scholarly journals Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery

2021 ◽  
Author(s):  
Helene Beloeil ◽  
Matthias Garot ◽  
Gilles Lebuffe ◽  
Alexandre Gerbaud ◽  
Julien Bila ◽  
...  
Keyword(s):  
Relative Risk ◽  
Adverse Events ◽  
Cognitive Dysfunction ◽  
Postoperative Nausea ◽  
Postoperative Nausea And Vomiting ◽  
Opioid Consumption ◽  
Nausea And Vomiting ◽  
Postanesthesia Care Unit ◽  
Balanced Anesthesia ◽  
Remifentanil Group

Background It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. Methods Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. Results The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay. Conclusions This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Prevention of Postoperative Nausea and Vomiting

2018 ◽  
pp. 147-152
Keyword(s):  
Risk Factors ◽  
Nitrous Oxide ◽  
Relative Risk ◽  
Adverse Events ◽  
Postoperative Nausea ◽  
Volatile Anesthetic ◽  
Postoperative Nausea And Vomiting ◽  
Nausea And Vomiting ◽  
Baseline Risk ◽  
Maximum Reduction

This case focuses on the prevention of postoperative nausea and vomiting (PONV) by asking the question: What is the efficacy of six well-established prophylactic antiemetic strategies individually and in combination for the prevention of postoperative nausea and vomiting? Each of the three antiemetics in this study (ondansetron, dexamethasone, and droperidol) reduced the risk for PONV by approximately 26%; substituting propofol for volatile anesthetic reduced the risk by 19%; and substituting nitrogen (air) for nitrous oxide reduced the risk by 12%. A maximum reduction of 70% in the relative risk for PONV can be expected when total intravenous anesthesia is used with three antiemetics. The appropriate approach to the management of PONV depends on the patient’s baseline risk factors as well as the likelihood of adverse events and costs from the antiemetic medications.

Alfentanil Causes Less Postoperative Nausea and Vomiting than Equipotent Doses of Fentanyl or Sufentanil in Outpatients 

1999 ◽  
Vol 91 (6) ◽  
pp. 1666-1666 ◽  
Author(s):  
Stephan Langevin ◽  
Martin R. Lessard ◽  
Claude A. Trépanier ◽  
Jean-Pierre Baribault
Keyword(s):  
Postoperative Nausea ◽  
Randomized Study ◽  
Recovery Period ◽  
Plasma Concentrations ◽  
Postoperative Nausea And Vomiting ◽  
Nausea And Vomiting ◽  
Oxygen Mixture ◽  
Postanesthesia Care Unit ◽  
Outpatient Basis ◽  
Opioid Administration

Background The relative potencies of alfentanil, fentanyl, and sufentanil as a risk factor for postoperative nausea and vomiting have not been determined. They were compared in a randomized study designed to obtain equipotent plasma concentrations of these three opioids at the beginning of the recovery period. Methods The study included 274 patients treated on an outpatient basis. The steady state opioid plasma concentration providing a predicted 50% reduction of the minimum alveolar concentration of isoflurane was used to determine the relative potency of the opioids. The opioids were prepared in equal volumes at concentrations of alfentanil 150 microg/ml, fentanyl 50 microg/ml, and sufentanil 5 microg/ml and were administered in vol/kg. Anesthesia was induced in a blinded fashion with a bolus of the study opioid (0.05 ml/kg) and 4-6 mg/kg thiopental and was maintained with isoflurane (0.6-1%) in a nitrous oxide-oxygen mixture with a continuous infusion of the study opioid (0.06 ml x kg(-1) x h(-1)). If necessary, up to five additional boluses of opioid (0.02 ml/kg) could be given. This opioid administration protocol was tested by pharmacokinetic simulations. Results The incidence of postoperative nausea and vomiting was not different in the postanesthesia care unit, but in the ambulatory surgery unit it was significantly lower for alfentanil compared with fentanyl and sufentanil (12, 34, and 35%, respectively P < 0.005). Pharmacokinetic modeling showed that the end-anesthesia opioid plasma concentrations were approximately equipotent in the three groups. However, modeling does not support that the difference between groups in the postoperative period can be explained by a more rapid disappearance of alfentanil from the plasma. Conclusions Alfentanil, compared with approximately equipotent doses of fentanyl and sufentanil, is associated with a lower incidence of postoperative nausea and vomiting in outpatients.

scholarly journals Efficacy of Three Different Prophylactic Treatments for Postoperative Nausea and Vomiting after Vitrectomy: A Randomized Clinical Trial

2019 ◽  
Vol 8 (3) ◽  
pp. 391 ◽  
Author(s):  
Michele Reibaldi ◽  
Matteo Fallico ◽  
Antonio Longo ◽  
Teresio Avitabile ◽  
Marinella Astuto ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Postoperative Pain ◽  
Adverse Events ◽  
Local Anesthesia ◽  
Postoperative Nausea ◽  
Therapy Group ◽  
Combined Therapy ◽  
Postoperative Nausea And Vomiting ◽  
Nausea And Vomiting ◽  
Combination Group

