Bernard V. Wetchler

A comparison of the efficacy, safety, and patient satisfaction of ondansetron versus droperidol as antiemetics for elective outpatient surgical procedures

Two identical, randomized, double-blind, placebo-controlled studies enrolled 2061 adult surgical outpatients at high risk of postoperative nausea and vomiting (PONV) to compare IV ondansetron 4 mg with droperidol 0.625 mg and droperidol 1.25 mg for the prevention of PONV. The antiemetic drugs or placebo were administered IV 20 min before the induction of anesthesia with a barbiturate compound, followed by maintenance with N2 O/isoflurane/enflurane. Nausea, emetic episodes, adverse events, and patient satisfaction were analyzed for the 0 to 2 h and 0 to 24 h postoperative periods. In the 0 to 2 h postoperative period, there was a complete response (no emesis or rescue antiemetic) in 46% of subjects given placebo (P < 0.05 versus antiemetic groups), in 62% given ondansetron, in 63% given droperidol 0.625 mg, and in 69% given droperidol 1.25 mg (P < 0.05 versus ondansetron). In the 0 to 24-h postoperative period, there were no significant differences in complete response between the ondansetron and droperidol 0.625 or 1.25 mg groups; all groups remained superior to placebo. The proportion of patients without nausea during the 0 to 24 h postoperative period was greater in the antiemetic groups compared with the placebo group; however, droperidol 1.25 mg was more effective than ondansetron 4 mg or droperidol 0.625 mg (43% vs 29% or 29%, respectively). Headache incidence was higher in the ondansetron group compared with either droperidol group. Patient satisfaction scores did not differ significantly among antiemetic treatment groups, although all were superior to placebo. In conclusion, all antiemetic treatment regimens were superior to placebo for the prevention of PONV in the immediate postoperative period; however, droperidol 1.25 mg was more efficacious than ondansetron during the early recovery period (0-2 h). There were no significant differences between ondansetron and either droperidol dose for emesis prevention during the 0 to 24 h postoperative period. Implications: More than 2000 patients at high risk of post-operative nausea and vomiting were given either placebo, ondansetron 4 mg, or droperidol 0.625 mg or 1.25 mg IV before the administration of general anesthesia. After surgery, the incidence of nausea, vomiting, medication side effects, and patient satisfaction were evaluated for 24 h. Droperidol 0.625 or 1.25 mg IV compared favorably with ondansetron 4 mg IV for the prevention of postoperative nausea and vomiting after ambulatory surgery. (Anesth Analg 1998;86:731-8)

A multicenter comparison of maintenance and recovery with sevoflurane or isoflurane for adult ambulatory anesthesia

Sevoflurane was compared with isoflurane in 246 adult ASA class I-III patients undergoing ambulatory surgery. After administration of midazolam 1-2 mg and fentanyl 1 microgram/kg, anesthesia was induced with propofol 2 mg/kg and maintained with either sevoflurane or isoflurane in 60% nitrous oxide to maintain arterial blood pressure at +/- 20% of baseline. Fresh gas flows were 10 L/min during induction and 5 L/min during maintenance. Times to eye opening, command response, orientation, and ability to sit without nausea and/or dizziness were significantly faster after sevoflurane. Significantly more sevoflurane patients met Phase 1 of postanesthesia care unit (PACU) Aldrete recovery criteria (> or = 8) at arrival, 95% vs 81%. Also, significantly more sevoflurane patients were able to complete psychomotor recovery tests during the first 60 min postanesthesia. Discharge times were not different. Sevoflurane patients had significantly lower incidences of postoperative somnolence (15% vs 26%) and of nausea both in the PACU (36% vs 51%) and in the 24-h postdischarge period (9% vs 24%). Patient satisfaction was high overall (sevoflurane 97%, isoflurane 93%). We conclude that sevoflurane is a useful inhaled anesthetic for maintenance of ambulatory anesthesia.

A double-blind, placebo-controlled pilot study examining the effectiveness of intravenous ondansetron in the prevention of postoperative nausea and emesis

STUDY OBJECTIVE To compare the efficacy and safety profiles of ondansetron and a placebo when infused immediately prior to anesthesia induction for the prevention of postoperative nausea and emesis (vomiting or retching). DESIGN Randomized, double-blind, placebo-controlled, parallel, multicenter pilot study. SETTING Three U.S. ambulatory surgical facilities. PATIENTS One hundred eighty ASA physical status I and II women scheduled to undergo ambulatory gynecologic surgical procedures while receiving general endotracheal anesthesia. INTERVENTIONS Ondansetron 8 mg or a placebo (equivalent volume) was given intravenously (IV) prior to anesthesia induction to prevent postoperative nausea and vomiting. MEASUREMENTS AND MAIN RESULTS For the first 24 hours following emergency from anesthesia, patients were monitored in the postanesthesia care unit by a research observer and at home via telephone contact and diary cards. More patients in the ondansetron group (62%) than in the placebo group (40%) were emesis-free over the 24-hour study period (p = 0.005). Ondansetron also was more efficacious than the placebo over the 24-hour study period when a surgery duration of more than 45 minutes was considered in the analyses. For all patients, regardless of surgery duration, there was a low degree of nausea during the course of the study. In all instances, the degree of nausea was slightly lower for ondansetron-treated patients than for placebo-treated patients; however, in no instances were the differences statistically significant. Ondansetron and placebo had similar safety profiles as established by laboratory test results, vital sign monitoring, and adverse event reporting. CONCLUSION Ondansetron, infused IV before anesthesia induction, appears to be safe and effective when used in the prevention of postoperative nausea and emesis.

