Effect of preoperative Cox-II-selective NSAIDs (coxibs) on postoperative outcomes: a systematic review of randomized studies

BACKGROUND: Preoperative use of coxibs has been claimed to reduce postoperative pain and analgesic consumption, and to affect other postoperative outcomes. METHODS: Systematic review of randomized trials comparing preoperative coxib with preoperative placebo, or active comparator. Searching of PubMed and Cochrane Library to August 2004. A qualitative and a quantitative analysis. RESULTS: Twenty-two included trials with 2246 patients had high reporting quality and validity scores, though treatment group sizes were small, with a median size of 30 patients. Most trials used oral preoperative rofecoxib (mainly 50 mg) or celecoxib (mainly 200 mg). Preoperative coxibs significantly reduced both postoperative pain and analgesic consumption compared with preoperative placebo in 15/20 trials. In one further trial postoperative pain was reduced and in one analgesic consumption. There was no significant difference in the incidence of postoperative nausea and vomiting in 13/17 studies or when data were pooled. Postoperative antiemetic use was significantly reduced in all five trials reporting it; the NNT to prevent one patient using postoperative antiemetic was 10 (5.5 to 66). No trial reported any significant difference in intraoperative blood loss or recovery from anaesthesia. Patient satisfaction was significantly increased with preoperative coxib use. No conclusions could be drawn from the three trials comparing preoperative coxib with preoperative NSAID. One study reported significantly improved cost-efficacy with rofecoxib. CONCLUSIONS: Preoperative coxibs had clear benefits in terms of reduced postoperative pain, analgesic consumption and patient satisfaction compared with placebo. Effects on postoperative nausea and vomiting remain uncertain, as do those on recovery from surgery or economic benefit. Future trials should be larger and more pragmatic in nature.     

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy

BACKGROUND: Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy. METHODS: This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded. RESULTS: No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0.001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P < 0.001). No difference in postoperative pain scores and analgesic requirements was detected between groups. CONCLUSION: Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.     

Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy

PURPOSE: Previous studies on dexamethasone's antiemetic and analgesic potential in children undergoing tonsillectomy have produced conflicting results. The aim of this study was to evaluate the effects of a single dose of dexamethasone on the incidence and severity of postoperative vomiting and pain in children undergoing electrocautery tonsillectomy under standardized general anesthesia. METHODS: In a double-blinded study, 120 patients were randomly allocated to receive either dexamethasone 0.5 mg.kg(-1) (maximum dose 8 mg) iv or an equivalent volume of saline preoperatively. The incidence of early and late vomiting, need for rescue antiemetics, time to first oral intake, time to first demand of analgesia and analgesic consumption were compared in both groups. Pain scores used included Children's Hospital Eastern Ontario Pain Scale, "faces", and a 0-10 visual analogue pain scale. RESULTS: Compared with placebo, dexamethasone significantly decreased the incidence of early and late vomiting (P < 0.05, P < 0.001 respectively). Fewer patients in the dexamethasone group needed antiemetic rescue (P < 0.01). The time to first oral intake was shorter, and the time to first dose of analgesic was longer in the dexamethasone group (P < 0.01). Pain scores 30 min after extubation were lower (P < 0.05) in the dexamethasone group. At 12 and 24 hr postoperative swallowing was still significantly less painful in the dexamethasone group than in the control group (P < 0.01). CONCLUSION: Preoperative dexamethasone 0.5 mg.kg(-1) iv reduced both postoperative vomiting and pain in children after electrocautery tonsillectomy.     

Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery

Background: Strabismus surgery is associated with both pain and vomiting. Ketoprofen is widely used in adults to treat acute pain, but there are only few reports of its use in children. This randomised, double-blind, placebo-controlled, parallel group study was designed to investigate the analgesic effect of i.v. ketoprofen and its effect on the incidence of vomiting in children after day-case strabismus surgery.
Methods: Fifty-nine ASA 1 children, aged 1–12 years, entered the study. After premedication with diazepam and glycopyrronium, anaesthesia was induced with fentanyl and propofol and maintained with isoflurane. After induction the children in the ketoprofen group received 1 mg kg⁻¹ ketoprofen followed by an infusion of 1 mg kg⁻¹ ketoprofen over 2 h. In the placebo group, children received 0.9% saline. The postoperative pain was assessed by the Maunuksela pain score (0=no pain, 10=worst possible pain). All children received fentanyl as a rescue analgesic if the Maunuksela score was ≥3.
Results: In the ketoprofen group the number of fentanyl doses was smaller compared to the placebo group (median 1, quartiles (0–2) vs. 2 (1–3), P =0.047). The children in the ketoprofen group had less pain at 30 min ( P =0.02) and the worst pain observed in the post anaesthesia care unit was lower (3 (0–6) vs. 5 (3–8), P =0.035). The incidence of vomiting was less in the ketoprofen group compared to the placebo group (17% vs. 41%, P =0.036). No serious adverse reactions occurred.
Conclusion: We concluded that ketoprofen administered i.v. during the operation produced analgesia and reduced opioid consumption and the incidence of vomiting in children after strabismus surgery.     

The safety of the same-day discharge for selected patients after laparoscopic fundoplication: a prospective cohort study

BACKGROUND: We conducted a prospective cohort study to assess the acceptability, feasibility and safety of day-case laparoscopic fundoplication for gastroesophageal reflux disease in an university-based tertiary care center. METHODS: The procedure was proposed as routine for patients with proven symptomatic uncomplicated gastroesophageal reflux disease fulfilling predetermined inclusion criteria from September 2003 to December 2005. Standard anesthetic, surgical, analgesic, and antiemetic protocols were used. Acceptability, admission, complication, and reoperation rates and patient satisfaction were evaluated. Postoperative pain and nausea were assessed using an 11-point numeric rating scale (NRS). The Gastrointestinal Quality of Life Index (GIQLI) was administered before and after surgery. RESULTS: Among 100 patients screened, 40 (40%) were included. Seven patients were admitted because of inadequate pain control (n = 3), nausea or vomiting (n = 3), or anxiety (n = 1); 33 were discharged as planned 6 to 8 hours after operation. Only 1 patient was readmitted and reoperated because of fundoplicature migration following uncontrolled vomiting. At follow-up, 92.5% of patients were satisfied with the day-case treatment. If offered a similar operation in the future, 82.5% of patients would have accepted day-case treatment. The Gastrointestinal Quality of Life Index was 90.7 (+/-21.2) preoperatively compared with 105.8 (+/-21.8) postoperatively (P < .001). CONCLUSIONS: Day-case laparoscopic fundoplication is feasible in selected patients. However, (1) strict control of postoperative nausea and pain is essential, and (2) preoperative standardized education program for ambulatory surgery might be useful in order to enhance patient acceptability and satisfaction rates.     

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery

METHODS: Fifty children (age 5-14 years, ASA I-II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique. RESULTS: Intraoperative values of haemodynamic variables were significantly higher in the control group (P < 0.01). Requirement for intraoperative rescue analgesic and postoperative analgesia was higher in the control group (P < 0.05 and P < 0.001, respectively). Children in the block group had lower postoperative pain scores at all times. Incidence of oculocardiac reflex was significantly higher (P < 0.001) in the control group. Seventy-six percent of children in the control group had postoperative nausea and vomiting compared to 20% children in the block group (P < 0.001). CONCLUSION: There were no complications related to the block. Peribulbar block appears to be a safe and useful analgesic technique for paediatric ophthalmic surgery.     

Postoperative nausea and vomiting and pain after transsphenoidal surgery: a review of 877 patients

Although postoperative nausea and vomiting and pain after supra- and infratentorial craniotomy have been evaluated in multiple studies, there are few data regarding pain or postoperative nausea and vomiting after transsphenoidal procedures. Therefore, we reviewed the perioperative records of 877 patients undergoing transsphenoidal surgery by the same surgeon. The overall incidence of postoperative emesis was 7.5%, significantly less than most studies of neurosurgical patients. An intraoperative cerebrospinal fluid leak and subsequent fat grafting, the use of lumbar intrathecal catheter, and patients presenting for the resection of a craniopharyngiomas all had a significantly increased incidence of postoperative emesis (11.4%, 17.1%, and 18%, respectively). Interestingly, antiemetic prophylaxis did not decrease the risk of vomiting overall or in any cohort of patients; however, both droperidol and ondansetron decreased the incidence of nausea in the postanesthesia care unit (PACU). Regarding pain and morphine consumption, patients who later developed diabetes insipidus had a significant increase in morphine requirements in the PACU. No other disease state was associated with increased pain or morphine consumption in the PACU.     

