Tong J. Gan

Postoperative Pain Experience: Results from a National Survey Suggest Postoperative Pain Continues to Be Undermanaged

Postoperative pain can have a significant effect on patient recovery. An understanding of patient attitudes and concerns about postoperative pain is important for identifying ways health care professionals can improve postoperative care. To assess patients’ postoperative pain experience and the status of acute pain management, we conducted a national study by using telephone questionnaires. A random sample of 250 adults who had undergone surgical procedures recently in the United States was obtained from National Family Opinion. Patients were asked about the severity of postsurgical pain, treatment, satisfaction with pain medication, patient education, and perceptions about postoperative pain and pain medications. Approximately 80% of patients experienced acute pain after surgery. Of these patients, 86% had moderate, severe, or extreme pain, with more patients experiencing pain after discharge than before discharge. Experiencing postoperative pain was the most common concern (59%) of patients. Almost 25% of patients who received pain medications experienced adverse effects; however, almost 90% of them were satisfied with their pain medications. Approximately two thirds of patients reported that a health care professional talked with them about their pain. Despite an increased focus on pain management programs and the development of new standards for pain management, many patients continue to experience intense pain after surgery. Additional efforts are required to improve patients’ postoperative pain experience.

Consensus guidelines for managing postoperative nausea and vomiting

IMPLICATIONS We present evidence-based guidelines developed by an international panel of experts for the management of postoperative nausea and vomiting.

Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery.

Background Intraoperative hypovolemia is common and is a potential cause of organ dysfunction, increased postoperative morbidity, length of hospital stay, and death. The objective of this prospective, randomized study was to assess the effect of goal-directed intraoperative fluid administration on length of postoperative hospital stay. Methods One hundred patients who were to undergo major elective surgery with an anticipated blood loss greater than 500 ml were randomly assigned to a control group (n = 50) that received standard intraoperative care or to a protocol group (n = 50) that, in addition, received intraoperative plasma volume expansion guided by the esophageal Doppler monitor to maintain maximal stroke volume. Length of postoperative hospital stay and postoperative surgical morbidity were assessed. Results Groups were similar with respect to demographics, surgical procedures, and baseline hemodynamic variables. The protocol group had a significantly higher stroke volume and cardiac output at the end of surgery compared with the control group. Patients in the protocol group had a shorter duration of hospital stay compared with the control group: 5 ± 3 versus 7 ± 3 days (mean ± SD), with a median of 6 versus 7 days, respectively (P = 0.03). These patients also tolerated oral intake of solid food earlier than the control group: 3 ± 0.5 versus 4.7 ± 0.5 days (mean ± SD), with a median of 3 versus 5 days, respectively (P = 0.01). Conclusions Goal-directed intraoperative fluid administration results in earlier return to bowel function, lower incidence of postoperative nausea and vomiting, and decrease in length of postoperative hospital stay.

Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil and nitrous oxide anesthesia

Background: The bispectral index (BIS), a parameter derived from the electroencephalograph (EEG), has been shown to correlate with increasing sedation and loss of consciousness. This study determined whether addition of BIS monitoring to standard anesthetic practice results in improvements in the conduct of anesthesia or in patient outcomes. Methods: Three hundred two patients receiving a propofol‐alfentanil‐nitrous oxide anesthetic were studied at four institutions. Thirty‐four patients were initially enrolled to determine preexisting anesthetic practice and patient outcomes at each institution. Subsequent patients were randomized to either standard clinical practice (SP group), or standard practice plus BIS monitoring (BIS group). In all patients, the anesthesiologist attempted to provide a stable anesthetic with the fastest possible recovery. BIS was recorded for all patients, but viewed only in the BIS group. In the BIS group, propofol infusions were adjusted to achieve a target BIS between 45–60, increasing to 60–75 during the final 15 min of the case. In the SP group, propofol dose adjustments were made based only on standard clinical signs. Drug use, intraoperative responses, and patient recovery parameters were recorded. Results: Demographics were similar between groups. Compared with the SP group, patients in the BIS group required lower normalized propofol infusion rates (134 vs. 116 micro gram [center dot] kg sup ‐1 [center dot] min sup ‐1; P < 0.001), were extubated sooner (11.22 vs. 7.25 min; P < 0.003), had a higher percentage of patients oriented on arrival to PACU (43% vs. 23%; P < 0.02), had better postanesthesia care unit (PACU) nursing assessments (P < 0.001), and became eligible for discharge sooner (37.77 vs. 31.70 min; P < 0.04). There was no significant difference in the incidence of intraoperative responses between the groups. Conclusions: Titrating propofol with BIS monitoring during balanced anesthesia decreased propofol use and significantly improved recovery. Intraoperative course was not changed. These findings indicate that the use of BIS may be valuable in guiding the administration of propofol intraoperatively.

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.

