception to 2020. Methodological quality of the trials was assessed using the Cochrane Risk of Bias Tool, and the relevant data were extracted using a predefined data extraction form.ResultsTen RCTs with 1100 knees were included. Our study showed a significant reduction in pain using a postoperative pain visual analog scale (VAS) at 24 hours and 48 hours, total opioid consumption at 24 hours and 48 hours, postoperative nausea and vomiting (PONV), active range of motion (ROM) limitation, and passive ROM limitation at 72 hours in dexamethasone-treated groups compared with controls.ConclusionIntravenous low-dose dexamethasone is potentially useful in the perioperative setting for reducing postsurgical immediate ROM limitations, pain, opioid consumption, and PONV. There are no data that directly attribute an increase in postoperative complications to intravenous dexamethasone. More high-quality studies are necessary to draw these conclusions.     

Factors Influencing Early Postoperative Recovery After Laparoscopic Cholecystectomy

PurposeTo study the factors influencing early postoperative recovery after laparoscopic cholecystectomy.DesignA nonexperimental retrospective study.MethodsThe study was performed using records from all patients who had undergone laparoscopic cholecystectomy at a hospital in Northern Sweden in 2017 (219 patients in total). Nonparametric data were analyzed using Spearman's rho, Mann-Whitney U test, and logistic regression. Parametric data were analyzed using Pearson's correlation, an independent t test, and analysis of variance.FindingsThe length of stay in the postanesthesia care unit was not predicted by factors such as age, gender, body mass index, American Society of Anesthesiologists classification, postoperative nausea and vomiting, premedication, or type of surgery. Younger age and high classification level were significant predictors of pain during rest and pain when in motion. No significant predictors of postoperative nausea were found. The majority of study participants experienced little or no pain or nausea. The documentation of pain, nausea, and premedication was inadequate in many cases.ConclusionsNurses in postanesthesia care units should work to preventively identify and address patients’ medical and emotional needs so that optimal conditions for postoperative recovery can be provided.