Preoperative ropivacaine infiltration in breast surgery

PURPOSE: The aim of the study was to investigate whether preoperative infiltration with ropivacaine in conjunction with breast surgery improves postoperative pain management and attenuates postoperative nausea and vomiting. METHOD: Prospective, randomised, double-blind study, including 60 healthy women (ASA 1-2) allocated to one of two groups. Thirty patients were given 0.3 ml/kg saline in the operating field before surgery. Another 30 patients received a similar volume of ropivacaine 3.75 mg/ml. A visual analogue scale (0-100 mm) was used for evaluation of postoperative pain, nausea and vomiting. If the score was more than 30 mm at rest, the patients were given ketobemidone i.v. as treatment for postoperative pain, and dixyrazine i.v. against nausea and vomiting. The intra-and postoperative analgesic requirements and postoperative nausea and vomiting were registered. RESULTS: The intraoperative fentanyl consumption was similar in the saline group 81 +/- 22 microg vs 76 +/- 28 microg; (ns) in the ropivacaine group. The postoperative 24-h ketobemidone consumption was also similar to those treated with ropivacaine (4.2 +/- 2.6 mg vs 4.2 +/- 4.3 mg; ns). Postoperative nausea and vomiting (PONV) occurred with similar frequencies in both groups. The 24-h dixyrazine consumption was the same in the two groups (2.1 +/- 2.7 mg in the saline group compared to 2.4 +/- 2.8 mg in the ropivacaine group; ns). After 6 h recovery, 41% of all patients had experienced nausea and 20% vomiting. CONCLUSION: We found no differences in postoperative pain management between 3.75 mg/ml ropivacaine and saline wound infiltration before breast surgery. The data show similar postoperative needs of analgesics and antiemetics with a similar frequency of PONV.     

Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis

Surgery is the primary therapeutic intervention for breast cancer and can result in significant postoperative pain. We searched the current literature and performed a meta-analysis in order to compare the analgesic efficacy of the pectoral type-2 (Pecs II) block with systemic analgesia alone and with a thoracic paravertebral block for breast cancer surgery. Primary outcome was postoperative opioid consumption in the first 24 h after surgery. Secondary outcomes were pain scores at 0, 3, 6, 9 and 24 h after surgery, intra-operative opioid consumption, time to first analgesic request and incidence of postoperative nausea and vomiting. We identified 13 randomised controlled trials that included 815 patients. The Pecs II block significantly reduced postoperative opioid consumption (standardised difference in means: −13.64 mg oral morphine equivalents; 95%CI: −21.22 to −6.05; p < 0.01) and acute postoperative pain at all intervals in the first 24 h after surgery compared with systemic analgesia alone. Compared with the thoracic paravertebral block, the Pecs II block resulted in similar postoperative opioid consumption (standardised difference in means: −8.73 mg oral morphine equivalents; 95%CI: −18.16 to 0.69; p = 0.07) and postoperative pain scores after first measurement. In conclusion, the Pecs II block offers improved analgesic efficacy compared with systemic analgesia alone and comparable analgesic efficacy to a thoracic paravertebral block for breast cancer surgery.     

Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts

Background: Postoperative nausea and vomiting (PONV) after general anesthesia and surgery may have an incidence as high as 70% irrespective of antiemetic drug therapy. The use of preoperative hypnosis and mental preparation by means of an audio tape was investigated in the prophylaxis of nausea and vomiting before elective breast reduction surgery. Similar interventions have not been found in the literature.
Methods: Fifty women were randomized to a control group or a hypnosis group; the latter listened to an audio tape daily 4–6 days prior to surgery. A hypnotic induction was followed by suggestions as to how to relax and experience states incompatible with nausea and vomiting postoperatively (e.g. thirst and hunger). There was a training part on the tape where the patients were asked to rehearse their own model for stress reduction. Premedication and anesthetic procedures were standardized.
Results: Patients in the hypnosis group had significantly less vomiting, 39% compared to 68% in the control group, less nausea and less need of analgesics postoperatively.
Conclusions: Preoperative relaxation and/or hypnotic techniques in breast surgery contribute to a reduction of both PONV and postoperative analgesic requirements.     

Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery

BACKGROUND AND OBJECTIVES: Pediatric strabismus surgery leads to undesirable intraoperative and postoperative side effects that include pain, postoperative nausea and vomiting (PONV), and oculocardiac reflex (OCR). We hypothesized that subtenon anesthesia performed before the start of surgery and combined with general intravenous anesthesia would reduce these adverse effects. METHODS: Forty children (2.5 to 6 years of age, ASA status I to II) were prospectively randomized to receive either subtenon bupivacaine 0.5% or a saline injection before the beginning of surgery in a double-blind manner. Perioperative analgesic requirements, pain scores (CHEOPS scale), hemodynamics, and incidence of OCR and PONV were compared. RESULTS: Postoperative pain scores were lower (P < .001) at removal of the laryngeal mask and 30 minutes later in the bupivacaine group. Intraoperative and postoperative analgesic requirements were significantly reduced in this group (P < .01). The incidence of OCR and PONV were also significantly decreased (P < .01). Intraoperative values of blood pressure were significantly higher in the saline group at 20 minutes (P < .02). CONCLUSION: We conclude that preoperative subtenon bupivacaine 0.5% compared with a saline injection contributed to reduction of perioperative pain and undesirable side effects in pediatric strabismus surgery performed under general anesthesia.     

Midazolam: an effective antiemetic after cardiac surgery--a clinical trial

Cardiac surgery has been associated with a significant incidence of postoperative nausea and vomiting (PONV). To assess the antiemetic property of midazolam, we undertook this double-blinded, randomized trial in 200 patients undergoing cardiac surgery involving cardiopulmonary bypass, and we compared its efficacy with that of ondansetron in preventing PONV. Assessments on the occurrence of PONV were made at regular intervals for the first 24 h after tracheal extubation, along with sedation and pain scoring. We report a 6% incidence of nausea and no incidence of vomiting in the midazolam group, compared with a 21% incidence of PONV in the ondansetron group (P < 0.001). All 21 patients (18 women and 3 men) in the ondansetron group and none of the 6 patients (all women) in the midazolam group required a rescue antiemetic drug (P < 0.001). The sedation scores and postoperative pain scores were comparable in both groups. We conclude that midazolam, instituted as a continuous infusion in a dose of 0.02 mg. kg(-1). h(-1), is a more effective antiemetic than ondansetron in a dose of 0.1 mg/kg IV every 6 h for the prevention of PONV after cardiac surgery.     

Double-blind, Randomized Comparison of Ondansetron and Intraoperative Propofol to Prevent Postoperative Nausea And Vomiting

Background: Breast surgery is associated with a high incidence of postoperative nausea and vomiting. Propofol and prophylactic administration of ondansetron are associated with a lower incidence of postoperative nausea and vomiting. To date no comparison of these two drugs has been reported. A randomized study was done to compare the efficacy of ondansetron and intraoperative propofol given in various regimens.

Methods: Study participants included 89 women classified as American Society of Anesthesiologists physical status 1 or 2 who were scheduled for major breast surgery. Patients were randomly assigned to one of four groups. Group O received 4 mg ondansetron in 10 ml 0.9% saline and groups PI, PIP, and PP received 10 ml 0.9% saline before anesthesia induction. Group O received thiopental, isoflurane, nitrous oxide-oxygen, and fentanyl for anesthesia. Group PI received propofol, isoflurane, nitrous oxide-oxygen, and fentanyl. Group PIP received propofol, isoflurane, nitrous oxide-oxygen, and fentanyl. Thirty minutes before expected skin closure, isoflurane was discontinued and 50 to 150 micro gram [centered dot] kg sup -1 [centered dot] min sup -1 propofol was given intravenously to maintain anesthesia. Group PP received propofol for induction and maintenance of anesthesia, nitrous oxide-oxygen, and fentanyl. Postoperative pain relief was provided with morphine administered by a patient-controlled analgesia pump. The incidence of nausea and vomiting, requests for rescue antiemetic and sedation, pain scores, and hemodynamic data were recorded for 24 h.

