Therapeutic Suggestion in Postoperative Pain Control: A Randomized Controlled Trial.

OBJECTIVES: There is conflicting research on the effect of therapeutic suggestion in the perioperative period. This study systematically compared subjective and objective measures of postoperative pain, nausea and vomiting, urinary and bowel function, and global perception of symptomatic improvement between participants receiving perioperative therapeutic suggestion versus routine perioperative care during minimally invasive pelvic reconstructive surgery. METHODS: This was a single-blinded, randomized controlled trial of participants undergoing vaginal hysterectomy with minimally invasive sacrocolpopexy and concomitant prolapse repairs. The intervention group received perioperative therapeutic suggestion, whereas the control group did not. Primary outcomes included postoperative pain scores and analgesic use. Secondary outcomes included a postoperative nausea and vomiting scale, the Pelvic Floor Distress Inventory Questionnaire-Short Form 20, the Patient Global Impression of Improvement scale, and time to return of bowel and bladder function. RESULTS: Sixteen participants were randomized to each group. Final analysis included 15 intervention and 14 control participants. Overall measures of postoperative pain and analgesic use were low across all participants without a significant difference between intervention and control groups (opioid: 52.5; interquartile range [IQR], 25.5-58.9 vs 66 IQR, 7.3-125.8; morphine milligram equivalents; P = 0.64; acetaminophen: 2225 mg; IQR, 500-2600 mg vs 2800 mg; IQR, 650-4775 mg; P = 0.38). There were no statistically significant differences in secondary outcomes of urinary symptoms, bowel function, and subjective improvement of prolapse symptoms. CONCLUSIONS: No differences in postoperative pain, analgesic use, return of bowel and bladder function, or pelvic organ prolapse symptoms were noted in participants receiving perioperative therapeutic suggestion versus routine perioperative care.

Management of postdischarge nausea and vomiting.

Postdischarge nausea and vomiting (PDNV) occurs in at least 30% of patients leaving hospital, especially after day-case surgery. A significant number of ambulatory patients may develop PDNV associated with the use of analgesics for postsurgical pain. A validated PDNV prediction score and international evidence-based consensus guidelines for PONV/PDNV management are available. High-risk patients benefit from a predischarge PDNV risk assessment and the use of adapted pharmacological intervention (combination of long- and short-acting antiemetics and access to antiemetics at home). Patient education is often overlooked in this context. All clinicians involved in the ambulatory surgery care process should participate in the development of institutional protocol for PONV/PDNV management. Constant quality control and patients' feedback should be integrated as part of an efficient implementation strategy.

Patients' self-reported nausea: Validation of the Numerical Rating Scale and of a daily summary of repeated Numerical Rating Scale scores.

AIM AND OBJECTIVES: To validate the Numeric Rating Scale (NRS) for postoperative nausea assessments, and determine whether a central tendency, median, based on patients' self-rated nausea is a clinically applicable daily measure to describe patients' nausea after major surgery. BACKGROUND: Postoperative nausea causes major discomfort, risks for complications and prolonged hospital stays. The NRS is recommended for the assessment of pain but is little explored for assessing nausea. DESIGN: A repeated measure design was carried out on patients who had undergone major surgery in three Swedish hospitals. METHODS: Nonparametric statistical methods were used to analyse (a) associations between the NRS and a verbal scale (no, mild, moderate and severe) and (b) to analyse associations between Measure 1 (nausea scores postoperative Day 1) and Measure 2 (retrospective nausea scores at rest and during activity, postoperative Day 2). Reporting of this research adheres to the Strobe Guidelines. RESULTS: The mean age of the 479 patients (44% women) in the sample was 65 years (range, 22-93 years). Self-assessed nausea scores from the NRS and the verbal scale correlated well (rS pearman  = 0.79). Correlation between nausea at rest and nausea during activity was rS pearman  = 0.81. The calculated median scores (Measure 1) showed only moderate correlations with retrospective nausea scores (Measure 2); 4-9 ratings, rS pearman  = 0.41; 6-9 ratings, rS pearman  = 0.54. CONCLUSIONS: Numeric Rating Scale scores showed strong associations with a verbal scale; therefore, the NRS seems to be a valid tool to measure nausea intensity. The quality of daily summarised median nausea scores needs to be further explored before clinical use. RELEVANCE TO CLINICAL PRACTICE: The use of the NRS in assessments of nausea in postoperative care will facilitate communication between patients and health care professionals regarding nausea intensity. When documenting nausea, it seems unnecessary to distinguish nausea at rest from nausea during activity.

