The use of transcutaneous acupoint electrical stimulation for preventing nausea and vomiting after laparoscopic surgery.

UNLABELLED: Nonpharmacologic techniques may be effective in preventing postoperative nausea and vomiting (PONV). This sham-controlled, double-blinded study was designed to examine the antiemetic efficacy of transcutaneous acupoint electrical stimulation (TAES) in a surgical population at high risk of developing PONV. We studied 221 outpatients undergoing laparoscopic cholecystectomy with a standardized general anesthetic technique in this randomized, multicenter trial. In the TAES group, an active ReliefBand(Woodside Biomedical, Inc., Carlsbad, CA) device was placed at the P6 acupoint, whereas in the Sham and Placebo groups, an inactive device was applied at the P6 acupoint and at the dorsal aspect of the wrist, respectively. The ReliefBand was applied after completion of electrocautery and remained in place for 9 h after surgery. The incidence of PONV and need for "rescue" medication were evaluated at predetermined time intervals. TAES was associated with a significantly decreased incidence of moderate-to-severe nausea as denoted on the Functional Living Index-Emesis score for up to 9 h after surgery (5%-11% for the TAES group vs 16%-38% [P < 0.05] and 15%-26% [P < 0.05] for Sham and Placebo groups, respectively). TAES was also associated with a larger proportion of patients free from moderate to severe nausea symptoms (73% vs 41% and 49% for Sham and Placebo groups, respectively; P < 0.05). However, there were no statistically significant differences among the three groups with regard to incidence of vomiting or the need for rescue antiemetic drugs. We conclude that TAES with the ReliefBand at the P6 acupoint reduces nausea, but not vomiting, after laparoscopic cholecystectomy. IMPLICATIONS: Transcutaneous acupoint electrical stimulation at the P6 acupoint reduced postoperative nausea, but not vomiting, in outpatients undergoing laparoscopic cholecystectomy procedures.

Dolasetron for the prevention of postoperative nausea and vomiting following outpatient surgery with general anaesthesia: a randomized, placebo-controlled study. The Dolasetron PONV Prevention Study Group.

In a multicentre, randomized, double-blind, placebo-controlled dose-ranging study, 1030 patients undergoing outpatient surgery with general anaesthesia received i.v. dolasetron mesylate (12.5, 25, 50, or 100 mg) or placebo. The principal outcome measure was the proportion of patients who were free of emesis or rescue medication for the 24-h period after the study drug was given; the subsidiary outcome measure was survival time without rescue medication. Effects on nausea were quantified using a visual analogue scale. Compared with placebo, a complete response was significantly higher when all four dolasetron doses were combined (49% vs. 58%, P =0.025). In females, dolasetron, 12.5-mg, dolasetron provided maximum clinical benefit (effectiveness compared with adverse events), with no additional benefit in complete response rates or nausea visual analogue scale scores at higher doses. No significant differences were observed in complete response for any dolasetron dose in males compared with placebo. The majority of adverse events reported were mild or moderate. Dolasetron provided well-tolerated, safe, and effective prophylaxis for post-operative nausea and vomiting with maximum effectiveness observed at a dose of 12.5 mg.

Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomiting: a randomized, double-blind, placebo-controlled multicenter trial.