Results: Within 6 h of surgery, groups O and PP had a lower incidence of nausea compared with groups PI and PIP (P < 0.05). Fewer patients in group PP (19%) vomited during the 24-h period compared with groups O (48%), PI (64%), and PIP (52%) (P < 0.05). The incidence of antiemetic use was also less in group PP (P < 0.05). Patients in group PP had lower sedation scores at 30 min and at 1 h (P < 0.05). There were no differences among the groups in pain scores, blood pressure, heart rate, respiratory rate, and incidence of pruritus.     

A randomized, double-blinded comparison of ondansetron, droperidol, and placebo for prevention of postoperative nausea and vomiting after supratentorial craniotomy

Nausea or vomiting occurs frequently after craniotomy. Because of the need for frequent postoperative neurological assessment, an effective antiemetic with minimal sedative side effects is needed. Therefore, we compared ondansetron to droperidol in a randomized, double-blinded, placebo-controlled study. A total of 60 adults requiring elective supratentorial craniotomy received standardized IV anesthesia with 4 mg of ondansetron, 0.625 mg of droperidol, or placebo at skin closure. The incidence of postoperative nausea, emesis, pain and sedation scores, and rescue antiemetic use were recorded at 0, 0.5, 1, 4, 8, 12, 24, and 48 h. All groups were demographically similar. Differences existed for cumulative 8, 12, and 24 h incidences of nausea (24 h, P = 0.03) and emesis (24 h, P = 0.04). Within 4 h, when maximal effect could be expected from treatment, 20% of the ondansetron group, 25% of the droperidol group and 50% of the placebo group received rescue antiemetic (P = 0.12). No differences in pain (P = 0.82) or sedation (P = 0.74) scores were detected. Both ondansetron and droperidol prevent nausea; however, only droperidol reduces emesis after supratentorial craniotomy. The dose of droperidol used was not more sedating than ondansetron. Sustained reduction in nausea and emesis over 24 h indicates a preemptive benefit of prophylactic antiemetic in this surgical population. Implications: Nausea and vomiting after brain surgery are particularly troubling, because effective treatment may cause sedation, making postoperative neurological assessment difficult. Our study shows that both ondansetron and droperidol are effective in reducing nausea, and that droperidol is particularly effective in reducing vomiting. Neither drug caused more sedation than placebo.     

Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial

OBJECTIVE: To determine the effects of preoperative dexamethasone on surgical outcome after laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: Pain and fatigue are dominating symptoms after LC and may prolong convalescence. METHODS: In a double-blind, placebo-controlled study, 88 patients were randomized to intravenous dexamethasone (8 mg) or placebo 90 minutes before LC. Patients received a similar standardized anesthetic, surgical, and multimodal analgesic treatment. All patients were recommended 2 days postoperative duration of convalescence. The primary endpoints were fatigue and pain. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein (CRP) and pulmonary function, pain scores, nausea, and number of vomiting episodes were registered. Analgesic and antiemetic requirements were recorded. Also, on a daily basis, patients reported scores of fatigue and pain before and during the first postoperative week and the dates for resumption of work and recreational activities. RESULTS: Eight patients were excluded from the study, leaving 40 patients in each study group for analysis. There were no apparent side effects of the study drug. Dexamethasone significantly reduced postoperative levels of CRP (P = 0.01), fatigue (P = 0.01), overall pain, and incisional pain during the first 24 postoperative hours (P < 0.05) and total requirements of opioids (P < 0.05). In addition, cumulated overall and visceral pain scores during the first postoperative week were significantly reduced (P < 0.05). Dexamethasone also reduced nausea and vomiting on the day of operation (P < 0.05). Resumption of recreational activities was significantly faster in the dexamethasone group versus placebo group (median 1 day versus 2 days) (P < 0.05). CONCLUSION: Preoperative dexamethasone (8 mg) reduced pain, fatigue, nausea and vomiting, and duration of convalescence in patients undergoing noncomplicated LC, when compared with placebo, and is recommended for routine use.     

