Influence of the menstrual cycle on the incidence of nausea and vomiting after laparoscopic gynecological surgery: a pilot study.

STUDY OBJECTIVE: To investigate whether the phase of menstrual cycle influences the incidence of postoperative nausea and vomiting (PONV) in women undergoing general anesthesia for elective laparoscopic gynecological surgery. DESIGN: Prospective, observational, blinded study. SETTING: General hospital, Postanesthesia Care Unit, and gynecologic floor room. PATIENTS: 111 ASA physical status 1 and 2 women, aged 18 to 53 years. INTERVENTIONS: Patients were classified into three groups according to the phase of menstrual cycle at the time of anesthesia: Group F1: follicular phase (menstrual days 1-8; n = 34); Group O2: ovulatory phase (days 9-15; n = 40); and Group L3: luteal phase (days 16 to end of cycle; n = 37). Anesthetic, postoperative pain management, and antiemetic regimens were standardized. MEASUREMENTS: Frequency of nausea, vomiting, or both were assessed for early (0-2 hrs). Late PONV (2-24 hrs) along with the use of rescue antiemetic, severity of nausea, and pain. MAIN RESULTS: In the follicular (n = 34), ovulatory (n = 40) and luteal phase (n = 37) groups, the frequencies of PONV over 24 hours were 35%, 38%, and 14% (P = 0.04), respectively. This was due to differences in the early postoperative period where the frequencies were 21%, 25%, and 3% (P = 0.02), respectively, as frequencies were similar in the late period (15%, 20% and 14%, P = 0.71), respectively. Nausea scores, rescue antiemetic usage, pain scores, and opioid consumption were similar in the groups. CONCLUSION: Patients in the luteal phase of their menstrual cycle may have a decreased risk of PONV after laparoscopic gynecological surgery in the early postoperative period

Root causes of intraoperative hypoglycemia: a case series.

STUDY OBJECTIVE: To describe the root causes of intraoperative hypoglycemic events. DESIGN: Retrospective analysis. SETTING: Large academic teaching hospital. MEASUREMENTS: Data from 80,379 ASA physical status 1, 2, 3, 4, and 5 surgical patients were reviewed. Blood glucose values, insulin, oral hypoglycemic medication doses, and doses of glucose or other medications for hypoglycemia treatment were recorded. MAIN RESULTS: Hypoglycemia in many patients had multiple etiologies, with many cases (8 of 17) involving preventable errors. The most common root causes of hypoglycemia were ineffective communication, circulatory shock, failure to monitor, and excessive insulin administration. CONCLUSION: Intraoperative hypoglycemia was rare, but often preventable. Better communication among providers and between providers and patients may reduce the number of intraoperative hypoglycemic events. Many transient episodes of hypoglycemia did not result in any apparent complications, rendering their clinical importance uncertain. Critically ill patients in circulatory shock represent a group that may require close glucose monitoring

Different Pharmacokinetics of Tramadol, O-Demethyltramadol and N-Demethyltramadol in Postoperative Surgical Patients From Those Observed in Medical Patients

Background: Most studies examining tramadol metabolism have been carried out in non-surgical patients and with oral tramadol. The aim of this study was 1) to measure concentrations of tramadol, O-demethyltramadol (ODT), and N-demethyltramadol (NDT) in the surgical patients admitted to the intensive care unit (ICU) within the first 24 postoperative hours after intravenous application of tramadol, and 2) to examine the effect of systemic inflammation on tramadol metabolism and postoperative pain.Methods: A prospective observational study was carried out in the surgical ICU in the tertiary hospital. In the group of 47 subsequent patients undergoing major abdominal surgery, pre-operative blood samples were taken for CYP2D6 polymorphism analysis. Systemic inflammation was assessed based on laboratory and clinical indicators. All patients received 100 mg of tramadol intravenously every 6 h during the first postoperative day. Postoperative pain was assessed before and 30 min after tramadol injections. Tramadol, ODT, and NDT concentrations were determined by high-performance liquid chromatography.Results:CYP2D6 analysis revealed 2 poor (PM), 22 intermediate (IM), 22 extensive (EM), and 1 ultrafast metabolizer. After a dose of 100 mg of tramadol, t1/2 of 4.8 (3.2–7.6) h was observed. There were no differences in tramadol concentration among metabolic phenotypes. The area under the concentration–time curve at the first dose interval (AUC1-6) of tramadol was 1,200 (917.9–1944.4) μg ×h ×L−1. NDT concentrations in UM were below the limit of quantification until the second dose of tramadol was administrated, while PM had higher NDT concentrations compared to EM and IM. ODT concentrations were higher in EM, compared to IM and PM. ODT AUC1-6 was 229.6 (137.7–326.2) μg ×h ×L−1 and 95.5 (49.1–204.3) μg ×h ×L−1 in EM and IM, respectively (p = 0.004). Preoperative cholinesterase activity (ChE) of ≤4244 U L−1 was a cut-off value for a prediction of systemic inflammation in an early postoperative period. NDT AUC1-6 were significantly higher in patients with low ChE compared with normal ChE patients (p = 0.006). Pain measurements have confirmed that sufficient pain control was achieved in all patients after the second tramadol dose, except in the PM.Conclusions:CYP2D6 polymorphism is a major factor in O-demethylation, while systemic inflammation accompanied by low ChE has an important role in the N-demethylation of tramadol in postoperative patients. Concentrations of tramadol, ODT, and NDT are lower in surgical patients than previously reported in non-surgical patients.Clinical Trial Registration: ClinicalTrials.gov, NCT04004481