Postoperative nausea and vomiting (PONV) after vitreoretinal surgery may potentially be associated with severe complications, such as suprachoroidal hemorrhage. The purpose of the present multicenter clinical trial (NCT02386059) was to assess the efficacy of three different prophylactic treatments for PONV after vitrectomy under local anesthesia. Patients undergoing primary vitrectomy were randomized to the control arm or to one of the treatment arms (4 mg ondansetron, 4 mg dexamethasone, combination of the two drugs). The primary outcome measure was the proportion of complete response (no nausea, no vomiting, no retching, and no use of antiemetic rescue medication) during 24 h after vitrectomy. Secondary outcomes included the severity standardized score of PONV, postoperative pain standardized score, and rate of ocular and non-ocular adverse events. Baseline demographics of the 1287 patients were comparable between the four arms. The combined therapy group showed a statistically significant lower incidence of PONV compared to the placebo and monotherapy (p < 0.001). PONV severity was also reduced in the combination group compared to the others (p < 0.001). Postoperative pain scores and adverse events were comparable among the four groups. Combined therapy with dexamethasone and ondansetron was the most effective treatment for reducing the incidence and severity of PONV in patients undergoing vitrectomy under local anesthesia.

scholarly journals Chronic Atypical Antipsychotic Use Is Associated With Reduced Need for Postoperative Nausea and Vomiting Rescue in the Postanesthesia Care Unit

2020 ◽  
Vol 130 (1) ◽  
pp. 141-150 ◽  
Author(s):  
Craig S. Jabaley ◽  
Dennis W. Gray ◽  
Gaurav S. Budhrani ◽  
Grant C. Lynde ◽  
Panagiotis Adamopoulos ◽  
...  
Keyword(s):  
Atypical Antipsychotic ◽  
Postoperative Nausea ◽  
Postoperative Nausea And Vomiting ◽  
Nausea And Vomiting ◽  
Postanesthesia Care Unit

Prophylactic Ondansetron in Prevention of Postoperative Nausea and Vomiting following Pediatric Strabismus Surgery

2000 ◽  
Vol 92 (4) ◽  
pp. 1035-1042 ◽  
Author(s):  
Senthilkumar Sadhasivam ◽  
Dilip Shende ◽  
Rashmi Madan
Keyword(s):  
Placebo Group ◽  
Outcome Measures ◽  
Postoperative Nausea ◽  
Postoperative Nausea And Vomiting ◽  
Strabismus Surgery ◽  
Nausea And Vomiting ◽  
Postanesthesia Care Unit ◽  
Assessment Scores ◽  
Parental Assessment ◽  
Prophylactic Use

Background This study evaluated the antiemetic effectiveness, dose-response, and clinical usefulness of prophylactic ondansetron in the prevention of postoperative nausea and vomiting (PONV) in children undergoing strabismus repair. Method The authors observed 180 children, American Society of Anesthesiologists physical status I or II, 2-12 yr of age, who were undergoing strabismus repair. After induction of anesthesia with halothane and nitrous oxide in oxygen or intravenous thiopental, children received either placebo (saline) or intravenous ondansetron in doses of 25, 50, 75, 100, and 150 /microg/kg (n = 30). The trachea was intubated and ventilation was controlled. Perioperative analgesic and fluid requirements were standardized. Episodes of nausea and vomiting were recorded for the first 24 h postoperatively. Data such as nonsurrogate (parental satisfaction scores and duration of postanesthesia care unit stay) and therapeutic (numbers needed to prevent and harm) outcome measures were collected. Results The incidences of PONV in the placebo and 25-, 50-, 75-, 100-, and 150-,microg/kg ondansetron groups were 83, 77, 47, 30, 30, and 27%, respectively. The incidence was less in the 75(P = 0.002), 100- (P = 0.002), and 150-microg/kg (P &lt; 0.001) ondansetron groups compared with placebo. Duration of stay in the postanesthesia care unit was shorter in the 75-, 100-, and 150-microg/kg ondansetron groups (P &lt; 0.002) compared with the placebo group. Parental assessment scores for the child's perioperative experience and the positive number needed to prevent PONV were also better and favorable in the 75-, 100-, and 150-microg/kg ondansetron groups compared with the placebo group. The incidence (P &gt; 0.99) and severity (P = 0.63) of PONV were similar in the 75- and 150-microg/kg ondansetron groups. Surrogate, nonsurrogate, and therapeutic outcome measures revealed that 75 microg/kg ondansetron provided the same benefits as did 100 and 150 microg/kg. Conclusion The routine prophylactic use of ondansetron at a dose of 75 microg/kg is as effective as 150 microg/kg in preventing PONV and improving the "true" outcome measures after strabismus repair in children.

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