STUDY OBJECTIVES: To compare repeat intravenous (i.v.) dosing of ondansetron 4 mg with placebo for the treatment of postoperative nausea and vomiting (PONV) in patients for whom prophylactic, preoperative ondansetron 4 mg i.v. was inadequate DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Ten outpatient surgical centers in the United States. PATIENTS: 2,199 male and female ASA physical status I, II, and III patients > or = 12 years old scheduled to undergo outpatient surgical procedures and receive nitrous oxide-based general anesthesia. INTERVENTIONS: Ondansetron 4 mg i.v. was administered to all patients before induction of general anesthesia. Patients who experienced PONV or requested antiemetic therapy within 2 hours after discontinuation of inhaled anesthesia were randomized (1:1) to either a repeat i.v. ondansetron 4 mg dose or placebo. MEASUREMENTS AND MAIN RESULTS: Of the 2,199 patients prophylactically treated with ondansetron 4 mg before anesthesia induction, 1,771 (80.5%) did not experience PONV or request antiemetic therapy during the 2 hours following discontinuation of anesthesia. Of the 428 patients who experienced PONV or requested antiemetic therapy during the same period, and were randomized to additional treatment (214 randomized to ondansetron, 214 randomized to placebo), the incidence of complete response (no emesis, no rescue medication, no study withdrawal) was similar for both ondansetron-randomized and placebo-randomized groups for the 2-hour (34% and 43%, respectively, p = 0.074) and 24-hour (28% and 32%, respectively, p = 0.342) postrandomization study periods. Repeat ondansetron dosing was not more effective than placebo in controlling either postoperative emesis or the severity/duration of postoperative nausea. The administration of an additional dose of ondansetron 4 mg postoperatively did not result in an increased incidence of adverse effects. CONCLUSIONS: In patients for whom preoperative prophylaxis with ondansetron 4 mg i.v. is not successful, a repeat dose of ondansetron 4 mg i.v. in the postanesthesia care unit does not appear to offer additional control of PONV.

Reduced resource utilization in patients treated for postoperative nausea and vomiting with dolasetron mesylate. MCPR44 Study Group.

STUDY OBJECTIVE: To compare the effect of four different increasing increasing intravenous (i.v.) doses of dolasetron mesylate (12.5 mg, 25 mg, 50 mg, and 100 mg) versus placebo on resource utilization in patients who experienced and were treated for postoperative nausea and vomiting (PONV). DESIGN: Prospective, double-blind, randomized, multicenter study. PATIENTS: 620 ASA physical status I, II, and III male and female outpatients scheduled for surgery with general anesthesia. INTERVENTIONS: Patients who experienced postoperative nausea (duration > or = 5 min, self-reported as moderate to severe) or vomiting (> or = 1 emetic episode) within 2 hours of arrival in the postanesthesia care unit (PACU) were given a single i.v. dose of dolasetron mesylate (12.5 mg, 25 mg, 50 mg, or 100 mg) or placebo infused for at least 30 seconds. MEASUREMENTS AND MAIN RESULTS: Resource utilization in the PACU was assessed by time spent by nurses and/or doctors with patients for PONV and the use of hospital resources such as patient/bed linens and staff/emesis supplies. A significantly (p < 0.05) lower proportion of dolasetron-treated patients compared to placebo-treated patients required new patient/bed linens and staff/emesis supplies. Patients in the placebo group required the greatest amount of care from nurses and/or doctors compared to patients receiving dolasetron. CONCLUSIONS: Treatment with dolasetron can significantly decrease the utilization of emesis supplies and other hospital resources, including staff/emesis supplies and patient/bed linens. In addition, patients receiving dolasetron used fewer health care resources in time spent by hospital personnel than patients who were not treated with dolasetron.

Mandated human services restructuring: a case study in local collaboration from Colorado.

The Colorado State Legislature has undertaken an historic restructuring of human services ranging from child welfare, mental health, and nursing services to substance abuse prevention, institutionalization, and health care financing. Significant steps in this process include an overhaul of child welfare legislation, major revisions to legislation affecting group health insurance policies, and a restructuring of the state departments that provide human services. A Democratic Governor and a Republican-dominated legislature have worked together hand-in-hand, although not always harmoniously, in moving these changes forward. This article examines the statewide restructuring of human services in a case study of how the local planning process was carried out in one region of Colorado. A highlight of the case study is the Working Together survey administered to participants of the planning committee midway through the process and again after the Local Area Plan was developed. In addition, lessons are presented from the process instructive for others considering whether to undertake significant organizational restructuring. The lesson section focuses on the local area planning process and how Colorado may have designed and facilitated a more effective process.

Remifentanil versus propofol as adjuncts to regional anesthesia. Remifentanil 3010 Study Group.

