Single Dose of Dexamethasone for Prevention of Nausea and Vomiting After Major Gynaecological Surgery

BACKGROUND: Post-operative nausea and vomiting (PONV) is a common complications following general anaesthesia and is a leading cause of morbidity following surgery . The mainstay of management them is by the use of antiemetic.METHOD: It was a randomized double blind placebo controlled study. The sample size was calculated as 90 from previous study with 10% attrition to make the 100. They were randomly divided into two groups; group Breceived dexamethasone prophylactically at induction while group A received placebo also at induction. All patients had balanced general anaesthesia and were taken to the recovery room postoperatively whereincidences of postoperative nausea and vomiting were recorded. Patients with incidences of nausea and vomiting were treated with 10mg metoclopramide intravenously while postoperative complications thatmay be associated with dexamethasone prophylaxis were also noted.RESULTS: The groups were comparable with respect to demographic characteristics. More patients in group A(placebo group)) had incidence of nausea than group B (dexamethasone group) with p value of 0.01 and also more patients in group A had vomiting than group B with p value of 0.02; which was significant. The duration of stay in the recovery room for both groups A and B were however comparable with no statistical difference.CONCLUSION: Dexamethasone when given prophylactically at induction reduces incidence of postoperative nausea and vomiting after  gynaecological surgeries.KEYWORDS: Postoperative nausea (PONV), Dexamethasone, prophylaxis, gynaecology

Prospective, randomized, double blind, placebo controlled clinical study to different doses of ketamine for prevention of shivering during spinal anaesthesia

Background: Ketamine has better effect than other drugs like pethidine, fentanyl, clonidine, tramadol, midazolam in prevention of shivering during anaesthesia and has a role in thermoregulation by different means. The objective of this study was to evaluate the safety, efficacy of Ketamine injection and to compare the different doses (0.25 mg/kg and 0.5 mg/kg) of inj. Ketamine in prevention of shivering in operative patients under spinal anaesthesia.Methods: The present study was a prospective, randomized, double blinded and clinical study conducted in L.T.M.M.C & L.T.M.G.H, Mumbai, India during January 2012 to September 2013. 120 patients with American Society of Anesthesiologist (ASA) physical status of I or II, between the age of 18 – 65 years of either sex and height 150-170 cms were randomly selected and included in the study as per eligibility.Results: The study suggests that prophylactic administration of injection Ketamine at doses of 0.25 mg/kg and 0.5 mg/kg was producing a significant antishivering effect but an incidence of sedation and hallucination was observed in the Ketamine 0.5 mg/kg receiving group throughout the perioperative period.Conclusions: From this study we can conclude that prophylactic dose of Ketamine 0.25 mg/kg i.v. has lesser side effects comparison to Ketamine 0.5 mg/kg i.v. in prevention of shivering in patients, undergoing surgical procedure under spinal anaesthesia

Comparison of dexmedetomidine, pethidine and tramadol in the treatment of post-neuraxial anaesthesia shivering

Objective: This study was performed to compare the effectiveness of intravenous dexmedetomidine with that of pethidine and tramadol in the treatment of post-neuraxial anaesthesia shivering.Design: This was a prospective, randomised, double-blinded study.Setting and subjects: One hundred and two patients of both genders, aged 18–70 years with American Society of Anesthesiologists physical status I and II undergoing spinal or combined spinal and epidural anaesthesia for elective surgery were enrolled in this study. Sixty of them developed shivering after an intrathecal injection of 0.5% hyperbaric bupivacaine 15 mg. They were then randomly allocated to receive either intravenous dexmedetomidine 0.5 μg/kg, pethidine 0.5 mg/kg or tramadol 0.5 mg/kg.Outcome measures: The response rate to treatment, the degree of sedation and the side-effects were recorded.Results: The response rate to treatment was highest in the dexmedetomidine group, and it was only significant when compared to tramadol group (p = 0.0012). It was noted that the response rate was higher in the pethidine than in the tramadol group. This difference was not statistically significant (p = 0.082). The sedation score post treatment was similar in all three groups, but more patients in the dexmedetomidine group developed hypotension and bradycardia (p < 0.05).Conclusion: Dexmedetomidine 0.5 μg/ml was more effective than tramadol 0.5 mg/ml and pethidine 0.5 mg/ml, and both tramadol and pethidine were found to have similar efficacy, in the treatment of post-neuraxial anaesthesia shivering. However, dexmedetomidine caused a higher incidence of  hypotension and bradycardia.Keywords: dexmedetomidine, pethidine, post-neuraxial anaesthesia shivering, tramado