The Relationship of Age and Postoperative Pain in Women after Surgery for Breast Cancer.

BACKGROUND: In the past, elderly women with breast cancer were not offered surgery because of beliefs that they would experience serious complications from comorbidities and increased chronological age. Today the decision to offer surgery is based on a woman's fitness rather than her age. OBJECTIVE: The purpose of this study is to compare the experience of postoperative nausea and vomiting (PONV), anxiety, and reported pain levels in women who represent four different age groups after breast cancer surgery. This study employed a prospective comparative design. A large women's hospital which houses a Comprehensive Breast Care Program. Women diagnosed with early stage breast cancer and scheduled for surgical resection. METHODS: Postoperative pain was measured in the postanesthesia care unit using an 11-point verbal pain scale, PONV was measured categorically, and if present, severity of nausea was assessed. Anxiety was measured preoperatively by the short-form Profile of Mood States. FINDINGS: A total of 97 women aged 37-78 participated in this study. Overall, 35% of all women experienced PONV; only two women (18%) in the highest age range (70-79) experienced PONV, yet they reported significantly more pain than women in the other age groups. Understanding the difference in postoperative symptoms experienced by older woman after surgery for breast cancer will support the development of age-specific strategies.

Daily Assessment of Stressful events and Coping in early post-operative recovery after colorectal cancer surgery.

This study describes the most stressful events and coping strategies used by patients with colorectal cancer 4-6 weeks after surgery and whether the coping strategies were considered helpful or not. For the investigation of situational coping, an exploratory design was used. One hundred and five patients from three Swedish hospitals were included to fill in the Daily Coping Assessment. Most stressful event, number and types of pre-defined coping strategies used, and if the coping strategy used was considered helpful or not, were measured for 5 days. Of 523 diary entries, 180 reported no stressful events. The most stressful event, also with worst level of control and expectation, was "Pain," followed by "Nausea/vomiting." The areas causing most stressful events were "Bowel-related" and "Surgery and treatment-related problems." Acceptance and Direct action were the most frequently used coping strategies. There was a wide range of perceived helpfulness if coping strategies were placed in relation to specific areas of events. The conclusion was that patients revealed several strategies for coping with stressful events but needed a higher level of preparedness for what might come and therefore need to be given appropriate support to cope during the early recovery phase. Such support is suggested to be person-centred and oriented towards individually adapting standardised regimens, given the variety of situations to which the stressful events reported in the study were related.

Shortened preoperative fasting for prevention of complications associated with laparoscopic cholecystectomy: a meta-analysis.

Objective Routine fasting (12 h) is always applied before laparoscopic cholecystectomy, but prolonged preoperative fasting causes thirst, hunger, and irritability as well as dehydration, low blood glucose, insulin resistance and other adverse reactions. We assessed the safety and efficacy of a shortened preoperative fasting period in patients undergoing laparoscopic cholecystectomy. Methods We searched PubMed, Embase and Cochrane Central Register of Controlled Trials up to 20 November 2015 and selected controlled trials with a shortened fasting time before laparoscopic cholecystectomy. We assessed the results by performing a meta-analysis using a variety of outcome measures and investigated the heterogeneity by subgroup analysis. Results Eleven trials were included. Forest plots showed that a shortened fasting time reduced the operative risk and patient discomfort. A shortened fasting time also reduced postoperative nausea and vomiting as well as operative vomiting. With respect to glucose metabolism, a shortened fasting time significantly reduced abnormalities in the ratio of insulin sensitivity. The C-reactive protein concentration was also reduced by a shortened fasting time. Conclusions A shortened preoperative fasting time increases patients' postoperative comfort, improves insulin resistance, and reduces stress responses. This evidence supports the clinical application of a shortened fasting time before laparoscopic cholecystectomy.

