G. S. De Oliveira

Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery

BACKGROUND Glucocorticoids are commonly administered before ambulatory surgery, although their effects on quality of recovery are not well characterized. The purpose of this study was to evaluate the dose-dependent effects of dexamethasone on patient recovery using the Quality of Recovery 40 questionnaire (QoR-40) after ambulatory surgery. METHODS This prospective, double-blind trial studied 106 female subjects undergoing outpatient gynaecological laparoscopy. Subjects were randomized to receive saline, dexamethasone 0.05 mg kg(-1) or dexamethasone 0.1 mg kg(-1) before induction. The primary outcome was global QoR-40 at 24 h. Postoperative pain, analgesic consumption, side-effects, and discharge time were also evaluated. RESULTS Global median (IQR) QoR-40 after dexamethasone 0.1 mg kg(-1) 193 (192-195) was greater than dexamethasone 0.05 mg kg(-1) 179 (175-185) (P=0.004) or saline, 171 (160-182) (P<0.005). Median (IQR) morphine equivalents administered before discharge were 2.7 (0-6.3) mg after dexamethasone 0.1 mg kg(-1) compared with 5.3 (2.4-8.8) mg and 5.3 (2.7-7.8) mg after dexamethasone 0.05 mg kg(-1) and saline (P=0.02). Time to meet discharge criteria was 30 min shorter after dexamethasone 0.1 mg kg(-1) compared with saline (P=0.005). At 24 h, subjects receiving dexamethasone 0.1 mg kg(-1) had consumed less opioid analgesics, reported less sore throat, muscle pain, confusion, difficulty in falling asleep, and nausea compared with dexamethasone 0.05 mg kg(-1) and saline. CONCLUSIONS Dexamethasone demonstrated dose-dependent effects on quality of recovery. Dexamethasone 0.1 mg kg(-1) reduced opioid consumption compared with dexamethasone 0.05 mg kg(-1), which may be beneficial for improving recovery after ambulatory gynaecological surgery.

The association between allogeneic perioperative blood transfusion on tumour recurrence and survival in patients with advanced ovarian cancer

Objective: To evaluate the association between perioperative blood transfusion on the recurrence and survival of patient with advanced ovarian cancer.

Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies

Previous evidence suggested that 10 mg systemic metoclopramide is not effective to prevent postoperative nausea and/or vomiting (PONV) in patients receiving general anaesthesia. However, the evidence included data with questioned validity by the author Yoshitaka Fujii. The objective of the current study was to examine the effect of a systemic dose of 10 mg metoclopramide to prevent PONV. This quantitative systematic review was performed according to the PRISMA guidelines. A wide search was performed to identify randomized clinical trials that evaluated systemic 10 mg metoclopramide as a prophylactic agent to reduce PONV. Meta-analysis was performed using a random-effect model. Thirty trials evaluating the effect of 10 mg systemic metoclopramide in 3328 subjects on PONV outcomes were included. Metoclopramide reduced the incidence of 24 h PONV compared with control, odds ratio (OR) [95% confidence interval (CI)] of 0.58 (0.43-0.78), number needed to treat (NNT)=7.8. When evaluated as separate outcomes, metoclopramide also decreased the incidence of nausea over 24 h, OR (95% CI) of 0.51 (0.38-0.68), NNT=7.1, and vomiting over 24 h, OR (95% CI) of 0.51 (0.40-0.66), NNT=8.3. A post hoc analysis examining three studies with questioned validity performed by the author Yoshitaka Fujii that would meet criteria for inclusion in the current study did not demonstrate a significant benefit of metoclopramide compared with control on the incidence of 24 h PONV. Our findings suggest that metoclopramide 10 mg i.v. is effective to prevent PONV in patients having surgical procedures under general anaesthesia. Metoclopramide seems to be a reasonable agent to prevent PONV.

Peripheral nerve catheters in children: an analysis of safety and practice patterns from the pediatric regional anesthesia network (PRAN)

BACKGROUND Peripheral nerve catheters (PNCs) are used with increasing frequency in children. Although adult studies have demonstrated safety with this technique, there have been few safety studies in children. The main objective of the current investigation was to examine the incidence of PNC complications in children undergoing surgery. METHODS This is an observational, multi-institutional study using the Pediatric Regional Anesthesia Network (PRAN) database. Data pertaining to PNCs were entered prospectively into a secure, online database by each participating centre. Patient characteristics, anatomic location, localization techniques, medications used, and complications were recorded for each catheter. All complications and any sequelae were followed until resolution. RESULTS There were 2074 PNCs included in the study. 251 adverse events and complications were recorded, resulting in an overall incidence (95% CI) of complications of 12.1% (10.7-13.5%). The most common complications were catheter malfunction, block failure, infection, and vascular puncture. There were no reports of persistent neurologic problems, serious infection, or local anaesthetic systemic toxicity, resulting in an estimated incidence (95% CI) of 0.04% (0.001-0.2%). Patients who developed an infection had used the catheters for a greater number of days, median (IQR) of 4.5 (3-7) days compared with 3 (1-3) days in the patients who did not develop an infection, P<0.0001. CONCLUSIONS Our data support the safety of placing PNCs in children, with adverse event rates similar to adult studies. Catheter problems are common, yet minor, in severity.

Virtual airway simulation to improve dexterity among novices performing fibreoptic intubation.