Eliminating Postoperative Nausea and Vomiting in Outpatient Surgery with Multimodal Strategies including Low Doses of Nonsedating, Off-Patent Antiemetics: Is “Zero Tolerance“ Achievable?

For ondansetron, dexamethasone, and droperidol (when used for prophylaxis), each is estimated to reduce risk of postoperative nausea and/or vomiting (PONV) by approximately 25%. Current consensus guidelines denote that patients with 0–1 risk factors still have a 10–20% risk of encountering PONV, but do not yet advocate routine prophylaxis for all patients with 10–20% risk. In ambulatory surgery, however, multimodal prophylaxis has gained favor, and our previously published experience with routine prophylaxis has yielded PONV rates below 10%. We now propose a “zero-tolerance” antiemetic algorithm for outpatients that involves routine prophylaxis by first avoiding volatile agents and opioids to the extent possible, using locoregional anesthesia, multimodal analgesia, and low doses of three nonsedating off-patent antiemetics. Routine oral administration (immediately on arrival to the ambulatory surgery suite) of perphenazine 8 mg (antidopaminergic) or cyclizine 50 mg (antihistamine), is followed by dexamethasone 4 mg i.v. after anesthesia induction (dexamethasone is avoided in diabetic patients). At the end of surgery, ondansetron (4 mg i.v., now off-patent) is added. Rescue therapy consists of avoiding unnecessary repeat doses of drugs acting by the same mechanism: haloperidol 2 mg i.v. (antidopaminergic) is prescribed for patients pretreated with cyclizine or promethazine 6.25 mg i.v. (antihistamine) for patients having been pretreated with perphenazine. If available, a consultation for therapeutic acupuncture procedure is ordered. Our approach toward “zero tolerance” of PONV emphasizes liberal identification of and prophylaxis against common risks

A meta-analysis of gabapentin and multimodal analgesics

Multimodal analgesia has been proposed as a useful strategy to reduce postoperative pain while decreasing opioid consumption and thus opioid adverse events. Gabapentin is one such agent although previous results have been heterogeneous. This thesis aimed to review randomised controlled trials of gabapentin for reducing pain, opioid adverse effects and the haemodynamic response to intubation while attempted to predict clinical effectiveness from these trials using meta-regression. Extending this principle, we evaluated other multimodal analgesic agents to identify whether heterogeneity could be explained by various clinical and methodological covariates. Our gabapentin review included 133 randomised controlled trials and demonstrated its efficacy in reducing pain scores, opioid consumption and opioid adverse events such as nausea, vomiting and pruritus. However, gabapentin increased the risk of sedation. Gabapentin was effective at reducing the haemodynamic response to intubation in 29 randomised controlled trials although trials failed to report on clinically relevant outcomes. Gabapentin exhibited no pre-emptive analgesic effect in 4 randomised controlled trials. There was evidence of considerable statistical heterogeneity on meta-analysis of gabapentin for pain scores and 24-hour morphine consumption. Meta-regression analysis showed however that baseline risk predicted the majority of the heterogeneity between studies. Extending this approach to other multimodal analgesics from 344 randomised controlled trials; we demonstrated this was true for analgesic agents in general. In addition to baseline risk, methodological limitations, especially inadequate allocation concealment, explained some of the residual heterogeneity. There was evidence of funnel plot asymmetry for most analgesic agents, suggesting publication bias. However, this may be a product of trials with higher baseline risk having larger standard errors, rather than true publication bias. Indeed, when we simulated meta-analyses with no publication bias, with both effect size and standard deviations dependent on baseline risk, funnel plot asymmetry was still evident (p<0.001). Therefore, conventional funnel plots may be an unsuitable method of detecting publication bias where baseline risk predicts between-study heterogeneity. We present an alternative method using meta-regression residuals that corrects funnel plot asymmetry in the presence of no publication bias. Finally, due to concerns that methodological limitations exaggerated effect estimates, we used trial sequential analysis to determine whether sufficient low risk of bias evidence exists to reject type I and type II errors in the analyses of analgesic adjuncts. We demonstrated there is currently insufficient evidence from low risk of bias trials to be confident of the efficacy of the majority of analgesic adjuncts