Analgesic benefits and clinical role of the posterior suprascapular nerve block in shoulder surgery: a systematic review,meta-analysis and trial sequential analysis

The posterior suprascapular nerve block has been proposed as an analgesic alternative for shoulder surgery based on the publication of several comparisons with interscalene block that failed to detect differences in analgesic outcomes. However, quantification of the absolute treatment effect of suprascapular nerve block on its own, in comparison with no block (control), to corroborate the aforementioned conclusions has been lacking. This study examines the absolute analgesic efficacy of suprascapular nerve block compared with control for shoulder surgery. We systematically sought electronic databases for studies comparing suprascapular nerve block with control. The primary outcomes included postoperative 24-h cumulative oral morphine consumption and the difference in area under the curve for 24-h pooled pain scores. Secondary outcomes included the incidence of opioid-related side-effects (postoperative nausea and vomiting) and patient satisfaction. Data were pooled using random-effects modelling. Ten studies (700 patients) were analysed; all studies examined landmark-guided posterior suprascapular nerve block performed in the suprascapular fossa. Suprascapular nerve block was statistically but not clinically superior to control for postoperative 24-h cumulative oral morphine consumption, with a weighted mean difference (99%CI) of 11.41 mg (−21.28 to −1.54; p = 0.003). Suprascapular nerve block was also statistically but not clinically superior to control for area under the curve of pain scores, with a mean difference of 1.01 cm.h. Nonetheless, suprascapular nerve block reduced the odds of postoperative nausea and vomiting and improved patient satisfaction. This review suggests that the landmark-guided posterior suprascapular nerve block does not provide clinically important analgesic benefits for shoulder surgery. Investigation of other interscalene block alternatives is warranted.     

Ondansetron inhibits the analgesic effects of tramadol: a possible 5-HT(3) spinal receptor involvement in acute pain in humans

To investigate a possible antinociceptive role of serotonin receptor subtype 3 (5-HT(3)), we evaluated the effects of a coadministration of ondansetron, a 5-HT(3) selective antagonist, and tramadol, a central analgesic dependent on enhanced serotonergic transmission. Fifty-nine patients undergoing ear, throat, and nose surgery, using tramadol for 24-h postoperative patient-controlled analgesia (bolus = 30 mg; lockout interval = 10 min) were randomly allocated either to a group receiving ondansetron continuous infusion (1 mg. mL(-1). h(-1)) for postoperative nausea and vomiting (Group O) or to a control group receiving saline (Group T). Pain and vomiting scores and tramadol consumption were evaluated at 4, 8, 12, and 24 h. Pain scores were never >4, according to a 0-10 numerical rating scale, in both groups. Group O required significantly larger doses of tramadol at 4 h (213 versus 71 mg, P < 0.001), 8 h (285 versus 128 mg, P < 0.002), and 12 h (406 versus 190 mg, P < 0.002). Vomiting scores were higher in Group O at 4 h (P < 0.05) and 8 h (P = 0.05). We conclude that ondansetron reduced the overall analgesic effect of tramadol, probably blocking spinal 5-HT(3) receptors. IMPLICATIONS: Serotonin is an important neurotransmitter of the descending pathways that down-modulate spinal nociception. In postoperative pain, ondansetron, a selective 5-HT(3) receptor antagonist, increased the analgesic dose of tramadol. We suggest that, when antagonized for antiemetic purpose, 5-HT(3) receptors foster nociception, because of their site-dependent action.     

