G. Geldner

The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients.

Risk scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0–14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery ≥30 min, age ≥3 yr, strabismus surgery, and a positive history of PV in the children or PV/postoperative nausea and vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68–0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.

Postoperative Analgesia and Functional Recovery After Total-Knee Replacement: Comparison of a Continuous Posterior Lumbar Plexus (Psoas Compartment) Block, a Continuous Femoral Nerve Block, and the Combination of a Continuous Femoral and Sciatic Nerve Block

Background and Objectives Continuous femoral nerve block is a well-accepted technique for regional analgesia after total-knee replacement. However, many patients still experience considerable pain at the popliteal space and at the medial aspect of the knee. The goal of this study is to evaluate whether a psoas compartment catheter provides better postoperative analgesia than a femoral nerve catheter does and whether it is as effective as the combination of a femoral and a sciatic nerve catheter and, thus, improves functional outcome. Methods Ninety patients who underwent total-knee replacement under standardized general anesthesia participated in this prospective randomized study. Group FEM received a continuous femoral nerve block, group FEM/SCI received a combination of a femoral and a sciatic continuous nerve block, and group PSOAS received a continuous psoas compartment block. Patient-controlled analgesia with piritramide was available for 48 hours. Maximal bending and extending of the knee and walking distance was assessed during the first 7 days. A standardized telephone survey was conducted after 9 to12 months to evaluate residual pain and functional outcome. Results Postoperative opioid consumption during 48 hours was significantly less in the FEM/SCI group (median: 18 mg; 25th/75th percentile: 6/40) compared with the FEM group (49 mg; 25/66) and the PSOAS group (44 mg; 30/62) (P =.002). Postoperative pain scores were not different, and no differences occurred with respect to short-term or long-term functional outcome. Conclusion The FEM/SCI catheter is superior to FEM and PSOAS catheter with respect to reduced analgesic requirements after total-knee replacement, but functional outcome does not differ with those 3 continuous regional analgesia techniques.

Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery.

Objectives/Hypothesis Controlled hypotension is used to improve surgical conditions during microscopic and endoscopic sinus surgery. New short‐acting anesthetics such as propofol and remifentanil allow exact control of intraoperative blood pressure and thus might be valuable tools to improve intraoperative conditions for the otorhinolaryngological surgeon. Intravenous anesthesia was compared with traditional balanced anesthesia by subjective assessment of surgical conditions made by two experienced otorhinolaryngological surgeons.

Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) are frequent and unpleasant symptoms. This prospective study aimed to assess the efficacy of a multimodal approach to prevent PONV, and patient satisfaction using the willingness‐to‐pay method. Two validated risk scores were applied to forecast the individual risk for PONV in 900 consecutive patients of whom 108 were identified as high‐risk patients (predicted risk: 79–87%). High‐risk patients received multimodal anti‐emetic prophylaxis: total intravenous anaesthesia with propofol, high fractional inspired oxygen (80%), omission of nitrous oxide, dexamethasone 8 mg, haloperidol 10 µg.kg−1, and tropisetron 2 mg. Of the remaining patients with low or moderate risk for PONV, a random sample of 71 females received balanced propofol‐desflurane anaesthesia without prophylactic anti‐emetics. All patients were interviewed 2 and 24 h after surgery for occurrence of nausea and vomiting. Patient satisfaction was measured using the willingness‐to‐pay method. The incidence of PONV (95%‐confidence interval) in the control‐group was 41% (29–51%), slightly lower than predicted by the risk scores (53–57%). The multimodal anti‐emetic approach reduced the predicted risk (79–87%) in the high risk‐group to 7% (3–14%). This was associated with a high willingness‐to‐pay median (25th/75th percentile) of £84 (£33–184) in the multimodal anti‐emetic grouped compared to £14 (£4–30) in the control group. A multimodal anti‐emetic approach can considerably reduce the incidence of PONV in high‐risk patients and is associated with a high patient satisfaction as measured by the willingness‐to‐pay method.