A meta-analysis of gabapentin and multimodal analgesics

Multimodal analgesia has been proposed as a useful strategy to reduce postoperative pain while decreasing opioid consumption and thus opioid adverse events. Gabapentin is one such agent although previous results have been heterogeneous. This thesis aimed to review randomised controlled trials of gabapentin for reducing pain, opioid adverse effects and the haemodynamic response to intubation while attempted to predict clinical effectiveness from these trials using meta-regression. Extending this principle, we evaluated other multimodal analgesic agents to identify whether heterogeneity could be explained by various clinical and methodological covariates. Our gabapentin review included 133 randomised controlled trials and demonstrated its efficacy in reducing pain scores, opioid consumption and opioid adverse events such as nausea, vomiting and pruritus. However, gabapentin increased the risk of sedation. Gabapentin was effective at reducing the haemodynamic response to intubation in 29 randomised controlled trials although trials failed to report on clinically relevant outcomes. Gabapentin exhibited no pre-emptive analgesic effect in 4 randomised controlled trials. There was evidence of considerable statistical heterogeneity on meta-analysis of gabapentin for pain scores and 24-hour morphine consumption. Meta-regression analysis showed however that baseline risk predicted the majority of the heterogeneity between studies. Extending this approach to other multimodal analgesics from 344 randomised controlled trials; we demonstrated this was true for analgesic agents in general. In addition to baseline risk, methodological limitations, especially inadequate allocation concealment, explained some of the residual heterogeneity. There was evidence of funnel plot asymmetry for most analgesic agents, suggesting publication bias. However, this may be a product of trials with higher baseline risk having larger standard errors, rather than true publication bias. Indeed, when we simulated meta-analyses with no publication bias, with both effect size and standard deviations dependent on baseline risk, funnel plot asymmetry was still evident (p<0.001). Therefore, conventional funnel plots may be an unsuitable method of detecting publication bias where baseline risk predicts between-study heterogeneity. We present an alternative method using meta-regression residuals that corrects funnel plot asymmetry in the presence of no publication bias. Finally, due to concerns that methodological limitations exaggerated effect estimates, we used trial sequential analysis to determine whether sufficient low risk of bias evidence exists to reject type I and type II errors in the analyses of analgesic adjuncts. We demonstrated there is currently insufficient evidence from low risk of bias trials to be confident of the efficacy of the majority of analgesic adjuncts