STUDY OBJECTIVE: To compare the safety and efficacy of remifentanil and propofol as adjuncts to regional anesthesia in patients undergoing orthopedic or urogenital surgery. DESIGN: Prospective, randomized study. SETTING: Multicenter university hospitals. PATIENTS: 107 ASA physical status I, II, and III adult patients who underwent orthopedic or urogenital surgery with axillary, ankle, or spinal block. INTERVENTIONS: Patients were randomized to receive either an infusion of remifentanil 0.2 microg/kg/min or propofol 100 microg/kg/min 5 minutes before nerve block placement. The infusions were decreased by 50% on block completion, increased by 50% for patient discomfort, and decreased by 50% for hypoventilation (< 8 breaths/min) or hemodynamic instability. MEASUREMENTS AND MAIN RESULTS: Pain, discomfort, anxiety, and sedation were assessed by both patient and investigator. Vital signs and adverse events were recorded. Fewer patients in the remifentanil group experienced pain during block placement (6%), and were oversedated (7%) than patients in the propofol group (23% and 26%, respectively; p < 0.05). Hypoventilation during and after block placement (21% and 25%, respectively) and nausea and vomiting during and after block placement (60% and 21%, respectively) were more common in the remifentanil group than in the propofol group (0% and 3%; 17% and 6%, respectively; p < 0.05). The incidence of hypoventilation in remifentanil-treated patients was higher in patients over 65 years of age (p < 0.05), but was transient, resolving within minutes of discontinuing the infusion. CONCLUSIONS: At the doses studied, remifentanil was more effective than propofol in minimizing pain without producing excessive sedation. Remifentanil was associated with more transient respiratory depression and short-term nausea. Our findings indicate that the initial remifentanil rate should be 0.1 microg/kg/min (50% lower than the study's initial rate) and should be further decreased an additional 50% in the elderly to minimize adverse effects.

Prolonged surgery increases the likelihood of admission of scheduled ambulatory surgery patients.

STUDY OBJECTIVE: To identify variables influencing the likelihood of unanticipated admission following scheduled ambulatory surgery. DESIGN: Retrospective case-controlled chart review study. SETTING: A large academic tertiary care hospital. PATIENTS: 8,549 ASA physical status I, II, III, and IV patients who underwent scheduled ambulatory surgery in 1991. MEASUREMENTS AND MAIN RESULTS: Of the 8,549 patients, 216 were admitted, with complete medical record information available for 167 of the admitted patients. The most common reasons for admission among the 167 were surgical (43%), anesthetic (28%), and medical (17%) complications. Odds for admission following long surgery (of at least 60 minutes) were 7.5 times (p < 0.001) greater than following short surgery (under 60 minutes). Among long cases, independent variables influencing admission were: general anesthesia [odds ratio 20.8; 95% confidence interval (CI) 4.4 to 45.6], and monitored anesthesia care or regional anesthesia (combined odds ratio 8.3; 95% CI 1.7 to 40.8). ASA physical status and patient age did not significantly influence admission rate for long cases. For short cases, patients over 65 years (odds ratio 5.6; 95% CI 2.6 to 12.0), ASA physical status III or IV (odds ratio 4.8; 95% CI 2.0 to 11.6), use of general anesthesia (odds ratio 4.7; 95% CI 1.5 to 14.2), and monitored anesthesia care or regional anesthesia (odds ratio 3.1; 95% CI 1.0 to 10.1) independently influenced the likelihood of admission. Type of surgery and gender had no detectable effect on admission. CONCLUSIONS: Surgery duration of 60 minutes or longer was the most important predictor of unanticipated admission following scheduled ambulatory surgery.

Propofol permits tracheal intubation but does not affect postoperative myalgias.