We developed a virtual reality software application (iLarynx) using built‐in accelerometer properties of the iPhone® or iPad® (Apple Inc., Cupertino, CA, USA) that mimics hand movements for the performance of fibreoptic skills. Twenty novice medical students were randomly assigned to virtual airway training with the iLarynx software or no additional training. Eight out of the 10 subjects in the standard training group had at least one failed (> 120 s) attempt compared with two out of the 10 participants in the iLarynx group (p = 0.01). There were a total of 24 failed attempts in the standard training group and four in the iLarynx group (p < 0.005). Cusum analysis demonstrated continued group improvement in the iLarynx, but not in the standard training group. Virtual airway simulation using freely available software on a smartphone/tablet device improves dexterity among novices performing upper airway endoscopy.

Randomized comparison of experts and trainees with nasal and oral fibreoptic intubation in children less than 2 yr of age

BACKGROUND We hypothesized that the time to successful fibreoptic tracheal intubation through the nasal route would be faster than the oral route for both experts and trainees in children <2 yr of age. METHODS One hundred children, 24 months and under in age, were randomized to an operator (expert or trainee), and route (nasal or oral) for fibreoptic tracheal intubation. Three separate times were then measured: (i) time to first glottic view, (ii) time to carinal view, and (iii) total time to successful tracheal intubation. The number of attempts made, manoeuvres needed to obtain an adequate laryngeal view, and manoeuvres for tracheal tube passage were also recorded. RESULTS Time to successful tracheal intubation was significantly faster for experts than trainees. There was no difference in the time to tracheal intubation between the nasal and oral routes for experts. In trainees, intubation times were shorter for the nasal route-median (inter-quartile range) time (s) to carinal view was 35 (27-63) for the nasal route vs 59 (38-94) for the oral route (P=0.03), and the median time to successful tracheal intubation were 62 (49-122) vs 117 (61-224), P=0.05, for the nasal and oral routes, respectively. For trainees, the oral route required a greater number of airway manoeuvres for adequate laryngeal views and passage of the tracheal tube compared with the nasal route. CONCLUSIONS For clinicians with less experience in using paediatric bronchoscopes, fibreoptic tracheal intubation through the nasal route may be a more straightforward process than the oral route in children <2 yr of age. CLINICAL TRIAL REGISTRATION NCT02029300 (www.clinicaltrials.gov).

A randomised comparison of free-handed vs air-Q™ assisted fibreoptic-guided tracheal intubation in children < 2 years of age†

We prospectively compared free‐handed and air‐Q™ assisted fibreoptic‐guided tracheal intubation in children < 2 years of age. Eighty healthy children were enrolled and randomly assigned to a technique (free‐handed or air‐Q assisted) and operator (trainee or attending). Time, number of attempts and manoeuvres required were assessed. There was no difference in median (IQR [range]) time to successful tracheal intubation between the free‐handed (52.2 (34.8–67.7 [19.7–108.0]) s), and the air‐Q assisted (60.3 (45.5–75.1 [28.1–129.0]) s; p = 0.13) groups, or the number of attempts needed. The air‐Q assisted group required fewer manoeuvres to optimise the laryngeal view (median (IQR [range]) 0 (0–1 [0–2])) than the free‐handed group (1 (1–1 [0–3]); p < 0.001). In conclusion, fibreoptic‐guided tracheal intubation times were similar with and without the use of the air‐Q, but supraglottic airway devices may be a consideration for their other practical advantages.

A randomised comparison of the Ambu® AuraGain™ and the LMA® supreme in infants and children.

We conducted a randomised trial in 100 children in order to compare the clinical performance of the Ambu® AuraGain™ and the LMA® Supreme* for airway maintenance during mechanical ventilation. The primary outcomes were initial and 10‐min airway leak pressures. Ease, time and success rates for device and gastric tube insertion, fibreoptic grades of view, airway quality during anaesthetic maintenance, and complications were also assessed. There were no differences in the initial and ten min airway leak pressures between the Ambu AuraGain and LMA Supreme, median (IQR [range]) initial: 19 (16–22 [10–34]) vs 18 (14–24 [8–40]) cmH2O, p = 0.4; and ten min: 22 (18–26 [11–40]) vs 20 (16–26 [12–40]) cmH2O, p = 0.08, respectively. Ease, time and success rates for device placement, gastric tube insertion and complications were also not significantly different. Children receiving the LMA Supreme required more airway manouevers (7 vs 1 patient, p = 0.06) to maintain a patent airway. Our results suggest that the Ambu AuraGain may be a useful alternative to the LMA Supreme, as demonstrated by comparable overall clinical performance in children.

Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort

Background: Maximising patient comfort during and after surgery is a primary concern of anaesthetists and other perioperative clinicians, but objective measures of what constitutes patient comfort in the perioperative period remain poorly defined. The Standardised Endpoints in Perioperative Medicine initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials. Methods: We undertook a systematic review to identify measures of patient comfort used in the anaesthetic, surgical, and other perioperative literature. A multi‐round Delphi consensus process that included up to 89 clinician researchers was then used to refine a recommended list of outcome measures. Results: We identified 122 studies in a literature search, which were the basis for a preliminary list of 24 outcome measures and their definitions. The response rates for Delphi Rounds 1, 2, and 3 were 100% (n=22), 90% (n=79), and 100% (n=13), respectively. A final list of six defined endpoints was identified: pain intensity (at rest and during movement) at 24 h postoperatively, nausea and vomiting (0–6 h, 6–24 h, and overall), one of two quality‐of‐recovery (QoR) scales (QoR score or QoR‐15), time to gastrointestinal recovery, time to mobilisation, and sleep quality. Conclusions: As standardised outcomes will support benchmarking and pooling (meta‐analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery.

A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications

Background: There is a need for robust, clearly defined, patient‐relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research. Methods: A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three‐stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials. Results: From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions); (ii) pneumonia (12 definitions); and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition. Conclusions: A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.