Neera Sah

Aprepitant plus ondansetron compared with ondansetron alone in reducing postoperative nausea and vomiting in ambulatory patients undergoing plastic surgery.

Background: Postoperative nausea and vomiting is a major challenge in the perioperative setting. The incidence can be as high as 80 percent, and the majority of the symptoms among outpatients occur after discharge. This study evaluated the efficacy of a neurokinin-1 receptor antagonist (aprepitant) in reducing postoperative symptoms for up to 48 hours in patients undergoing outpatient plastic surgery. Methods: A prospective, double-blinded, randomized, two-arm evaluation of 150 ambulatory plastic surgery patients receiving a standardized general anesthetic, including postoperative nausea and vomiting prophylaxis with ondansetron and either aprepitant or placebo, was performed. The main outcome measures were the occurrence of vomiting and the severity of nausea for up to 48 hours postoperatively. Results: Overall, 9.3 percent of patients who received aprepitant versus 29.7 percent in group B had vomiting, with the majority of vomiting episodes occurring after hospital discharge. The Kaplan-Meier plot of the hazards of vomiting revealed an increased incidence of emesis in patients receiving ondansetron alone compared with the combination of ondansetron and aprepitant (p = 0.006). The incidence of nausea was not significantly different in the two groups. Severity of nausea, however, was significantly higher in those receiving ondansetron alone compared with those receiving ondansetron and aprepitant, as measured by a peak nausea score (p = 0.014) and by multivariate analysis of variance results comparing repeated verbal rating scale scores over 48 hours after surgery (p = 0.024). Conclusion: In patients undergoing plastic surgery, the addition of aprepitant to ondansetron significantly decreases postoperative vomiting rates and nausea severity for up to 48 hours postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Preemptive Analgesia With Bupivacaine for Segmental Mastectomy

Background and Objectives: Preemptive analgesia is the concept of providing analgesia before surgical incision, resulting in less postoperative pain. The purpose of this study is to determine if preemptive and/or postoperative local anesthetic infiltration of bupivacaine in patients undergoing segmental mastectomy results in less postoperative pain compared with patients receiving placebo. Methods: In this prospective, double-blinded study, 120 patients were randomized into 4 groups: group 1, preincisional (10 mL) and postoperative (10 mL) wound infiltration of 0.5% bupivicaine, (+Pre+Post); group 2, preincisional bupivacaine (10 mL) and postoperative infiltration (10 mL) of placebo (normal saline solution), (+Pre−Post); group 3, preincisional placebo (10 mL) and postoperative bupivacaine (10 mL), (−Pre+Post); or group 4, preincisional (10 mL) and postoperative infiltration of placebo (10 mL), (−Pre−Post). All patients received a standardized laryngeal mask general anesthetic. Data were recorded at the following time intervals: preoperative admission, postanesthesia care unit (PACU) admission, PACU stay, stepdown-unit admission, stepdown-unit stay, hospital discharge, and 24 hours post operation. Results: No difference was noted with respect to preoperative pain visual analog scale (VAS, 0-100 mm), surgical duration, PACU stay time, stepdown-unit stay time, incidence of postoperative nausea, or treatment for nausea in all measured time periods. The placebo group (group 4) had significantly higher mean pain VAS scores during the early postoperative period (PACU admission and PACU stay) compared to the other groups (PACU admission: group 1 = 2 ± 8, group 2 = 4 ± 11, group 3 = 3 ± 15, group 4 = 17 ± 21, P < .01; PACU stay: group 1 = 6 ± 13, group 2 = 6 ± 10, group 3 = 10 ± 21, group 4 = 20 ± 18, P < .01). Likewise, the number of patients who reported pain (pain frequency) was significantly higher in group 4 (placebo) compared with all other groups at PACU admission, PACU stay, stepdown-unit admission, and stepdown-unit stay (P ≤ .01). Conclusion: Preincisional and/or postoperative wound bupivacaine infiltration lacks preemptive analgesic effects for segmental mastectomy.

Transdermal scopolamine patch in addition to ondansetron for postoperative nausea and vomiting prophylaxis in patients undergoing ambulatory cosmetic surgery

STUDY OBJECTIVE To determine the efficacy of transdermal scopolamine in addition to ondansetron in decreasing the incidence of postoperative nausea and vomiting (PONV). DESIGN Randomized controlled trial. SETTING Academic hospital. PATIENTS 126 ASA physical status I and II patients undergoing outpatient plastic surgery with three or more risk factors for PONV. INTERVENTIONS Patients were randomly assigned to one of two groups to receive (Group 1) a transdermal scopolamine (TDS) patch or (Group 2), a placebo patch two hours before surgery. MEASUREMENTS Occurrence of vomiting, severity of nausea using a visual analog scale (VAS), rescue medication, pain intensity and pain medications, and side effects were recorded every hour until discharge from hospital, then every 4 hours thereafter for a total of 24 hours. MAIN RESULTS A statistically significant reduction in postoperative nausea between 8 and 24 hours in patients receiving TDS was noted. CONCLUSIONS Transdermal scopolamine in addition to ondansetron benefits patients at high risk for PONV undergoing outpatient plastic surgery for up to 20 hours after surgery.

