Leopold Eberhart

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.

Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomized controlled trials.

Shivering is a frequent complication in the postoperative period. The relative efficacy of interventions that are used for the treatment of postoperative shivering is not well understood. We performed a systematic search (MEDLINE, EMBASE, Cochrane Library, hand searching, all languages, to August, 2000) for full reports of randomized comparisons of any pharmacological antishivering intervention (active) with placebo (control) in the postoperative period. Dichotomous data on absence of further shivering after treatment and adverse effects were extracted from original reports. Relative risk (RR) and number-needed-to-treat (NNT) were calculated with 95% confidence interval (CI) using a fixed effect model. Data from 20 trials (944 adults received an active intervention, 413 were controls) were analyzed. Antishivering efficacy depended on the active regimen and the length of follow-up. Efficacy with meperidine 25 mg, clonidine 150 &mgr;g, ketanserin 10 mg, and doxapram 100 mg was reported in at least three trials; all were significantly more effective than control. After 1 min, the NNT of meperidine 25 mg for no further shivering compared with placebo was 2.7 (RR, 6.8; 95% CI, 2.5–18.5). After 5 min, the NNT of meperidine 25 mg was 1.3 (RR, 9.6; 95% CI, 5.7–16), the NNT of clonidine 150 &mgr;g was 1.3 (RR, 6.8; 95% CI, 3.3–14.2), the NNT of doxapram 100 mg was 1.7 (RR 4.0; 95% CI, 2.4–6.5), and the NNT of ketanserin 10 mg was 2.3 (RR 3.1; 95% CI, 1.9–5.1). After 10 min, the NNT of meperidine 25 mg was 1.5 (RR 4.0; 95% CI, 2.5–6.2). After 15 min, the NNT of ketanserin 10 mg was 3.3 (RR 1.5; 95% CI, 1.2–1.9). Long-term outcome data were lacking. There were not enough data for alfentanil, fentanyl, morphine, nalbuphine, lidocaine, magnesium, metamizol, methylphenidate, nefopam, pentazocine, and tramadol to draw meaningful conclusions. Reporting of adverse drug reactions was sparse. Fewer than two shivering patients need to be treated with meperidine 25 mg, clonidine 150 &mgr;g, or doxapram 100 mg for one to stop shivering within 5 min who would have continued to shiver had they all received a placebo.

Evaluation of three risk scores to predict postoperative nausea and vomiting

Background: So far there are three different scores to predict postoperative vomiting (PV: Apfel et al., 1998) or postoperative nausea and vomiting (PONV: Koivuranta et al., 1997; Palazzo and Evans, 1993). All three scores used logistic regression analysis to identify and create weights for the risk factors for PV or PONV. In short, these were sex, age, history of previous PONV, motion sickness, duration of anaesthesia, and use of postoperative opioids. However, an external evaluation and a comparison of these scores has not been performed so far.

Dimenhydrinate for prophylaxis of postoperative nausea and vomiting: a meta‐analysis of randomized controlled trials

Background: Diphenhydramine and its theoclate salt dimenhydrinate are traditional antiemetics still in use. However, so far the quantitative effect of dimenhydrinate in the prophylaxis of postoperative nausea and vomiting (PONV) has not been evaluated systematically.

The Efficacy and Safety of Transdermal Scopolamine for the Prevention of Postoperative Nausea and Vomiting: A Quantitative Systematic Review

The role of scopolamine administered via transdermal therapeutic systems in the prevention of postoperative vomiting, nausea, and nausea and vomiting is unclear. We performed a systematic search for full reports of randomized comparisons of transdermal scopolamine with inactive control. Dichotomous data were extracted. In the meta-analysis, relative risks and numbers-needed-to-treat/harm were calculated with 95% confidence intervals (CI). In 23 trials, 979 patients received transdermal scopolamine, and 984 patients received placebo. Sensitivity analyses were performed using restricted data for truncated control event rates (40%–80%) and for large trials. With these data, the relative risks for postoperative vomiting (five reports), nausea (five reports), nausea and vomiting (eight reports), and rescue treatment (three reports) were 0.69 (95% CI, 0.58–0.82), 0.69 (95% CI, 0.54–0.87), 0.76 (95% CI, 0.66–0.88), and 0.68 (95% CI, 0.54–0.85), respectively. This means that of 100 patients who receive transdermal scopolamine, approximately 17 will not experience postoperative vomiting who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, eight will report dry mouth, two will report dizziness, one will be classified as being agitated, and 1–13 patients who are prescribed transdermal scopolamine will not use it correctly. The timing of application does not alter efficacy.

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.

A Randomized, Double-blind Study to Evaluate the Efficacy and Safety of Three Different Doses of Palonosetron Versus Placebo in Preventing Postoperative Nausea and Vomiting Over a 72-hour Period

BACKGROUND: We designed this multicenter, randomized, double-blind study to assess the efficacy and safety of three doses of palonosetron, compared with placebo, on the incidence and severity of postoperative nausea and vomiting (PONV) in inpatients for 72 h after surgery. METHODS: Female patients undergoing either elective gynecological or breast surgery were stratified according to two additional PONV risk factors: nonsmoking status and history of PONV and/or motion sickness. Five hundred forty-four patients with one or both of these risk factors were randomized to receive one of the three doses of IV palonosetron (0.025 mg, 0.050 mg, 0.075 mg) or placebo immediately before induction of anesthesia. The primary efficacy end-point was complete response (CR: no emesis and no use of rescue medications) evaluated at the 0–24 and 24–72 h time intervals after surgery. RESULTS: CR rates for placebo and palonosetron 0.075 mg were 36% and 56% for 0–24 h (P = 0.001), 52% and 70% for 24–72 h (P = 0.002) and 36% and 52% (P = 0.010) for the 0–72 h postoperative interval. Palonosetron 0.075 mg was associated with less intense nausea (e.g., toward “mild” or “none”) versus placebo during the 0–24 h (P < 0.001) time interval and significantly delayed median time to emesis (P = 0.002) and treatment failure (P = 0.004). Although CR rates for both the 0.025 mg and 0.050 mg palonosetron doses were not statistically superior to placebo for the 0–24 h or 24–72 h periods, both lower doses reduced nausea severity during the 0–24 h period (P = 0.040 and P = 0.004). CONCLUSION: A single 0.075-mg IV dose of palonosetron effectively reduced the severity of nausea and delayed the time to emesis and treatment failure in the inpatient surgical setting; lower doses were not as effective.

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.

Comparison of surgical site and patient's history with a simplified risk score for the prediction of postoperative nausea and vomiting

Although site of surgery and previous occurrence of postoperative nausea and vomiting are often used to decide whether prophylactic anti‐emetic drugs are indicated, the value of these predictors is unclear. We compared these two risk factors against a simplified four‐factor risk score. We analysed data from 1566 adult inpatients who received balanced anaesthesia without prophylactic anti‐emetics. Sensitivity, specificity, predictive value and area under the receiver operating characteristic curve were used to quantify predictive properties. Nausea and vomiting occurred in 600 (38.3%) patients within 24 h. Sensitivity and specificity were, respectively, 47% and 59% for surgical site; 47% and 70% for history of postoperative nausea and vomiting; and 58% and 70% for risk score with three or more factors. The area under the curve for surgical site was 0.53 (95% CI 0.50–0.56); that for patients history was 0.58 (95% CI 0.56–0.61) while for risk score it was 0.68 (95% CI 0.66–0.71; P < 0.001). Prediction using surgical site or patients history alone was poor while the simplified risk score provided clinically useful sensitivity and specificity.