Incidence and duration of residual paralysis at the end of surgery after multiple administrations of cisatracurium and rocuronium

In a randomised, controlled, double‐blind, multicentre trial in 338 patients, we assessed the incidence of residual paralysis following administration of cisatracurium or rocuronium. The incidence at the end of surgery was significantly lower in patients treated with rocuronium (62 of 142 patients, 44%) than in those given cisatracurium (99 of 175 patients, 57%) (p < 0.05). In contrast, with rocuronium the mean (SD) time between skin closure and extubation was 28 (28) min vs 18 (19) min for cisatracurium, and the duration 0.9 (time from administration of last top‐up dose to recovery of the train‐of‐four ratio to 0.9) was significantly longer and more variable for rocuronium than for cisatracurium. Thus, after repeated administration, the duration and variability of duration of action are greater with rocuronium compared with cisatracurium. These pharmacodynamic differences do not necessarily translate into a higher incidence of residual paralysis, because clinicians compensate for the longer duration of action and variability of rocuronium by terminating administration of the neuromuscular blocking earlier.

Does Femoral Nerve Catheter Placement with Stimulating Catheters Improve Effective Placement? A Randomized, Controlled, and Observer-Blinded Trial

Continuous peripheral nerve blocks offer the benefit of extended postoperative analgesia and accelerated functional recovery after major knee surgery. Conventional nerve localization is performed over a stimulating needle followed by blind insertion of the peripheral catheter. Correct catheter placement is confirmed by testing for satisfactory analgesia. Stimulating catheters offer the advantage of verifying correct placement close to the nerve during catheter placement. The aim of this randomized trial was to determine whether accurate catheter positioning under continuous stimulation accelerates the onset of sensory and motor block, improves the quality of postoperative analgesia, and enhances functional recovery. We compared femoral nerve catheters inserted under continuous stimulation with catheters that were placed using the conventional technique of blind advancement in 81 patients undergoing major knee surgery. Time of catheter placement was similar in both groups with 4 min (3/7.3; median, 25th/75th percentile) in the conventional group and 5 min (4/8.8) in the stimulating catheter group. In both groups, 42% of the catheters could be correctly placed (motor response of the patella with a current ≤0.5 mA) at first attempt. In 22 patients (58%) of the stimulating catheter group, the catheter had to be redirected 1–20 times, including 2 that could not be correctly placed within 20 min. The onset time of sensory and motor block was almost similar in both groups. There were no differences in the postoperative IV opioid consumption, and visual analog scale pain scores at rest and movement, or maximal bending and stretching of the knee joint during the 5 days after surgery. We conclude that with continuous femoral nerve blocks, blind catheter advancement is as effective as the stimulating catheter technique with respect to onset time of sensory and motor block as well as for postoperative pain reduction and functional outcome.

Ginger does not prevent postoperative nausea and vomiting after laparoscopic surgery

IMPLICATIONS The potential antiemetic effect of two different oral doses of the herbal remedy ginger (Zingiber officinale) to prevent postoperative nausea and vomiting in 180 patients undergoing gynecologic laparoscopy was investigated in this randomized, double-blinded trial. Ginger failed to reduce the incidence of postoperative nausea and vomiting after these procedures.

Tropisetron zur Prophylaxe von Übelkeit und Erbrechen in der postoperativen Phase