The incidence of awareness during anesthesia: a multicenter United States study.

Awareness with recall after general anesthesia is an infrequent, but well described, phenomenon that may result in posttraumatic stress disorder. There are no recent data on the incidence of this complication in the United States. We, therefore, undertook a prospective study to determine the incidence of awareness with recall during general anesthesia in the United States. This is a prospective, nonrandomized descriptive cohort study that was conducted at seven academic medical centers in the United States. Patients scheduled for surgery under general anesthesia were interviewed in the postoperative recovery room and at least a week after anesthesia and surgery by using a structured interview. Data from 19,575 patients are presented. A total of 25 awareness cases were identified (0.13% incidence). These occurred at a rate of 1–2 cases per 1000 patients at each site. Awareness was associated with increased ASA physical status (odds ratio, 2.41; 95% confidence interval, 1.04–5.60 for ASA status III–V compared with ASA status I–II). Age and sex did not influence the incidence of awareness. There were 46 additional cases (0.24%) of possible awareness and 1183 cases (6.04%) of possible intraoperative dreaming. The incidence of awareness during general anesthesia with recall in the United States is comparable to that described in other countries. Assuming that approximately 20 million anesthetics are administered in the United States annually, we can expect approximately 26,000 cases to occur each year.

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.

Risk factors for postoperative nausea and vomiting

Knowledge of postoperative nausea and vomiting (PONV) risk factors allows anesthesiologists to optimize the use of prophylactic regimens. Modern PONV risk research began in the 1990s with publication of studies using logistic regression analysis to simultaneously identify multiple independent PONV predictors and publication of meta-analyses and systematic reviews. This literature shows that female gender post-puberty, nonsmoking status, history of PONV or motion sickness, childhood after infancy and younger adulthood, increasing duration of surgery, and use of volatile anesthetics, nitrous oxide, large-dose neostigmine, or intraoperative or postoperative opioids are well established PONV risk factors. Possible risk factors include history of migraine, history of PONV or motion sickness in a child’s parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration, increasing duration of anesthesia, general versus regional anesthesia or sedation, balanced versus total IV anesthesia, and use of longer-acting versus shorter-acting opioids. Early-phase menstruation, obesity and lack of supplemental oxygen are disproved risk factors. Current risk scoring systems have ∼55%–80% accuracy in predicting which patient groups will suffer PONV. Further research examining genetic and under-investigated clinical patient characteristics as potential risk factors, and involving outpatients and children, should improve predictive systems.

Perioperative fluid management and clinical outcomes in adults

The administration of IV fluid to avoid dehydration, maintain an effective circulating volume, and prevent inadequate tissue perfusion should be considered, along with the maintenance of sleep, pain relief, and muscular relaxation, a core element of the perioperative practice of anesthesia. Knowledge of the effects of different fluids has increased in recent years, and the choice of fluid type in a variety of clinical situations can now be rationally guided by an understanding of the physicochemical and biological properties of the various crystalloid and colloid solutions available. However, there are few useful clinical outcome data to guide this decision. Deciding how much fluid to give has historically been more controversial than choosing which fluid to use. A number of clinical studies support the notion that an approach based on administering fluids to achieve maximal left ventricular stroke volume (while avoiding excess fluid administration and consequent impairment of left ventricular performance) may improve outcomes. In this article, we review the available fluid types and strategies of fluid administration and discuss their relationship to clinical outcomes in adults.

Gabapentin and postoperative pain: a systematic review of randomized controlled trials

&NA; The objective of this systematic review was to evaluate the efficacy and tolerability of perioperative gabapentin administration for the control of acute postoperative pain. We searched Medline (1966–2006), the Cochrane Library (2006), Scopus, CINAHL and bibliographies from clinical trials and review articles. We included randomized controlled trials (RCTs) comparing gabapentin with inactive controls in surgical patients. Sixteen valid RCTs were included. Weighted mean difference (WMD) for postoperative pain intensity (0–100 mm visual analogue scale) was −16.55 mm at 6 h and −10.87 mm at 24 h for treatment with a single preoperative dose of gabapentin 1200 mg. Cumulative opioid consumption at 24 h was also significantly decreased with gabapentin (WMD, −27.90 mg). When gabapentin was administered at doses less than 1200 mg, pain intensity was also lower at 6 h (WMD, −22.43 mm) and 24 h (WMD, −13.18 mm). Cumulative 24 h opioid consumption was also lower (WMD, −7.25 mg). Gabapentin was associated with an increased risk of sedation (Peto OR 3.86; 95% CI 2.50–5.94) but less opioid‐related side effects such as vomiting (Peto OR 0.58; 95% CI 0.39–0.86) and pruritus (Peto OR 0.27; 95% CI 0.10–0.74). In conclusion, gabapentin has an analgesic and opioid‐sparing effect in acute postoperative pain management when used in conjunction with opioids.