STUDY OBJECTIVE: To determine the effect of propofol without succinylcholine on intubating conditions and postoperative myalgias in ambulatory surgical patients undergoing general anesthesia. DESIGN: Prospective, double-blind, randomized study. SETTING: Ambulatory surgery adult patients. PATIENTS: 56 ASA physical status I and II adult patients undergoing general endotracheal anesthesia. INTERVENTIONS: Group 1 patients received thiamylal plus succinylcholine, Group 2 patients received propofol plus succinylcholine; and Group 3 patients received propofol plus saline. All patients received fentanyl, lidocaine, and nitrous oxide plus isoflurane in oxygen. MEASUREMENTS AND MAIN RESULTS: Incidence and severity of fasciculations, tracheal intubating conditions, and myalgias on the first and third postoperative days were measured. Propofol did not affect the incidence or severity of fasciculations following succinylcholine, or the incidence of myalgias. Of patients who received propofol without succinylcholine, intubation was successful in 85%. CONCLUSIONS: Propofol did not affect the incidence or severity of postoperative myalgias following succinylcholine.

Surgical patients' attitudes regarding participation in clinical anesthesia research.

We designed a questionnaire to identify the factors influencing both day of admission surgery (DAS) and ambulatory (AMB) patients in their decision whether to participate in and give informed consent for clinical anesthesia research. On the day of surgery, 276 patients were approached to complete a questionnaire and a visual analog scale (VAS) to assess anxiety. The data collected were observational and are presented as percentages for each group (DAS and AMB). One hundred eighty-two patient (60 DAS and 122 AMB) completed questionnaires. Both DAS and AMB patients desired 20-30 min to read a consent form. Preferred conditions for enrollment by both groups were as follows: interview at the time of preadmission testing; after consulting with their physician; in a private setting while dressed in street clothes; and with assurance that the investigator would also participate in the study, if eligible. Unacceptable conditions were as follows: research associated with any risk and interview in the operating room holding area. All patients responded that they were capable of making the decision whether to participate in research on the day of surgery. Most AMB and DAS patients found it acceptable to be recruited on the day of surgery, if approached appropriately.

Recovery advantages of regional anesthesia compared with general anesthesia: adult patients.

The data support but do not conclusively prove, that RA results in a superior recovery compared with GA. However, several questions need to be answered. Even though the patient may leave the hospital or surgicenter sooner after RA, how does the patient treat pain at home once the block has "worn off"? Since short-acting sedatives and opioids are so commonly used with RA, to what extent is recovery due to them and to what extent is recovery due to the RA alone? Many of the studies examining beneficial effects of RA have been poorly conducted, combining RA with GA and producing inconclusive results. Anesthetic techniques need to be carefully compared to determine whether they are equal in quality, efficiency, and cost. Finally, to determine whether RA is cost-effective, future studies involving ambulatory patients with a focus on outcome and well-being need to be conducted.

Treatment of postoperative nausea and vomiting after outpatient surgery with the 5-HT3 antagonist ondansetron.

BACKGROUND: Postoperative nausea and vomiting following outpatient surgery can significantly delay discharge. This study evaluates the safety and efficacy of ondansetron (a new 5-HT3 antagonist) in the treatment of postoperative nausea and vomiting in patients following outpatient surgery. METHODS: Five hundred outpatient surgical patients (53 male and 447 female), receiving general endotracheal anesthesia, were studied at ten centers. Patients were stratified by gender and received, in a randomized, double-blind manner, 1, 4, or 8 mg ondansetron or placebo in response to nausea and/or vomiting postoperatively. Episodes of vomiting, nausea scores, adverse events, vital signs, and laboratory values were evaluated before and during the 24 h after study drug administration. RESULTS: Complete response to study medication (no vomiting and/or retching, and no rescue antiemetic over the initial 0-2-h period) was more frequent in the ondansetron groups (1 mg 57%, 4 mg 61%, and 8 mg 57%) than in the placebo group (30%, P < .001). For the 0-24-h study a complete response occurred in only 15% of the placebo group compared to 41%, 47%, and 47% of the 1-, 4-, and 8-mg ondansetron groups, respectively (P < .001 for all comparisons with placebo). Median nausea scores (range 0-10) during the initial observation period (0-2 h) were significantly lower for all doses of ondansetron (1.3, 0.8, 1.8 for 1, 4, and 8 mg, respectively) as compared with placebo (2.3). No significant differences occurred in hemodynamic stability, incidence of adverse events, or changes in laboratory values in the ondansetron groups compared to the placebo group. CONCLUSIONS: Ondansetron, in doses less than 8 mg, is a safe, effective antiemetic for treating postoperative nausea and vomiting.