ZusammenfassungFragestellung. Ziel der Untersuchung war die systematische Aufarbeitung randomisierter, kontrollierter Studien, in denen Tropisetron im Placebovergleich zur Prophylaxe von Übelkeit (PÜ) und Erbrechen (PE) in der postoperativen Phase untersucht wurde. Methodik. Nach systematischer Literatursuche (Cochrane-Library, MEDLINE, EMBASE, Literaturverzeichnisse; bis Dezember 2001) wurden die Inzidenzen für PÜ, PE bzw. PÜ und/oder PE (PÜ&E) extrahiert. Zudem wurden der Bedarf an zusätzlicher antiemetischer Medikation und unerwünschte Arzneimittelwirkungen erfasst. Ergebnisse. In 19 Studien und 22 Vergleichen erhielten 1.012 Patienten Placebo und 1.267 Patienten Tropisetron. Bei statistisch nicht zu sichernder Dosis-Wirkung-Beziehung zwischen 2 mg iv.-Gabe (4 Vergleiche) und 5 mg iv.-Gabe (12 Vergleiche) sind die zusammengefassten Effektdaten angegeben. Das relative Risiko (RR) für PÜ, PE und PÜ&E unter Prophylaxe mit Tropisetron lag bei 0,72 (95%-CI: 0,62–0,83), 0,59 (95%-CI: 0,47–0,73) und 0,70 (95%-CI: 0,62–0,79). Das RR für den Bedarf an antiemetischer Medikation lag bei 0,63 (95%-CI: 0,54–0,74); die hierfür berechnete NNT bei 5,6 (95%-CI: 4,0–9,1). Das RR bei Kindern für Dosierungen von 0,1–0,2 mg×kg−1 lag bei 0,49 (95%-CI: 0,38–0,63), 0,49 (95%-CI: 0,38–0,63) und 0,32 (95%-CI: 0,15–0,70) für PE, PÜ&E und Bedarfsmedikation. Für Erwachsene mit erhöhtem Risiko (Placeboinzidenz 40–80%) lag die NNT für PÜ bei 6,7 (95%-CI: 4,8–11,1). Unter gleicher Prämisse lag die NNT für PE bei 5,0 (95%-CI: 3,6–8,3), für PÜ&E bei 4,6 (95%-CI: 3,6–6,3). Bei erheblicher Differenz der Inzidenzen für unerwünschte Wirkungen innerhalb der untersuchten Studien, ergaben sich für keines der untersuchten Symptome signifikante Unterschiede zur Kontrollgruppe. Schlussfolgerungen. Die prophylaktische iv.-Gabe von mindestens 2 mg Tropisetron reduziert PÜ&E signifikant und klinisch relevant. Sie scheint außerdem gut verträglich zu sein. Für die 2-mg-Dosierung liegen allerdings nur wenige Untersuchungen vor. Bei Kindern ist eine Dosierung von 0,1 mg×kg−1 Körpergewicht effektiv. Für eine orale Applikation von Tropisetron fehlen Daten.SummaryObjective. A quantitative systematic review of randomised controlled trials investigating the efficacy of tropisetron versus placebo to prevent postoperative nausea (PN) and vomiting (PV) as well as PN and/or PV (PONV). Methods. The relevant results for the 24 h postoperative period were extracted from systematically searched studies (MEDLINE, EMBASE, Cochrane-Library, reference lists; last update December 2001). Results. In 19 studies and 22 comparisons, 1,012 patients received a placebo and 1,267 patients tropisetron and the pooled analyses (2–5 mg iv) are presented. The relative risks (RR) for PN, PV and PONV with tropisetron prophylaxis were 0.72 (95%-CI: 0.62–0.83), 0.59 (95%-CI: 0.47–0.73) and 0.70 (95%-CI: 0.62–0.79), respectively. The RR for rescue treatment was 0.63 (95%-CI: 0.54–0.74). The RR in children for a variable dose of 0.1-0.2 mg×kg−1 was 0.49 (95%-CI: 0.38–0.63), 0.49 (95%-CI: 0.38–0.63) and 0.32 (95%-CI: 0.15–0.70) for PV, PONV and rescue treatment, respectively. Restricting the analysis to a predefined control event rate of 40–80% revealed that about 6–7 patients need to be treated with tropisetron for PN to be prevented in 1 patient who would have had PN if all had received a placebo (NNT=6.7; 95%-CI: 4.8–11.1). The corresponding NNT for preventing PV and PONV was 5.0 (95%-CI: 3.6–8.3) and 4.6 (95%-CI: 3.6–6.3), respectively. Conclusion. Tropisetron significantly reduced the incidence of PONV. There is no clear evidence for a dose response between 2 and 5 mg iv. For children a dose of 0.1 mg×kg−1 of body weight is effective. Sufficient data for the oral application of tropisetron are lacking.

