Peter Kranke

Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting

The present guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in postoperative nausea and vomiting (PONV) under the auspices of The Society of Ambulatory Anesthesia. The panel critically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. In brief, these guidelines identify risk factors for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic monotherapy and combination therapy regimens for PONV prophylaxis; recommend approaches for treatment of PONV when it occurs; and provide an algorithm for the management of individuals at increased risk for PONV.

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials

BACKGROUND Thoracic paravertebral blocks (PVBs) are successfully performed for pain management after breast surgery. The aim of the present quantitative systematic review was to assess the efficacy and adverse events of PVB in women undergoing breast surgery. METHODS The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated using the RevMan statistical software for dichotomous and continuous outcomes, respectively. Pain scores were converted to a scale ranging from 0 (no pain) to 10 (worst pain). RESULTS Fifteen randomized controlled trials (published between 1999 and 2009) including 877 patients met the inclusion criteria. There was a significant difference in worst postoperative pain scores between PVB and general anaesthesia (GA) at <2 h (MD: -2.68; 95% CI: -3.33 to -2.02; P<0.00001), 2-24 h (MD: -2.34; 95% CI: -2.42 to -1.12; P<0.00001), and 24-48 h (MD: -1.75; 95% CI: -3.19 to 0.31; P=0.02). Accordingly, lower pain scores were observed for combined PVB with GA compared with GA alone for <2 h (MD: -1.87; 95% CI: -2.53 to -1.21; P<0.00001), 2-24 h (MD: -2.21; 95% CI: -3.07 to -1.35; P<0.00001), and 24-48 h (MD: -1.80; 95% CI: -2.92 to 0.68; P=0.002). The RR for the reported adverse events (e.g. pneumothorax) was low. CONCLUSIONS There is considerable evidence that PVB in addition to GA or alone provide a better postoperative pain control with little adverse effects compared with other analgesic treatment strategies.

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.

Systematic review of hyperbaric oxygen in the management of chronic wounds.

Many therapeutic options exist for chronic wounds. Hyperbaric oxygen therapy (HBOT) is one such option. It may be used for diabetic, venous, arterial and pressure ulcers.

Impact of Epidural Analgesia on Mortality and Morbidity After Surgery Systematic Review and Meta-analysis of Randomized Controlled Trials

Objective:To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia. Background:It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality. Methods:We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint. Results:A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39–0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients. Conclusions:In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk–benefit analyses and professional care are recommended.

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.

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.

Remote Ischemic Conditioning to Protect against Ischemia-Reperfusion Injury: A Systematic Review and Meta-Analysis

Background Remote ischemic conditioning is gaining interest as potential method to induce resistance against ischemia reperfusion injury in a variety of clinical settings. We performed a systematic review and meta-analysis to investigate whether remote ischemic conditioning reduces mortality, major adverse cardiovascular events, length of stay in hospital and in the intensive care unit and biomarker release in patients who suffer from or are at risk for ischemia reperfusion injury. Methods and Results Medline, EMBASE and Cochrane databases were searched for randomized clinical trials comparing remote ischemic conditioning, regardless of timing, with no conditioning. Two investigators independently selected suitable trials, assessed trial quality and extracted data. 23 studies in patients undergoing cardiac surgery (15 studies), percutaneous coronary intervention (four studies) and vascular surgery (four studies), comprising in total 1878 patients, were included in this review. Compared to no conditioning, remote ischemic conditioning did not reduce mortality (odds ratio 1.22 [95% confidence interval 0.48, 3.07]) or major adverse cardiovascular events (0.65 [0.38, 1.14]). However, the incidence of myocardial infarction was reduced with remote ischemic conditioning (0.50 [0.31, 0.82]), as was peak troponin release (standardized mean difference −0.28 [−0.47, −0.09]). Conclusion There is no evidence that remote ischemic conditioning reduces mortality associated with ischemic events; nor does it reduce major adverse cardiovascular events. However, remote ischemic conditioning did reduce the incidence of peri-procedural myocardial infarctions, as well as the release of troponin.