Ondansetron in the treatment of postoperative nausea and vomiting in ambulatory outpatients: a dose-comparative, stratified, multicentre study.

The safety and efficacy of ondansetron were evaluated in the treatment of postoperative nausea and vomiting. Five hundred patients who experienced nausea or vomiting in the Post-Anaesthesia Care Unit within the first 2 h of recovery were randomized to receive either 1, 4, or 8 mg of ondansetron, or placebo. All patients had undergone ambulatory surgery with general endotracheal anaesthesia. Episodes of emesis, nausea scores, adverse events, vital signs, and laboratory values were assessed before and during the 24 h after study drug administration. Patients were evaluated for the first 2 h in the Post-Anaesthesia Care Unit then followed up for the next 22 h. Complete response was defined as no emetic episodes, no nausea or no rescue anti-emetic medication. For the 0-24 h study period, complete response occurred in only 15% of the placebo group compared to 41%, 47%, and 47% in the 1, 4, and 8 mg ondansetron groups, respectively. Mean nausea scores (scale of 0-10) during the initial observation period (0-2 h) were significantly lower for all doses of ondansetron [2.2 (1 mg), 1.7 (4 mg), and 2.1 (8 mg)] compared to placebo (3.0). The optimal dose of ondansetron for the treatment of postoperative nausea and vomiting was found to be 4 mg. All doses of ondansetron were well tolerated. No clinically significant increases in laboratory parameters or alterations in haemodynamic stability occurred in the ondansetron groups compared to placebo.

Attenuation of suxamethonium myalgias. Effect of midazolam and vecuronium.

We studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone, N2O, isoflurane anaesthesia. Four groups of 20 patients each were pretreated with saline (group 1), tubocurarine 0.05 mg/kg (group 2), vecuronium 0.006 mg/kg (group 3), or midazolam 0.025 mg/kg (group 4), followed by suxamethonium 1.5 mg/kg. Group 5 received only vecuronium 0.1 mg/kg as relaxant (no suxamethonium). Fasciculations were graded, and postoperative myalgias rated on the first and third postoperative days. In groups 1-5 the incidence of fasciculations was 95, 15, 25, 95 and 0%; the incidence of myalgias on the first day after operation was 70, 45, 65, 75 and 60%, and on the third day after operation 20, 5, 20, 20, and 5%, respectively. We conclude that pretreatment with vecuronium, but not midazolam, decreases the incidence of fasciculations after suxamethonium (p less than 0.05) and that in this patient population, postoperative myalgias appear to be unrelated to the use of suxamethonium.

A defasciculating dose of d-tubocurarine causes resistance to succinylcholine.

Forty-four patients, ASA physical status I or II, undergoing thiamylal, fentanyl, N2O/O2 anaesthesia were studied to determine the dose-response to succinylcholine (Sch) without prior defasciculation (24 pt - Group 1), or three minutes following d-tubocurarine (dTC), 0.043 mg.kg-1 (20 pt - Group 2). The individual log dose-logit response curve for each patient was determined using a cumulative dose plus infusion technique and integrated EMG monitoring of the first dorsal interosseous muscle. The mean (+/- SEM) ED50, ED90 and ED95 values for Sch in Group 1 were 0.13 +/- 0.01, 0.19 +/- 0.01 and 0.22 +- 0.01 mg.kg-1, and in Group 2 were 0.16 +/- 0.01, 0.25 +/- 0.01 and 0.29 +/- 0.02 mg.kg-1, respectively. The mean ED values in Group 2 were significantly greater than the equivalent values in Group 1 (P less than 0.05). Compared with values in Group 1, ED values in Group 2 represented mean increases of 23, 32, and 32 per cent, respectively. These pharmacodynamic data indicate that the dose of Sch needs to be increased by 32 per cent following a defasciculating dose of dTC 3 mg.70 kg-1 (0.043 mg.kg-1).