Impact of Opioid-Free Anesthesia on Postoperative Nausea & Vomiting: A Scoping Review

Purpose The purpose of this DNP Scoping Review is to compare the current literature regarding the incidence of postoperative nausea and vomiting (PONV) in adult patients who underwent general anesthesia when opioids are used intraoperatively versus a multimodal non-opioid-based intraoperative general anesthetic plan Specific Aims: Incidence of postoperative nausea & vomiting Postoperative rescue antiemetic administration Length of stay in postoperative anesthesia care unit (PACU) Incidence of intraoperative adverse event

Esmolol Compared to Fentanyl for Hemodynamic Attenuation during Intubation: A Scoping Review

Purpose/Background Endotracheal intubation and laryngoscopy potentiate the cardiovascular response in the form of hypertension, tachycardia, and ventricular arrhythmias. Suppression of this adrenergic response is necessary to ensure patient safety. Currently, anesthesia providers employ many methods to attenuate the sympathetic response without established guidelines. As such, our project aimed to determine the effectiveness of fentanyl compared to esmolol in attenuating the hemodynamic response during laryngoscopy and endotracheal intubation within the first five minutes and throughout the intraoperative period. Methods A literature review was completed of ten critically appraised articles from the years 2011-2022. Articles in the review included randomized control studies, peer reviews, evidence-based practice, comparative studies, and meta-analyses. All articles included must have addressed fentanyl or esmolol groups associated with hemodynamics before and after intubation. A level of evidence outcomes table was composed to provide a synthesis of results from the ten chosen articles. Results Of the multiple articles reviewed, the majority concluded fentanyl was the better choice to administer before induction for attenuating hemodynamic responses to intubation. Many studies differ in the patient populations evaluated, but overall, fentanyl caused the least number of hypertensive episodes. Esmolol was typically more effective on the heart rate response, while the combination of the two medications was more effective on the arterial pressure. However, such combination resulted in significant post-intubation hypotension, requiring an immediate response. Implications for Nursing Practice Results provided in this scoping review afforded the authors a diverse level of evidence that using fentanyl or esmolol can attenuate hemodynamic responses to endotracheal intubation. The individual need of each patient is highly regarded as the decision-making aspect of each case, with fentanyl as the preferred agent for overall hemodynamic stability. These findings suggest further evaluations regarding patient individualization are needed when choosing the appropriate drug for attenuating the hemodynamic response to intubation

Postoperative Nausea and Vomiting Implications in Neostigmine versus Sugammadex

Purpose/Background: Postoperative nausea and vomiting (PONV) is a frequent complaint in the postoperative period, which can delay discharge, result in readmission, and increase cost for patients and facilities. Inducing paralysis is common in anesthesia, as is utilizing the drugs neostigmine and sugammadex as reversal agents for non-depolarizing neuromuscular blockers. Many studies are available that compare these two drugs to determine if neostigmine increases the risk of PONV over sugammadex. Sugammadex has a more favorable pharmacologic profile and may improve patient outcomes by reducing PONV. Methods: This review included screening a total of 39 studies and peer-reviewed articles that looked at patients undergoing general anesthesia who received non-depolarizing neuromuscular blockers requiring either neostigmine or sugammadex for reversal, along with their respective PONV rates. 8 articles were included, while 31 articles were removed based on our exclusion criteria. These were published between 2014 and 2020 exclusively. The key words used were “neostigmine”, “sugammadex”, “PONV”, along with combinations “paralytic reversal agents and PONV”. This search was performed on the scholarly database MEDLINE. The data items were PONV rates in neostigmine group, PONV rates in sugammadex group, incidence of postoperative analgesic consumption in neostigmine group, and incidence of postoperative analgesic consumption in sugammadex group. Results: Despite numerical differences being noted in the incidence of PONV with sugammadex over reversal with neostigmine, there did not appear to be any statistically significant data in the multiple peer-reviewed trials included in our review, for not one of the 8 studies concluded that there was a higher incidence of PONV in one drug or the other of an y clinical relevance. Although the side-effect profile tended to be better in the sugammadex group than neostigmine in areas other than PONV, there was not sufficient evidence to conclude that one drug was superior to the other in causing a direct reduction of PONV. Implications for Nursing Practice: There were variable but slight differences noted between both drug groups in PONV rates, but it remained that none of the studies determined it was statically significant or clinically conclusive. This review did, however, note other advantages to sugammadex over neostigmine, including its pharmacologic profile of more efficiently reversing non-depolarizing neuromuscular blocking drugs and its more favorable pharmacokinetics. This lack of statistically significant evidence found within these studies consequentially does not support pharmacologic decision-making of one drug in favor of the other for reducing PONV; therefore, PONV alone is not a sufficient rationale for a provider to justify using one reversal over another at the current time until further research proves otherwise