Transnasal butorphanol tartrate for pain control following ambulatory surgery

Thirty patients who had undergone laparoscopic Yoon fallopian ring sterilization, laparotomy tubal sterilization, arthroscopy with meniscectomy, inguinal herniorrhaphy, or rectal surgery and who had moderate to severe postsurgical pain were enrolled in an open study conducted in an ambulatory surgical setting. Over a 3-day period after discharge from the surgical unit, patients self-administered transnasal butorphanol tartrate 0.5 mg under a flexible dosage regimen. Before surgery, patients were trained on the proper use of the nasal spray device for administering transnasal butorphanol. At the clinic before discharge, measurements of analgesia and safety were made at specified intervals. At discharge, patients were given a diary to record daily the number and time of drug administration, any adverse experiences, and global assessment of pain relief. At the clinic, 50% relief from baseline pain was achieved for the 30 patients after a mean total dose of 1.07 mg had been administered. The average time to 50% relief was 1 hour after the initial 0.5-mg dose. Of the patients who required analgesia at home, transnasal butorphanol provided satisfactory pain relief for 79% of the patients on day 1, 95% on day 2, and 91% on day 3. Adverse experiences were reported by 70% of the patients on day 1, with dizziness, nausea, and drowsiness, being the most frequent. On day 2, 36% reported such experiences, with headache and dizziness being the most frequent. Of the 11 patients who required medication on day 3, only one reported an adverse experience (sneezing). None of the adverse effects were serious. The results from this study support the usefulness of transnasal butorphanol in an ambulatory surgical setting for the management of pain when the use of an opioid analgesic is appropriate.

Bupivacaine infiltration of the mesosalpinx in ambulatory surgical laparoscopic tubal sterilization

Bupivacaine infiltration of the mesosalpinx was compared to lidocaine, normal saline or no injection for pain relief in women having elective laparoscopic tubal sterilization by Yoon fallopian ring application, One hundred women were assigned randomly to four groups. In a double-blind study, the mesosalpinx was infiltrated in three groups: Group I - lidocaine one per cent; Group II - bupivacaine 0.5 per cent; Group III - normal saline. Group IV (control) received no injection. Pain intensity was reported at four study times by the patients on a self-assessment pain intensity scale. Responses were compared using the Kruskall-Wallis H-Test and Wilcoxen’s Rank-Sum Test. Both tests indicated significant differences in pain intensity levels at various study times. The amount of supplemental fentany I given was used as a secondary measure of effectiveness. One-way analysis of variance (ANOVA) and Duncan’s Multiple-Range Test showed the bupivcaine group to receive significantly less fentanyl (p < 0.05) in the postanesthesia care unit.RésuméOn a comparé ľinfiltration de bupivacaine dans le mésosalpinx, è celle de la lidocaïne, du salin normal ou è aucune injection pour le soulagement de la douleur chez des femmes subissant une laparoscopie élective pour stérilisation tuhaire par anneaux de trompes de Yoon. On a réparti de façon aléatoire, 100 femmes en quatre groupes. Dans une étude è double insu, on a infiltré le mésosalpinx dans trois groupes: Groupe 1 - 1.0 pour cent de lidocaïne; Group II-0.5 pour cent de bupivacaine; Groupe III-salin normal. Le groupe IV (groupe-témoin) n’a pas reçu ď injection. Les patients ont rapporté ľintensité de leur douleur è quatre moments dans ľétude, en faisant une évaluation personnelle sur une échelle ďintensité de la douleur. On a comparé les réponses en utilisant le test H Kruskall-Wallis et le test de somme des rangs de Wilcoxen. Les deux tests démontraient des différences significatives dans les niveaux ďintensité de la douleur, è différents moments de ľétude. La quantité de fentanyl supplémentaire donnée a été utilisée comme mesure secondaire de ľefficacité. Une analyse de variance unidirectionnelle (ANOVA) et le,test è écarts multiples de Duncan ont démontré que le groupe bupivacaine recevait significativement moins de fentanyl (p < 0.05) dans ľunité des soins postanesthésiques.

What are the problems in the recovery room

SummaryAs more patients are provided with the compacted perioperative care that is part of outpatient surgery, the anaesthetist must assume an active role in recovery room problem solving, or we will find more patients than necessary will face unanticipated hospitalization following an outpatient procedure.