Piriformis syndrome in a patient after cesarean section under spinal anesthesia

Objectives The diagnosis, pathogenesis, and treatment of piriformis syndrome as a cause of persistent buttock and hip pain after spinal anesthesia are presented in this case report. Case Report A 29-year-old woman presented 5 days after cesarean delivery with sudden onset of pain in the left buttock and left hip radiating to the posterior knee with fever. She was subsequently diagnosed with piriformis syndrome. Conclusions Back pain with radiation into the buttocks after spinal anesthesia is frequently attributed to the spinal procedure itself. However, prolonged sitting and weight bearing in the upright position after cesarean delivery can cause sciatic nerve compression at the sacroiliac joint with concomitant irritation, inflammation, and spasm of the piriformis muscle. Piriformis syndrome is frequently underdiagnosed in the obstetric population. Because the diagnosis of piriformis syndrome is based mainly on clinical signs and symptoms, the clinician must have a high index of suspicion.

Epidural Catheter Placement in Morbidly Obese Parturients with the Use of an Epidural Depth Equation prior to Ultrasound Visualization

Background. Previously, Balki determined the Pearson correlation coefficient with the use of ultrasound (US) was 0.85 in morbidly obese parturients. We aimed to determine if the use of the epidural depth equation (EDE) in conjunction with US can provide better clinical correlation in estimating the distance from the skin to the epidural space in morbidly obese parturients. Methods. One hundred sixty morbidly obese (≥40 kg/m2) parturients requesting labor epidural analgesia were enrolled. Before epidural catheter placement, EDE was used to estimate depth to the epidural space. This estimation was used to help visualize the epidural space with the transverse and midline longitudinal US views and to measure depth to epidural space. The measured epidural depth was made available to the resident trainee before needle insertion. Actual needle depth (ND) to the epidural space was recorded. Results. Pearsons correlation coefficients comparing actual (ND) versus US estimated depth to the epidural space in the longitudinal median and transverse planes were 0.905 (95% CI: 0.873 to 0.929) and 0.899 (95% CI: 0.865 to 0.925), respectively. Conclusion. Use of the epidural depth equation (EDE) in conjunction with the longitudinal and transverse US views results in better clinical correlation than with the use of US alone.

Perioperative dental injury at a tertiary care health system: An eight-year audit of 816,690 anesthetics

Among all complications of airway management, dental injury is the most common cause of patient complaints with medicolegal consequences. Over an 8-year period, data on dental injury were collected within a large university hospital system that included community, tertiary, and quaternary care centers. Patient characteristics were compared among all patients receiving anesthesia care using billing data collected from the same period. Of the 816,690 patients who received anesthesia care, there were 360 dental injuries, giving an overall incidence of 1:2,269 (0.044%). Patients receiving general anesthesia were at an increased risk for dental injuries, with an incidence of 1:1,754 (0.057%) compared with patients receiving monitored anesthesia care in whom the incidence was 1:12,500 (0.008%). Patients in the age group 18 to 65 years had a higher incidence of dental injuries of 1:1,818 (0.055%) compared with pediatric patients, who had an incidence of 1:7,692 (0.013%). Emergency procedures were not associated with an increased risk of dental injury in the 816,690 cases. However, of the 360 patients who sustained a dental injury, emergency procedures were associated with a higher incidence of injuring multiple teeth.

Epidural Labor Analgesia: Continuous Infusion Versus Patient-controlled Epidural Analgesia With Background Infusion Versus Without a Background Infusion

UNLABELLED The purpose of this study was to compare the total epidural dose of 3 commonly used labor epidural modalities. After local institutional review board approval, 195 laboring parturients received an epidural catheter for labor analgesia. All patients received an initial bolus of 0.1% ropivacaine (10 mL) and fentanyl (100 microg). Maintenance of labor analgesia consisted of ropivacaine 0.1% with fentanyl 2 microg/mL. Patients were then randomly assigned into 3 groups: Group 1 (continuous epidural infusion [CEI]), continuous infusion at 10 mL/h; group 2 (CEI + patient-controlled epidural analgesia [PCEA]), CEI at 5 mL/h with a demand dose of 5 mL allowed every 20 minutes with a 20 mL/h maximum dose; group 3 (PCEA), demand doses only of 5 mL every 15 minutes with a 20 mL/h maximum dose. Measured variables included total epidural dose, total bolus requests and boluses delivered, number of staff interventions, pain Visual Analog Scale (VAS; 0-100), modified Bromage scores, stage I and II labor duration, delivery outcome, and maternal satisfaction after delivery. No differences were noted with respect to pain VAS, modified Bromage scores, stage I and II labor duration, number of staff interventions, delivery outcome, and maternal satisfaction score. Total infusion dose was lower in demand dose only PCEA compared with CEI and CEI + PCEA groups (P = < .01). Demand dose-only PCEA results in less total epidural dose compared with CEI and CEI + PCEA without affecting labor duration, motor block, pain VAS, maternal and neonatal outcomes, and maternal satisfaction. PERSPECTIVE This article compares 3 commonly used labor epidural delivery modalities (traditional continuous epidural infusion, patient-controlled epidural analgesia with a background infusion, and demand dose-only patient-controlled epidural analgesia). Benefits in epidural dose reduction with demand dose only PCEA does not translate into improved maternal and neonatal outcome.