Pain Control: Opioid vs. Nonopioid Analgesia During the Immediate Postoperative Period

Background Opioid analgesia has become the mainstay for acute pain management in the postoperative setting. However, the use of opioid medications comes with significant risks and side effects. Due to increasing numbers of prescriptions to those with chronic pain, opioid medications have become more expensive while becoming less effective due to the buildup of patient tolerance. The idea of opioid-free analgesic techniques has rarely been breached in many hospitals. Emerging research has shown that opioid-sparing approaches have resulted in lower reported pain scores across the board, as well as significant cost reductions to hospitals and insurance agencies. In addition to providing adequate pain relief, the predicted cost burden of an opioid-free or opioid-sparing approach is significantly less than traditional methods. Methods The following groups were considered in our inclusion criteria: those who speak the English language, all races and ethnicities, male or female, home medications, those who are at least 18 years of age and able to provide written informed consent, those undergoing inpatient or same-day surgical procedures. In addition, our scoping review includes the following exclusion criteria: those who are non-English speaking, those who are less than 18 years of age, those who are not undergoing surgical procedures while admitted, those who are unable to provide numeric pain score due to clinical status, those who are unable to provide written informed consent, and those who decline participation in the study. Data was extracted by one reviewer and verified by the remaining two group members. Extraction was divided as equally as possible among the 11 listed references. Discrepancies in data extraction were discussed between the article reviewer, project editor, and group leader. Results We identified nine primary sources addressing the use of ketamine as an alternative to opioid analgesia and post-operative pain control. Our findings indicate a positive correlation between perioperative ketamine administration and postoperative pain control. While this information provides insight on opioid-free analgesia, it also revealed the limited amount of research conducted in this area of practice. The strategies for several of the clinical trials limited ketamine administration to a small niche of patients. The included studies provided evidence for lower pain scores, reductions in opioid consumption, and better patient outcomes. Implications for Nursing Practice Based on the results of the studies’ randomized controlled trials and meta-analyses, the effects of ketamine are shown as an adequate analgesic alternative to opioids postoperatively. The cited resources showed that ketamine can be used as a sole agent, or combined effectively with reduced doses of opioids for multimodal therapy. There were noted limitations in some of the research articles. Not all of the cited studies were able to include definitive evidence of proper blinding techniques or randomization methods. Small sample sizes and the inclusion of specific patient populations identified within several of the studies can skew data in one direction or another; therefore, significant clinical results cannot be generalized to patient populations across the board

Intraoperative Dexmedetomidine for Reduction of Postoperative Delirium in the Elderly: A Scoping Review

Background/Purpose: Post-operative delirium leads to significant morbidity in elderly patients, yet there is no regimen to prevent POD. Opioid use in the elderly surgical population is of the most significant risk factors for developing POD. The purpose of this scoping review is to recognize that Dexmedetomidine mitigates cognitive dysfunction secondary to acute pain and the use of narcotic analgesia by decreasing the amount of norepinephrine (an excitatory neurotransmitter) released during times of stress. This mechanism of action also provides analgesia through decreased perception and modulation of pain. Methods: The authors developed eligibility criteria for inclusion of articles and performed a systematic search of several databases. Each of the authors initially selected five articles for inclusion in the scoping review. We created annotated literature tables for easy screening by co-authors. After reviewing the annotated literature table four articles were excluded, leaving 11 articles for inclusion in the scoping review. There were six level I meta-analysis/systematic reviews, four level II randomized clinical trials, and one level IV qualitative research article. Next, we created a data-charting form on Microsoft Word for extraction of data items and synthesis of results. Results: Two of the studies found no significant difference in POD between dexmedetomidine groups and control groups. The nine remaining studies noted decreases in the rate, duration, and risk of POD in the groups receiving dexmedetomidine either intraoperatively or postoperatively. Multiple studies found secondary benefits in addition to decreased POD, such as a reduction of tachycardia, hypertension, stroke, hypoxemia, and narcotic use. One study, however, found that the incidence of hypotension and bradycardia were increased among the elderly population. Implications for Nursing Practice: Surgery is a tremendous stressor in any age group, but especially the elderly population. It has been shown postoperative delirium occurs in 17-61% of major surgery procedures with 30-40% of the cases assumed to be preventable. Opioid administration in the elderly surgical population is one of the most significant risk factors for developing POD. With anesthesia practice already leaning towards opioid-free and opioid-limited anesthetic, the incorporation of dexmedetomidine could prove to be a valuable resource in both reducing opioid use and POD in the elderly surgical population. Although more research is needed, the current evidence is promising

Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines: A Comprehensive Interdisciplinary Approach

Purpose/Background Enhance Recovery After Surgery (ERAS) protocols are multimodal transdisciplinary care guidelines that can improve clinical outcomes and cost savings. Although surgical practices currently vary significantly among healthcare institutions, perioperative outcomes and safety appear to improve with ERAS pathways. This scoping review evaluates patient outcomes and satisfaction in adult patients during their first week postoperatively while utilizing ERAS pathways. Methods This scoping review includes a variety of peer-reviewed and published academic journals within the last five years to guarantee the information surveyed is current. Even though this scoping review focuses on the interdisciplinary method to executing ERAS pathways, studies demonstrating alternate approaches were included to ratify evidence-based interventions. Databases utilized for this review include EBSCO, CINAHL, Pubmed, and Medline. The literature search resulted in 2,222 articles meeting initial criteria but was narrowed down based on level of evidence, citation, methodology, sample/setting, data analysis, description, results/findings, and evaluation of practice worth. Results Although many outcomes were examined throughout the literature, postoperative complications, patient outcomes, LOS, and potential savings were most common. Additionally, the RCTs included in this scoping review encompassed many measured results. Nearly all of the published ERAS trials and studies analyzed demonstrated a reduction in LOS and postoperative complications with the use of ERAS interventions when compared to traditional postoperative surgery guidelines. Implications for Nursing Practice Overwhelming evidence supports the implementation of standardized, evidence-based ERAS pathways to decrease surgical costs and improve surgical outcomes. However, variations in the capabilities of different healthcare systems currently limit the implantation of every possible ERAS intervention. Implications for nursing practice emphasize further implication and participation of standardized ERAS guidelines for surgical patients during all phases of their perioperative journey

Dexmedetomidine to Reduce PONV

Purpose/Background Postoperative nausea and vomiting (PONV) contribute to patient dissatisfaction, discomfort, adverse outcomes, and increased healthcare costs. Despite current protocols that aim to reduce PONV by prevention/antiemetic administration, PONV continues to be a common manifestation in many postoperative patients (Elvir-Lazo et al., 2020). This scoping review aimed to analyze available research on the efficacy of dexmedetomidine to reduce perioperative opioid requirements and PONV. Methods Synthesis of this scoping review began with a systematic approach to search databases and identify eligibility criteria articles. Of the 21 articles that met criteria, a synthesis table was formed to visualize the qualitative (smoking status, surgery type, medical history, etc.) and quantitative (sex, age, American Society of Anesthesiology (ASA) status, etc.) data points of interest. Ten articles were then selected for review via Rapid Critical Appraisal (RCA). Finally, each article’s comparison of two study groups (patients receiving dexmedetomidine without opioids and those who did not) were analyzed to find a direct correlation between dexmedetomidine administration and a decrease in PONV. Results For 100% of studies analyzed, dexmedetomidine reduced the incidence and severity of PONV. 90% of studies showed decreased perioperative opioid requirements. The method of dexmedetomidine administration was the most potent predictor of undesirable hemodynamic changes, highlighting the need for further research on appropriate dosing of dexmedetomidine when using it in an opioid-sparing manner to reduce PONV. Implications for Nursing Practice The evidence found highlights the efficacy of using dexmedetomidine to reduce perioperative opioid usage and PONV. Nevertheless, the practice of using two classes of antiemetics to prevent PONV remains the standard in anesthetic practice, making some providers hesitant to attempt using dexmedetomidine for this purpose. Providers should be educated on the findings of this scoping review, and further studies aiming to identify the efficacy of using dexmedetomidine should be conducted

