Ashraf S. Habib

Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting

The present guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in postoperative nausea and vomiting (PONV) under the auspices of The Society of Ambulatory Anesthesia. The panel critically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. In brief, these guidelines identify risk factors for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic monotherapy and combination therapy regimens for PONV prophylaxis; recommend approaches for treatment of PONV when it occurs; and provide an algorithm for the management of individuals at increased risk for PONV.

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Gabapentin and postoperative pain: a systematic review of randomized controlled trials

&NA; The objective of this systematic review was to evaluate the efficacy and tolerability of perioperative gabapentin administration for the control of acute postoperative pain. We searched Medline (1966–2006), the Cochrane Library (2006), Scopus, CINAHL and bibliographies from clinical trials and review articles. We included randomized controlled trials (RCTs) comparing gabapentin with inactive controls in surgical patients. Sixteen valid RCTs were included. Weighted mean difference (WMD) for postoperative pain intensity (0–100 mm visual analogue scale) was −16.55 mm at 6 h and −10.87 mm at 24 h for treatment with a single preoperative dose of gabapentin 1200 mg. Cumulative opioid consumption at 24 h was also significantly decreased with gabapentin (WMD, −27.90 mg). When gabapentin was administered at doses less than 1200 mg, pain intensity was also lower at 6 h (WMD, −22.43 mm) and 24 h (WMD, −13.18 mm). Cumulative 24 h opioid consumption was also lower (WMD, −7.25 mg). Gabapentin was associated with an increased risk of sedation (Peto OR 3.86; 95% CI 2.50–5.94) but less opioid‐related side effects such as vomiting (Peto OR 0.58; 95% CI 0.39–0.86) and pruritus (Peto OR 0.27; 95% CI 0.10–0.74). In conclusion, gabapentin has an analgesic and opioid‐sparing effect in acute postoperative pain management when used in conjunction with opioids.

A retrospective comparison of anesthetic management of robot-assisted laparoscopic radical prostatectomy versus radical retropubic prostatectomy

STUDY OBJECTIVE To compare anesthetic management and postoperative outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) and radical retropubic prostatectomy (RRP) with general anesthesia. DESIGN Retrospective database study of RALP and RRP patients at Duke University Medical Center from 6/2003 to 6/2006. SETTING University teaching hospital. PATIENTS 541 ASA physical status I, II, and III men, 280 of whom were RRP patients and 256 RALP patients. MEASUREMENTS Patient demographics, intraoperative fluids and blood products, hemodynamic parameters, pain scores in the Postanesthesia Care Unit (PACU), intraoperative and postoperative analgesic consumption, need for rescue antiemetics in the PACU, and intraoperative use of vasopressors and antihypertensives, were all recorded. Additional data included postoperative transfusion data; clinical status of the patients cancer preoperatively and postoperatively; hematocrit, platelet count, and creatinine levels; and length of hospital stay. MAIN RESULTS Estimated blood loss (EBL) was higher for RRP than RALP patients (mean +/- SD; 1,087 +/- 853 mL vs. 287 +/- 317 mL; P < 0.0001). Likewise, 24% of RRP patients received red blood cell (RBC) transfusions intraoperatively, compared with 0.4% RALP patients (P < 0.0001). Intraoperatively, RALP patients received more antihypertensive agents (37% vs. 21%; P < 0.0001), and fewer vasopressors (63% vs. 78%; P < 0.0001) than did RRP patients. The two groups had similar morphine-equivalent opioid use intraoperatively, but in the PACU, RALP patients required fewer morphine equivalents (mean +/- SD; 11.4 +/- 7.7 mg vs. 14.9 +/- 9.8 mg; P < 0.0001). The RALP patients had longer surgical times (mean +/- SD; 296 +/- 76 vs.193 +/- 69 min; P < 0.0001) but shorter PACU stays (mean +/- SD; 113 +/- 55 min vs. 143 +/- 58 min; P < 0.0001) and shorter hospital stays (mean +/- SD; 44 +/- 77 hrs vs. 56 +/- 26 hrs; P = 0.009). CONCLUSIONS Duration of surgery was greater with RALP, but it was associated with less EBL, fewer transfusions of blood products, and shorter PACU and hospital stays.

Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis

BACKGROUND The analgesic efficacy and adverse effects of a single perioperative dose of dexamethasone are unclear. We performed a systematic review to evaluate the impact of a single i.v. dose of dexamethasone on postoperative pain and explore adverse events associated with this treatment. METHODS MEDLINE, EMBASE, CINAHL, and the Cochrane Register were searched for randomized, controlled studies that compared dexamethasone vs placebo or an antiemetic in adult patients undergoing general anaesthesia and reported pain outcomes. RESULTS Forty-five studies involving 5796 patients receiving dexamethasone 1.25-20 mg were included. Patients receiving dexamethasone had lower pain scores at 2 h {mean difference (MD) -0.49 [95% confidence interval (CI): -0.83, -0.15]} and 24 h [MD -0.48 (95% CI: -0.62, -0.35)] after surgery. Dexamethasone-treated patients used less opioids at 2 h [MD -0.87 mg morphine equivalents (95% CI: -1.40 to -0.33)] and 24 h [MD -2.33 mg morphine equivalents (95% CI: -4.39, -0.26)], required less rescue analgesia for intolerable pain [relative risk 0.80 (95% CI: 0.69, 0.93)], had longer time to first dose of analgesic [MD 12.06 min (95% CI: 0.80, 23.32)], and shorter stays in the post-anaesthesia care unit [MD -5.32 min (95% CI: -10.49 to -0.15)]. There was no dose-response with regard to the opioid-sparing effect. There was no increase in infection or delayed wound healing with dexamethasone, but blood glucose levels were higher at 24 h [MD 0.39 mmol litre(-1) (95% CI: 0.04, 0.74)]. CONCLUSIONS A single i.v. perioperative dose of dexamethasone had small but statistically significant analgesic benefits.

Impact of Intravenous Lidocaine Infusion on Postoperative Analgesia and Recovery from Surgery: A Systematic Review of Randomized Controlled Trials

Postoperative pain continues to be inadequately managed. While opioids remain the mainstay for postoperative analgesia, their use can be associated with adverse effects, including ileus, which can prolong hospital stay. A number of studies have investigated the use of perioperative intravenous lidocaine infusion for improving postoperative analgesia and enhancing recovery of bowel function.This systematic review was performed to determine the overall efficacy of intravenous lidocaine infusion on postoperative analgesia and recovery from surgery in patients undergoing various surgical procedures. We searched the databases of MEDLINE, CINAHL and the Cochrane Library from 1966 to December 2009. We searched for randomized controlled comparisons of lidocaine infusion with placebo in the surgical setting and reporting on postoperative analgesia and other aspects of patient recovery from surgery. The quality of all included studies was assessed using the Modified Oxford Scale. Information on postoperative pain intensity and analgesic requirements was extracted from the trials and compared qualitatively. Other relevant data such as return of bowel function, length of hospital stay, intraoperative anaesthetic requirement and adverse effects were also compared.Sixteen trials were included. A total of 395 patients received intravenous lidocaine with 369 controls. In open and laparoscopic abdominal surgery, as well as in ambulatory surgery patients, intravenous perioperative infusion of lidocaine resulted in significant reductions in postoperative pain intensity and opioid consumption. Pain scores were reduced at rest and with cough or movement for up to 48 hours postoperatively. Opioid consumption was reduced by up to 85% in lidocaine-treated patients when compared with controls. Infusion of lidocaine also resulted in earlier return of bowel function, allowing for earlier rehabilitation and shorter duration of hospital stay. First flatus occurred up to 23 hours earlier, while first bowel movement occurred up to 28 hours earlier in the lidocaine-treated patients. Duration of hospital stay was reduced by an average of 1.1 days in the lidocaine-treated patients. Administration of intravenous lidocaine infusion did not result in toxicity or clinically significant adverse events. Lidocaine had no impact on postoperative analgesia in patients undergoing tonsillectomy, total hip arthroplasty or coronary artery bypass surgery.In conclusion, intravenous lidocaine infusion in the perioperative period is safe and has clear advantages in patients undergoing abdominal surgery. Patients receiving lidocaine infusion had lower pain scores, reduced postoperative analgesic requirements and decreased intraoperative anaesthetic requirements, as well as faster return of bowel function and decreased length of hospital stay. Further studies are needed to assess whether lidocaine has a beneficial effect in patients undergoing other types of surgery and to determine the optimum dose, timing and duration of infusion of lidocaine in this setting.