POST DISCHARGE NAUSEA AND VOMITING IN AMBULATORY SURGICAL PATIENTS: INCIDENCE AND MANAGEMENT STRATEGIES

Approximately 65% of all surgeries are conducted in the outpatient surgery setting involving more than 35 million patients. Thirty-five to fifty percent of these outpatients will experience post discharge nausea and vomiting (PDNV), nausea and vomiting that occurs after discharge from the health care facility after surgery. A dearth of literature details the problems associated with nausea and vomiting experienced by patients after discharge home from outpatient surgery. The purposes of this dissertation were to (1) review the current knowledge in the area of post discharge nausea and vomiting; (2) present results of an integrative review of the research literature to determine best evidence for prevention of PDNV in adults or rescue of patients who suffer from post discharge nausea and vomiting (PDNV); (3) present a critical review and analysis of measurement of nausea and vomiting after discharge from outpatient surgery, and (4) present findings of a prospective research study. The purposes of the research study were to: 1) describe the incidence and severity of PDNV over a 7-day period in a sample of adult surgical patients undergoing outpatient surgeries under general anesthesia, 2) describe the pharmacologic and nonpharmacologic modalities of care used by patients with PDNV to manage it, 3) compare the incidence and severity of PDNV between those who do and do not use pharmacologic and nonpharmacologic modalities, and 4) determine outcomes associated with PDNV. This study was part of a multi-site study that had as a primary objective development of a simplified risk model for predicting patients most likely to suffer PDNV. In this research study we described the incidence and severity of PDNV in adult outpatients after ambulatory surgery, described the pharmacologic and nonpharmacologic modalities of care used by patients with PDNV to manage it, compared the incidence and severity of PDNV between those who do and do not use pharmacologic and nonpharmacologic modalities, and determined outcomes associated with PDNV

Alternative site for the placement of totally implantable vascular access device (TIVAD). A case report of two successful TIVAD implantations in the thigh after femoral vein catheterization

Background: Totally implantable venous access devices (TIVADs) have improved the quality of life for seriously ill and cancer patients. These devices represent a convenient option when long-term venous access is indicated. The Subclavian and Internal Jugular Veins are the vessels of choice for catheterization [1]. However, if it is not possible to catheterize them, an alternative vein should be sought for [2]. Femoral vein can be used in such cases [3].Clinical problem: In 2 cases, it was not possible to catheterise any vein ending in the Superior Vena Cava and implant a TIVAD in the chest wall, although this was very necessary for them. Femoral vein was chosen despite higher risk of complications.Case 1: A 47 years old female with a metastatic breast cancer and infected ulcerations of the anterior chest wall. Veins in both arms were occluded. Her implanted TIVAD could not be used. Case 2: A 44 years old female who had a newly diagnosed lung cancer and Superior Vena Cava Syndrome. She was treated by a high-dose anti-coagulants.Surgical intervention: The catheter was inserted in the left femoral vein using ultrasound-guided percutaneous technique. After making a small incision, PORT-A-CATH® II POWER P.A.C. single-lumen standard port was implanted subcutaneously in the anterior surface of the left thigh. Verification of the catheter’s tip intra-operatively was difficult in Case 1 due to fluoroscopy problems. Prior consideration of the required instruments prevented the occurrence of a similar problem in Case 2. We performed these operations in the University Hospital of Norrland in Sweden in 2013.Follow-up: Apart from later adjustment of the catheter positioning in Case 1, we did not get any complications or problems with the use of the TIVAD. Frequent flushing of the device was recommended. Patients’ and staff’s satisfaction were good. Conclusion: Placement of TIVAD in the thigh is to be considered when the veins of the neck and upper arm are not accessible or the area on the chest wall is not appropriate for implanting the device. Experience improves with more cases.References: 1- Di Carlo I, Toro A. Choice of venous sites. Surgical Implant/technique. Springer-Verlag, Italia, 2011;43-54. 2- Toro A, Mannino M, Cappello G et al. Totally implanted venous access devices implanted in saphenous vein. Relation between the reservoir site and comfort/discomfort of the patient. Ann Vasc Surg 2012;26(8):1127.e9-1127.e13. 3- Chen SY, Lin CH, Chang HM, Hsu HM, Yu JC. A safe and effective method to implant a totally implantable access port in patients with synchronous bilateral mastectomies: modified femoral vein approach. J Surg Oncol 2008;98(3):197-199