The use of neuromuscular monitoring in Germany

ZusammenfassungFragestellung. Ziel dieser Untersuchung war es die aktuellen Anwendungsgewohnheiten und die Arbeitsplatzverfügbarkeit des neuromuskulären Monitorings (NMM) in Deutschland zu untersuchen. Methodik. Dazu wurden 2.996 Fragebogen an die Leiter deutscher Anästhesieabteilungen und an freie Anästhesiepraxen versandt. Gefragt wurde nach der Arbeitsplatzausstattung mit NMM, welche Nervenstimulatoren verwendet werden und wozu sie verwendet werden. Darüber hinaus wurde untersucht,welche Faktoren den Einsatz des NMM begünstigen können. Ergebnisse. Von 2.054 Abteilungen gaben 574 (28%) an NMM regelmäßig zu verwenden. Das NMM wird signifikant häufiger regelmäßig zur intraoperativen Überwachung der neuromuskulären Blockade (25%) sowie zur Beurteilung der neuromuskulären Erholung (18%) angewendet als zum Festlegen des Intubationszeitpunktes (8%) bzw. postoperativ im Aufwachraum (p<0,01). Klinische Zeichen sind das mit Abstand häufigste Zeichen sowohl zur intraoperativen Nachrelaxierung als auch zur Indikationsstellung zur Antagonisation. Die Akzelerometer TOF-Guard® und TOF-Watch® werden signifikant häufiger eingesetzt als die “einfachen Nervenstimulatoren” (25% vs.10%; p<0,01). In Kliniken der Maximalversorgung waren häufiger NMM vorhanden als in anderen Krankenhäusern und in Anästhesiepraxen (p<0,01). Schlussfolgerungen. Nach wie vor wird NMM nur unregelmäßig eingesetzt. Insbesondere die seltene Verwendung zur Beurteilung der NM-Erholung gilt es im Interesse der Patienten zu verbessern.AbstractAim. As there are no reliable epidemiological data for the use of muscle relaxants in Germany,we conducted a mailing study. The aim of the study was to compare the use of muscle relaxants between German anaesthesia departments. In the present part of the presentation we focused on neuromuscular monitoring (NMM) and management of residual paralysis. Methods. A total number of 2,996 questionnaires were sent to all registered anaesthesiological facilities in Germany and the return was 68.6% (2054 questionnaires). Results. In 574 of the returned questionnaires (28%) the regular use of NMM was confirmed. Intraoperative monitoring of neuromuscular block and assessment of neuromuscular recovery were the most frequent applications of NMM, i.e. 25% and 18% of returned questionnaires, respectively. Clinical signs, however, are still the most popular way to estimate the degree of neuromuscular blockade. Moreover, routine reversal at the end of surgery with a neostigmin/atropine mixture was not practiced in 75% of the anaesthesia departments. Conclusions. This survey revealed that NMM is still very rarely used in daily clinical practice. Especially the seldom use of NMM to assess residual paralysis has to be improved.

Ist Ingwer ein klinisch relevantes Antiemetikum? Eine systematische Übersicht randomisierter kontrollierter Studien

Background and Objective: The aim of this systematic review was to evaluate the clinical impact of ginger (Zingiber officinale) as an antiemetic. Methods: A systematic search of the literature was performed using the databases of MEDLINE, EMBASE, and the Cochrane-Library. Results: Of 100 published reports discerned as potentially relevant, 24 randomized controlled trials were evaluated, covering 1073 patients which had received ginger. Of these reports, 16 contained information regarding the antiemetic activity of the phytotherapeutic agent against kinetosis, postoperative nausea and vomiting (PONV), and morning sickness and hyperemesis gravidarum, respectively. Only a few studies were eligible for a quantitative analysis (meta-analysis). Thus, the majority of the reports were analyzed descriptively. To analyze the potential side effects of the drug, 15 reports with 777 patients were eligible. Of these, 3.3% suffered from slight side effects, mainly mild gastrointestinal symptoms and sleepiness, both not requiring specific treatments. One severe adverse event was reported in a study: an abortion occurred in the 12th week of gestation. However, a total of 136 patients were treated with ginger within the first trimenon of pregnancy without complications. Conclusion: There is no clear evidence for the efficacy of ginger in the treatment of PONV and of kinetosis. The results for the treatment of nausea and vomiting in pregnancy are encouraging, however, ginger should be applied for the time being only in controlled clinical studies. Applied in daily doses up to 6 g ginger seems to be a drug with few side effects.BACKGROUND AND OBJECTIVE The aim of this systematic review was to evaluate the clinical impact of ginger (Zingiber officinale) as an antiemetic. METHODS A systematic search of the literature was performed using the databases of MEDLINE, EMBASE, and the Cochrane-Library. RESULTS Of 100 published reports discerned as potentially relevant, 24 randomized controlled trials were evaluated, covering 1073 patients which had received ginger. Of these reports, 16 contained information regarding the antiemetic activity of the phytotherapeutic agent against kinetosis, postoperative nausea and vomiting (PONV), and morning sickness and hyperemesis gravidarum, respectively. Only a few studies were eligible for a quantitative analysis (meta-analysis). Thus, the majority of the reports were analyzed descriptively. To analyze the potential side effects of the drug, 15 reports with 777 patients were eligible. Of these, 3.3% suffered from slight side effects, mainly mild gastrointestinal symptoms and sleepiness, both not requiring specific treatments. One severe adverse event was reported in a study: an abortion occurred in the 12th week of gestation. However, a total of 136 patients were treated with ginger within the first trimenon of pregnancy without complications. CONCLUSION There is no clear evidence for the efficacy of ginger in the treatment of PONV and of kinetosis. The results for the treatment of nausea and vomiting in pregnancy are encouraging, however, ginger should be applied for the time being only in controlled clinical studies. Applied in daily doses up to 6 g ginger seems to be a drug with few side effects.