Postoperative Delirium in Elderly Patients Undergoing Major Spinal Surgery: Role of Cerebral Oximetry.

BACKGROUND: Perioperative cerebral hypoperfusion/ischemia is a major inciting factor of postoperative delirium, which is coupled with adverse outcome in elderly patients. Cerebral oximetry enables noninvasive assessment of the regional cerebral oxygen saturation (rSO2). This study aimed to investigate whether perioperative rSO2 variations were linked to delirium in elderly patients after spinal surgery. MATERIALS AND METHODS: Postoperative delirium was assessed for 48 hours postsurgery in 109 patients aged over 60 years without a prior history of cerebrovascular or psychiatric diseases by the Confusion Assessment Method for the intensive care unit and the intensive care delirium screening checklist. The rSO2 values immediately before and throughout surgery were acquired. The preoperative cognitive functions, patient characteristics, and perioperative data were recorded. RESULTS: During the 48-h postoperative period, 9 patients (8%) exhibited delirium. The patients with delirium showed similar perioperative rSO2 values as those without, in terms of the median lowest rSO2 values (55% vs. 56%; P=0.876) and incidence (22%, both) and duration of decline of rSO2<80% of the baseline values. The serially assessed hemodynamic variables, hematocrit levels, and blood gas analysis variables were also similar between the groups, except for the number of hypotensive events per patient, which was higher in the patients with delirium than in those without (4, interquartile range [IQR] 3 to 6 vs. 2, IQR: 1to 3; P=0.014). CONCLUSIONS: The degree and duration of decrease of the perioperative rSO2 measurements were not associated with delirium in elderly patients after spinal surgery.

Aprepitant for postoperative nausea and vomiting: a systematic review and meta-analysis.

Postoperative nausea and vomiting (PONV) is an important clinical problem. Aprepitant is a relatively new agent for this condition which may be superior to other treatment. A systematic review was performed after searching a number of medical databases for controlled trials comparing aprepitant with conventional antiemetics published up to 25 April 2015 using the following keywords: 'Aprepitant for PONV', 'Aprepitant versus 5-HT3 antagonists' and 'NK-1 versus 5-HT3 for PONV'. The primary outcome for the pooled analysis was efficacy of aprepitant in preventing vomiting on postoperative day (POD) 1 and 2. 172 potentially relevant papers were identified of which 23 had suitable data. For the primary outcome, 14 papers had relevant data. On POD1, 227/2341 patients (9.7%) patients randomised to aprepitant had a vomiting episode compared with 496/2267 (21.9%) controls. On POD2, the rate of vomiting among patients receiving aprepitant was 6.8% compared with 12.8% for controls. The OR for vomiting compared with controls was 0.48 (95% CI 0.34 to 0.67) on POD1 and 0.54 (95% CI 0.40 to 0.72) on POD2. Aprepitant also demonstrated a better profile with a lower need for rescue antiemetic and a higher complete response. Efficacy for vomiting prevention was demonstrated for 40 mg, 80 mg and 125 mg without major adverse effects. For vomiting comparison there was significant unexplainable heterogeneity (67.9% and 71.5% for POD1 and POD2, respectively). We conclude that (1) aprepitant reduces the incidence of vomiting on both POD1 and POD2, but there is an unexplained heterogeneity which lowers the strength of the evidence; (2) complete freedom from PONV on POD1 is highest for aprepitant with minimum need for rescue; and (3) oral aprepitant (80 mg) provides an effective and safe sustained antivomiting effect.