Prophylacticiv ondansetron reduces nausea, vomiting and pruritus following epidural morphine for postoperative pain control

PURPOSE: To evaluate the prophylactic effect of ondansetron on nausea and vomiting following epidural morphine for postoperative pain control. METHODS: Seventy women (n = 35 in each group) undergoing abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blinded, and placebo-controlled study. At the end of surgery, all patients received epidural morphine 3 mg for postoperative pain relief. Before morphine injection, the ondansetron group received iv ondansetron 4 mg, whereas the placebo group received iv saline. RESULTS: Patients in the ondansetron group reported a lower frequency of total postoperative nausea and vomiting (22%) and lower frequency of rescue antiemetic request (12%) than those in the placebo group (52% and 39%, respectively; P < 0.05). In addition, ondansetron was associated with a reduced incidence of pruritus following epidural morphine (28% vs 58%; P < 0.05). CONCLUSION: We conclude that iv ondansetron 4 mg is effective in the prevention of nausea, vomiting, and pruritus following epidural morphine for postoperative pain control.     

Dexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy

PURPOSE: The combination of antiemetic drugs could be a solution to prevent severe postoperative nausea and vomiting (PONV). The aim of this randomized double blind, dose-ranging study was to determine the minimum single effective dose of dexamethasone combined with ondansetron for the prevention of PONV in patients undergoing laparoscopic cholecystectomy. METHODS: One hundred eighty patients were allocated randomly to one of six groups to receive saline (P group), ondansetron 4 mg (O group), or ondansetron 4 mg and dexamethasone at doses of 2 mg (OD2 group), 4 mg (OD4 group), 8 mg (OD8 group), and 16 mg (OD16 group). A standardized general anesthetic was used. All episodes of PONV during the intervals of zero to six hours, 6-12 hr and 12-24 hr after surgery were evaluated using a numeric scoring system. Mean visual analogue scale pain scores at rest and on movement, the time to first demand of analgesia, total analgesic consumption in 12 hr epochs, duration of hospital stay, and side effects were recorded. RESULTS: The incidence of PONV in the OD8 (16%) and OD16 (16%) groups was lower than in the 83% (P < 0.001) and O groups (50%) at the 12-24 hr epoch (P < 0.05). There were no differences in antiemetic effect between the O, OD2 and OD4 groups and between the OD8 and OD16 groups. Pain scores, total analgesic consumption, duration of hospital stay and side effects were similar among groups. CONCLUSION: Our results suggest that 8 mg is the minimum dose of dexamethasone that, combined with ondansetron 4 mg will effectively prevent PONV in patients undergoing laparoscopic cholecystectomy.     

Preoperative administration of controlled-release oxycodone for the management of pain after ambulatory laparoscopic tubal ligation surgery

STUDY OBJECTIVE: To examine the analgesic efficacy of administering controlled-release (CR) oxycodone 10 mg before elective ambulatory laparoscopic tubal ligation surgery. DESIGN: Randomized, double-blind study. PATIENTS: 50 healthy women presenting for elective ambulatory laparoscopic tubal ligation surgery. SETTING: Ambulatory surgery center of a university hospital. INTERVENTIONS: Fifty patients were administered either placebo (n = 25) or CR oxycodone 10 mg (n = 25) 1 hour before surgery. All patients were administered a similar general anesthetic. In the postanesthesia care unit (PACU), fentanyl 25 microg was administered for a verbal analog scale (VAS) pain score >or=3. Patients were discharged home when they were awake and alert, had stable vital signs, were able to void, tolerated oral fluids, experienced no side effects, had a VAS or=3. MEASUREMENTS: VAS pain scores and the frequency of postoperative nausea and vomiting were recorded in the PACU. While at home, patients were contacted by telephone after surgery and asked about their pain score, time to first analgesic use, frequency of postoperative nausea and vomiting, and total acetaminophen/oxycodone use in the 24 hours following surgery. MAIN RESULTS: Patients in the CR oxycodone group had a shorter time to discharge (p < 0.001), reported lower postoperative pain scores (p < 0.001), lower frequency of postoperative nausea and vomiting (p < 0.05), longer time to first analgesic use (p < 0.0,001), and required less fentanyl in the PACU (p < 0.01) and fewer acetaminophen/oxycodone tablets in the 24 hours following surgery. CONCLUSION: The preoperative administration of CR oxycodone 10 mg is an effective analgesic technique in the management of pain following ambulatory laparoscopic tubal ligation surgery, and may facilitate earlier postoperative discharge.