Acupuncture and related techniques for postoperative pain : a systematic review of randomized controlled trials

Postoperative pain management remains a significant challenge for all healthcare providers. The objective of this systematic review was to quantitatively evaluate the efficacy of acupuncture and related techniques as adjunct analgesics for acute postoperative pain management. We searched the databases of Medline (1966-2007), CINAHL, The Cochrane Central Register of Controlled Trials (2006), and Scopus for randomized controlled trials (RCTs) using acupuncture for postoperative pain management. We extracted data about postoperative opioid consumption, postoperative pain intensity, and opioid-related side-effects. Combined data were analysed using a random effects model. Fifteen RCTs comparing acupuncture with sham control in the management of acute postoperative pain were included. Weighted mean difference for cumulative opioid analgesic consumption was -3.14 mg (95% confidence interval, CI: -5.15, -1.14), -8.33 mg (95% CI: -11.06, -5.61), and -9.14 mg (95% CI: -16.07, -2.22) at 8, 24, and 72 h, respectively. Postoperative pain intensity (visual analogue scale, 0-100 mm) was also significantly decreased in the acupuncture group at 8 and 72 h compared with the control group. The acupuncture treatment group was associated with a lower incidence of opioid-related side-effects such as nausea (relative risk, RR: 0.67; 95% CI: 0.53, 0.86), dizziness (RR: 0.65; 95% CI: 0.52, 0.81), sedation (RR: 0.78; 95% CI: 0.61, 0.99), pruritus (RR: 0.75; 95% CI: 0.59, 0.96), and urinary retention (RR: 0.29; 95% CI: 0.12, 0.74). Perioperative acupuncture may be a useful adjunct for acute postoperative pain management.

Evidence-based management of postoperative nausea and vomiting: a review.

PurposeTo provide evidence-based guidelines for the prophylaxis and treatment of postoperative nausea and vomiting (PONV).SourceLiterature from randomized controlled trials, systematic reviews, logistic regression analyses and expert opinion in the management of PONV.Principal findingsThe etiology of PONV is multifactorial. Patient, anesthesia, and surgery related risk factors have been identified. Universal PONV prophylaxis is not cost-effective. Identification of patients at high-risk of PONV allows targeting prophylaxis to those who will benefit most from it. No prophylaxis is needed for patients at low risk for PONV. For patients at moderate risk for PONV, prophylaxis using a single antiemetic or a combination of two agents should be considered. Double and triple antiemetic combinations should be considered for patients at high risk for PONV. Furthermore, a multimodal approach should be adopted incorporating steps to keep the baseline risk of PONV low. The optimum cost-effective approach to the management of PONV will differ between an ambulatory centre and an inpatient hospital setting. For the treatment of established PONV in patients who failed prophylaxis, patients should not receive a repeat dose of the prophylactic antiemetic. Rather, a drug acting at a different receptor should be used. Beyond six hours after surgery, patients can be treated with any of the agents used for prophylaxis, except dexamethasone and transdermal scopolamine.ConclusionPONV are common after anesthesia and surgery. We provided evidence-based guidelines for the management of this problem based on the available literature.RésuméObjectifÉnoncer des lignes de conduite fondées sur des données probantes pour la prévention et le traitement des nausées et des vomissements postopératoires (NVPO).SourceLes publications d’essais contrôlés et randomisés, les études méthodiques, les analyses de régression logistique et l’opinion d’experts sur le traitement des NVPO.Constatations principalesL’origine des NVPO est multifactorielle. Les facteurs de risque reliés au patient, à l’anesthésie et au type de chirurgie sont connus. La prévention universelle des NVPO n’est pas rentable. L’identification des patients à haut risque de NVPO permet une prévention mieux ciblée. Aucune prophylaxie n’est nécessaire en cas de risque faible. En cas de risque modéré, l’usage d’un seul antiémétique ou d’une combinaison de deux médicaments est une mesure préventive à envisager. On peut combiner deux ou trois antiémétiques en cas de risque élevé. De plus, une approche multimodale doit être adoptée et utilisée par étapes afin de conserver le risque de base faible. La méthode de traitement des NVPO la plus rentable sera différente selon qu’il s’agit d’un patient ambulatoire ou hospitalisé. Le traitement des NVPO établis chez des patients qui n’ont pas répondu au traitement préventif ne doit pas comporter une seconde dose de l’antiémétique prophylactique. Un médicament actif au niveau d’un autre récepteur sera privilégié. Au delà de six heures après l’opération, on peut traiter avec n’importe quel médicament utilisé comme prévention, sauf la dexaméthasone et la scopolamine transdermique.ConclusionLes NVPO sont fréquents après l’anesthésie et la chirurgie. Nous avons présenté des lignes de conduite à adopter fondées sur les données probantes de la documentation disponible.

Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey.

Abstract Objective: During the past two decades, professional associations, accrediting bodies, and payors have made post-surgical pain treatment a high priority. In light of the disappointing findings in previous surveys, a survey was conducted to assess patient perceptions and characterize patient experiences/levels of satisfaction with post-surgical pain management. Research design and methods: Survey included a random sample of US adults who had undergone surgery within 5 years from the survey date. Participants were asked about their concerns before surgery, severity of perioperative pain, pain treatments, perceptions about post-surgical pain and pain medications, and satisfaction with treatments they received. Results: Of the 300 participants, ∼86% experienced pain after surgery; of these, 75% had moderate/extreme pain during the immediate post-surgical period, with 74% still experiencing these levels of pain after discharge. Post-surgical pain was the most prominent pre-surgical patient concern, and nearly half reported they had high/very high anxiety levels about pain before surgery. Approximately 88% received analgesic medications to manage pain; of these, 80% experienced adverse effects and 39% reported moderate/severe pain even after receiving their first dose. Study limitations: Key study limitations include the relatively small population size, potential for recall bias associated with the 14-month average time delay from surgery date to survey date, and the inability to account for influences of type of surgery and intraoperative anesthetic/analgesic use on survey results. Conclusions: Despite heightened awareness and clinical advancements in pain management, there has been little improvement in post-surgical analgesia as measured by this survey of post-surgical patients.

Food and drug administration black box warning on the perioperative use of droperidol: A review of the cases

I n a recent Editorial (1), it was suggested that the use of small-dose droperidol has been a highly costeffective antiemetic for over 30 years. Droperidol, 0.625–1.25 mg IV, has been widely accepted as a firstline therapy for the management of postoperative nausea and vomiting (PONV) (2,3). The decision by the Food and Drug Administration (FDA) to issue a “black box” warning regarding the use of droperidol for the treatment and/or prevention of PONV has been challenged by many anesthesiologists (4). Under the Freedom of Information Act, we requested information about the cases on which the FDA warning was based. In response, we received data contained in the adverse event reporting system: a computerized database that contains a summary of all adverse events reported to the FDA. There were 273 cases reported to the FDA over the period from November 1, 1997 until January 2, 2002. This information has been previously presented (5). After reviewing the database, we requested copies of the individual case reports (MedWatch forms) in which cardiac adverse events were reported after the use of droperidol at doses of 1.25 mg or less. These forms contain the information voluntarily submitted to the FDA or to the drug manufacturer by consumers or health care professionals. The reporting person determined whether droperidol was the primary or secondary suspect. The content of these forms represents ALL the information that the FDA has about the reported cases. The information extracted from the MedWatch forms is presented in Table 1.