Psychometric Properties of the Ambulatory Surgery Index of Nausea, Vomiting, and Retching.

BACKGROUND AND PURPOSE: At least one-third of ambulatory surgery patients will experience nausea or vomiting during the recovery period. The purpose of this study was to examine the psychometric properties of the Ambulatory Surgery Index of Nausea, Vomiting, and Retching (AS-INVR). METHODS: Secondary analysis of longitudinal data from a study of 203 adult ambulatory surgery patients was conducted. RESULTS: Based on the results of factor analysis, the retching item was eliminated and the 6-item, 2-dimensional AS-INV was formed. Cronbach's alphas for the AS-INV ranged from .83 to .87 across the 5 days postsurgery. Higher AS-INV scores were associated with self-reported presence of nausea and lower quality of life. CONCLUSIONS: The shortened AS-INV provides a reliable and valid measure of the amount and distress because of nausea and vomiting in adult patients after ambulatory surgery and should be considered for use in future studies.

Preanesthetic nurse communication with children and parents--an observational study.

BACKGROUND: The impact of communication within the perioperative period is an area of increasing research interest. Suggestions are phrases or actions that can lead to subconscious nonvolitional changes in patient perception, mood, and/or behavior. Statements functioning as suggestions may induce positive or negative perceptual responses and experiences. Children and anxious patients are particularly responsive to the effects of suggestion. We aimed to identify positively and negatively worded statements used during the provision of preoperative information by nursing staff in a tertiary referral center for pediatric care. METHODS: Audio recordings of preoperative consultations between nurses, children, and their parents were made between February and May 2014. Two researchers independently reviewed the transcripts and identified positively and negatively worded suggestions. Examples of negative suggestions were, 'he is going to be sore for a week or two' or 'normal to feel a bit sick....', and a positive suggestion was 'so she will be feeling quite comfortable...'. RESULTS: There were 51 consultations transcribed and analyzed. Of the 130 suggestions independently agreed by both researchers to be either positive or negative, 40 were identified as positive (31%) and 90 negative (69%). Commonly occurring negative suggestions described: pain in 21 consultations (41%); nausea and sickness in 19 (37%); and irritability or agitation in nine (18%). Positive suggestions included a description of a return of normal activities such as eating and drinking in 14 (28%), comfort in nine (18%), and well-being in nine (18%). Twelve consultations (24%) contained only negative suggestions, while four (8%) had only positive suggestions. CONCLUSIONS: This is the first prospective observational study investigating the language used by nurses during the preoperative child-parent encounter. Suggestions for negative perceptual experiences were frequently used during the preoperative nurse consultations. Education of nurses regarding awareness and understanding of negative suggestions and their potential adverse effects is recommended.

[Anxieties of patients before anesthesia - what information can the family physician provide?]. / Ängste der Patienten vor einer Anästhesie - welche Informationen kann der Hausarzt geben?

Patients' fears of anesthesia mostly focus on a possibly inadequate anesthetic effect, on postoperative wound pain and/or nausea and vomiting (PONV). Concerning the possibility of an inadequate anesthetic effect, patients usually express two different kinds of fears: first, that they might stay conscious during surgery («Awareness¼) without it being noticed, and second that they might not wake up again after the operation or that they might sustain neurological damages or deficits after the anesthesia. Last but not least patients are afraid they might suffer from substantial pain after waking up from the anesthesia. In this article we take a closer look at these aspects and discuss ways and possibilities of handling them, suggesting useful approaches for the general practitioner when talking these issues through with his patients prior to an operation.