Comparison of recovery after sugammadex or neostigmine reversal of rocuronium in geriatric patients undergoing spine surgery: a randomized controlled trial

Aim To evaluate the effect of sugammadex compared with neostigmine on speed and quality of recovery after rocuronium neuromuscular blockade (NMB) in geriatric patients undergoing posterior lumbar spine surgery. Methods This randomized controlled study at a tertiary academic medical center involved 40 patients (age ≥65 years, ASA PS II/III) scheduled for elective surgery under general anesthesia. Patients were randomized to sugammadex or neostigmine for reversal of moderate NMB with rocuronium. The primary outcome was recovery time from NMB after surgery to a train-of-four (TOF) ratio ≥0.9 measured at the adductor pollicis (TOF-Watch® SX). Secondary outcomes included hemodynamic change after administration of reversal agent (heart rate, blood pressure, dysrhythmia), time to extubation, pain medication requirement, time to first ambulation, and length of postanesthesia care unit (PACU) and total hospital stay. Results Sugammadex (4±2.2 min) compared with neostigmine reversal (26.3±17.5 min) was on average 22 min faster (95% CI 14.1-30.5; P≤0.001) with less variability (range 2-11 min vs 5-72 min). The groups significantly differed in time for tracheal extubation, response to verbal commands (open eyes, squeeze hand, lift head), and operating room exit. However, they had similar PACU stay, time to first ambulation, total hospital stay, postoperative pain, and opioid use. Sugammadex had less hemodynamic variability than neostigmine. No patient developed treatmentemergent dysrhythmias. Conclusion Sugammadex reversal significantly hastened NMB recovery compared with neostigmine reversal in geriatric patients. It significantly decreased operating room time but not PACU time or hospital sta

Intraoperative Accuracy of a Point-of-Care Glucose Meter Compared with Simultaneous Central Laboratory Measurements

Background: Concerns have been raised about the use of point-of-care (POC) glucose meters in the hospital setting. Accuracy has been questioned especially in critically ill patients. Although commonly used in intensive care units and operating rooms, POC meters were not approved by the Food and Drug Administration for such use. Data on POC glucose meter performance during anesthesia are lacking. We evaluated accuracy of a POC meter in the intraoperative setting. Methods: We retrospectively reviewed 4,333 intraoperative records in which at least one intraoperative glucose was measured using electronic medical records at a large academic hospital. We evaluated the accuracy of a POC glucose meter (ACCU-CHEK® Inform, Roche Pharmaceuticals) based on the 176 simultaneous central laboratory (CL) blood glucose (BG) measurements that were found (i.e., documented collection times within 5 minutes). Point-of-care and central lab BG differences were analyzed by Bland-Altman and revised error grid analysis (rEGA). Results: Mean POC BG was 163.4 ± 64.7 mg/dl [minimum (min) 48 mg/dl, maximum (max) 537 mg/dl] and mean CL BG was 162.6 ± 65.1 mg/dl (min 44 mg/dl, max 502 mg/dl). Mean absolute difference between POC and CL BG was 24.3 mg/dl. Mean absolute relative difference was 16.5% with standard deviation 26.4%. Point-of-care measurements showed a bias of 0.8 relative to the corresponding CL value, with a precision of 39.0 mg/dl. Forty (23%) POC BG values fell outside the Clinical and Laboratory Standards Institute guideline and 3.4% POC measurements fell in zones C and D of the rEGA plot. Conclusions: The tested POC glucose meter performed poorly compared to a CL analyzer intraoperatively. Perioperative clinicians should be aware of limitations of specific POC glucose meters, and routine use of POC glucose meters as sole measurement devices in the intraoperative period should be carefully considered

Intraoperative Insulin Administration and Hypoglycemia in Diabetic Patients

Introduction: Although studies are conflicting as to the benefit of intensive insulin therapy (IIT) in the critically ill, there is a 6x increase in hypoglycemia incidence in patients treated with IIT. Anesthesia masks signs and symptoms of hypoglycemia, making intraop hypoglycemia difficult to detect clinically. We performed this retrospective, observational analysis to: Determine the incidence of intraoperative hypoglycemia and severe hypoglycemia Evaluate possible causes of hypoglycemia Determine intraop monitoring and treatment practices of diabetic patients at a large academic hospita

Intraoperative Point-of-Care Blood Glucose Values Show Poor Agreement with Central Lab Blood Values

Introduction: Accuracy of point-of-care (POC) glucose devices compared to central lab values in critically ill patients has come into question, particularly during intensive insulin therapy. POC devices perform particularly poorly in the hypoglycemic range. Typically tested under ideal conditions in the lab; intraoperative, real-life data are lacking