Dexmedetomidine vs. Propofol in Postoperative Delirium Prevention

Purpose/Background Postoperative delirium (POD) is an acute neurological condition affecting large numbers of surgical patients in various practice settings. Patients suffering from this condition face postoperative complications, increased lengths of stay, and tremendous financial burden. Understanding the contributing factors for POD, and how adjustments in intraoperative agents can prevent or reduce the incidence, is a crucial aspect of anesthesia practice. This scoping review will examine associations between POD and the intraoperative use of propofol versus dexmedetomidine with general anesthesia. Methods Studies in this review were limited to peer-reviewed literature, published in medical and nursing journals within the last five years. All studies were in English and consisted of randomized controlled trials, systemic reviews, and meta-analyses. The studies compared a cohort of participants who received dexmedetomidine versus the mainstay agent, propofol, in the development of POD. Limitations were placed to assure that evidence was current, high quality, and relevant to the objectives. Results Nine of the ten studies used in this research favored dexmedetomidine use over propofol in the reduction of POD. The one study excluded had equal occurrences of POD in both propofol and dexmedetomidine groups. The use of different levels of evidence in this research provides significant results for advocating for the use of dexmedetomidine over propofol in the reduction of POD. Implications for Nursing Practice Dexmedetomidine has multiple promising implications for enhancing nursing practice. Unlike propofol, dexmedetomidine possesses analgesic properties, promoting postoperative recovery. Other advantages include reliable neurologic assessments, decreased POD, earlier extubation, decreased opioid administration, and earlier ambulation. These combined factors result in decreased overall length-of-stay and enhanced cost-effectiveness. If continued research supports these findings, future recommendation changes may suggest incorporating dexmedetomidine as the new standard of care for anesthetic protocols

Comparing the Effectiveness of Perioperative Ketorolac to Opioids: A Scoping Review

Abstract Purpose/Background Opioids are commonly administered in the perioperative period to manage surgical pain. However, the ongoing opioid epidemic in the United States makes it necessary to evaluate other modalities of pain management that do not cause respiratory depression, nausea, vomiting and addiction. Ketorolac is a nonsteroidal anti-inflammatory drug that can manage pain safely and effectively. This scoping review examines the available literature on the effectiveness and feasibility of using ketorolac to minimize perioperative opioid use. Methods A comprehensive literature review was performed between October 2020 and September 2021 utilizing five scholarly databases: GoogleScholar ™, PubMed, Ovid, Cochrane Library, and the University of Tennessee Health Science Center (UTHSC) library databases. The key terms searched were “narcotics,” “opioids,” “intraoperative,” “ketorolac,” and “Toradol.” 28 articles met the initial inclusion criteria and were subjected to a rapid critical appraisal by each team member. Fifteen articles were included in the final review and the results of the literature were organized in a synthesis table. Findings The literature surveyed in this scoping review suggests that perioperative ketorolac administration reduces postoperative opioid consumption and postoperative pain scores in adult patients undergoing a variety of surgical procedures. Furthermore, perioperative ketorolac administration significantly reduced the incidence of PONV and was not associated with any significant adverse effects or negative postoperative outcomes in adult surgical patients. Finally, the authors identified significant heterogeneity in the current data, which limited their ability to provide specific guidance for practice. Interpretations The scoping review authors suggest that further, more robust, and homogenous studies should be performed regarding the efficacy and safety of ketorolac in the perioperative period. In general, intraoperative ketorolac administration provided sufficient, opioid-sparing analgesia without the adverse effects of narcotics. Ketorolac is a valuable adjunct in a multimodal perioperative analgesia regiment. Anesthesia providers should strongly consider utilizing ketorolac as an alternative to perioperative opioids to improve postoperative patient outcomes and combat the opioid epidemic in America

Esmolol Compared to Fentanyl on Hemodynamic Effects: A Scoping Review

Purpose The purpose of this DNP project is to compare the efficacy of esmolol to fentanyl in attenuation the hemodynamic response associated with direct laryngoscopy. Specific Aims Compare the effects of esmolol to fentanyl on patient heart rate during laryngoscopy. Compare the effects of esmolol to fentanyl on patient mean arterial pressure during laryngoscopy