Les craintes des malades avant une anesthésie ont trait principalement à un effet anesthésiant insuffisant en cours de l'intervention ainsi que de la survenue d'une douleur ou de nausées et de vomissements dans la période post-opératoire. En ce qui concerne la crainte d'un effet anesthésiant insuffisant, elle comporte deux aspects: d'une part la crainte de devenir conscient pendant l'opération sans que cela se remarque et d'autre part de ne pas se réveiller après l'opération ou de développer des atteintes ou es déficits neurologiques. Finalement il y a aussi une crainte non négligeable concernant l'existence d'une douleur en post-opératoire. Dans ce travail sont discutées en détail les craintes potentiellement engendrées lors de la planification d'une anesthésie. Est proposée également une approche utile de discuter de ces craintes entre la malade et le médecin généraliste en préparation de l'intervention.

The effects of religion and spirituality on postoperative pain, hemodynamic functioning and anxiety after cesarean section.

Spiritual elements play an important role in the recovery process from acute postoperative pain. This study was conducted to assess the effect of pray meditation on postoperative pain reduction and physiologic responds among muslim patients who underwent cesarean surgery under spinal anesthesia. This double-blinded randomized clinical trial study was conducted among muslim patients who underwent cesarean surgery under spinal anesthesia during 2011-2013 at tertiary regional and teaching hospital in Lorestan, Iran. The patients were randomly divided into interventional group (n=80) and control group (n=80). For about 20 minutes using a disposable phone mentioned and listened to pray meditation "Ya man esmoho davaa va zekroho shafa, Allahomma salle ala mohammad va ale mohammad" in interventional group and phone off in control group. Before and during pray meditation, 30, 60 minutes, 3 and 6 hours after pray meditation pain intensity, blood pressure, heart rate and respiratory rate were measured. No statistically significant improvement in pain score was found before and during pray meditation, 30, 60 minutes after pray meditation (P>0.05). Statistically significant improvement in pain score was found at 3 and 6 hours after pray meditation than control group (1.5 ± 0.3 vs. 3 ± 1.3, P=0.030) and (1.3 ± 0.8 vs. 3 ± 1.1, P=0.003). However, there was no significant difference in the physiological responses (systolic and diastolic blood pressure, respiration, and heart rate) any time between the groups. Religion and spirituality intervention such as pray meditation could be used as one of non-pharmacological pain management techniques for reducing pain after cesarean surgery. Also, Pray meditation provides less postoperative nausea and vomiting (PONV) and more relaxation.

The effectiveness of suggestive techniques in reducing postoperative side effects: a meta-analysis of randomized controlled trials.

BACKGROUND: Suggestive interventions such as hypnosis and therapeutic suggestions are frequently used to alleviate surgical side effects; however, the effectiveness of therapeutic suggestion intervention has not yet been systematically evaluated. In the present study, we tested the hypotheses that (1) suggestive interventions are useful for reducing postoperative side effects; (2) therapeutic suggestions are comparable in effectiveness to hypnosis; (3) live presentation is more effective than recordings; and (4) suggestive interventions would be equally effective used in minor and major surgeries. METHODS: We performed random effect meta-analysis with meta-regression and sensitivity analysis by moderating factors on a pool of 26 studies meeting the inclusion criteria (N = 1890). Outcome variables were postoperative anxiety, pain intensity, pain medication requirement, and nausea. RESULTS: Suggestive interventions reduced postoperative anxiety (g = 0.40; 99% confidence interval [CI] = 0.13-0.66; P < 0.001) and pain intensity (g = 0.25; 99% CI = 0.00-0.50; P = 0.010), but did not significantly affect postoperative analgesic drug consumption (g = 0.16; 99% CI = -0.16 to 0.47; P = 0.202) and nausea (g = 0.38; 99% CI = -0.06 to 0.81; P = 0.026). No significant differences were found for intervention type, presentation method, and severity of surgery; however, sensitivity analysis only supported the effectiveness of hypnosis (g = 0.62; 99% CI = 0.31-0.92; P < 0.001) and live presentation (g = 0.55; 99% CI = 0.23-0.88; P < 0.001) for decreasing postoperative anxiety, and that of live presentation for alleviating postoperative pain (g = 0.44; 99% CI = 0.07-0.82; P = 0.002). Sensitivity analyses also suggested that suggestive interventions are only effective for decreasing pain intensity during minor surgical procedures (g = 0.39; 99% CI = 0.00-0.78; P = 0.009). CONCLUSIONS: Suggestive techniques might be useful tools to alleviate postoperative anxiety and pain; however, strength of the evidence is weak because of possible bias in the reviewed articles. The lack of access to within-subjects data and the overlap between moderator conditions also limit the scope of the analysis. More methodologically correct studies are required with sensitivity to moderating factors and to within-subjects changes. For clinical purposes, we advise the use of hypnosis with live presentation to reduce postoperative anxiety and pain, until convincing evidence is uncovered for the effectiveness of therapeutic suggestions and recorded presentation. Pain management with adjunct suggestive interventions is mostly encouraged in minor rather than major surgeries.

A psychosomatic approach to severe nausea and vomiting in liver transplant recipients with familial amyloid polyneuropathy: clinical outcome in 10 cases.

After transplant, patients with familial amyloid polyneuropathy may manifest several medical and psychiatric symptoms that can be difficult to diagnose and treat. We describe 10 liver transplant candidates with familial amyloid polyneuropathy who had severe somatic signs and symptoms (nausea and vomiting) after transplant. Their physical examinations were performed by physicians from different specialties. Before transplant, the patients' evaluations did not reveal relevant medical or psychiatric symptoms. After transplant, they had severe nausea and vomiting and high scores on the Hospital Anxiety and Depression Scale. A psychopharmacological trial with a selective serotonin reuptake inhibitor plus an antiemetic drug was unsuccessful. Remission was obtained with tricyclic antidepressants and low-dose atypical antipsychotic agents. Previous researchers had concluded that the mental quality of life in patients with familial amyloid polyneuropathy was worse after receiving a liver transplant, unlike other transplant recipients. The 10 cases described in this study are a good example of comorbid physical and mental symptoms occurring after transplant in patients with familial amyloid polyneuropathy. The conclusions of this study have implications for clinical practice, showing how a careful holistic approach in the posttransplant period is relevant in these cases.

[Postoperative complaints : gender differences in expectations, prevalence and appraisal]. / Postoperative Beschwerden : Geschlechtsunterschiede in Erwartung, Auftreten und Bewertung.

OBJECTIVE: Women report more severe postoperative complaints than men (e.g. nausea and pain) and expectations of complaints prior to surgery influence the postoperative complaints. Therefore, the aim of this study was to explore if gender differences in complaint expectation can account for differences in postoperative complaints. A further objective was to investigate the effective load of complaints and to look for gender differences. METHODS: In total 281 patients (128 men and 153 women) were included in the study and all patients underwent elective general surgery. Patients were asked for symptom expectations and symptom experiences prior to surgery. After surgery they answered the Anesthesiological Questionnaire (ANP) a validated self-rating method for the assessment of postoperative symptoms and complaints. The symptoms referred to in the questionnaire included sensation of cold, sensation of heat, nausea and vomiting, tickly throat, croakiness, dry mouth and thirst, difficulty in breathing, sore throat, pain in the area of surgery, pain in the area of infusion, muscle pain, back pain, headache, difficulties in urination, difficulty in awakening and feeling of somatic discomfort. In addition patients rated the affective load of the postoperative complaints. RESULTS: In previous surgery women reported experiencing more postoperative somatic complaints than men. Sex-related differences were significant (p < 0.05) for sensation of cold, nausea and vomiting, tickly throat, croakiness, sore throat, pain and the feeling of somatic discomfort. Likewise, women expected more intensive postoperative complaints following the forthcoming operation. After surgery women reported significantly more severe complaints in negative symptoms of the ANP (e.g. nausea and vomiting, pain and somatic discomfort). Effect sizes of sex-related differences varied according to the symptom (e.g. for pain effect strength d = 0.50, for nausea d = 0.60 and for thirst d = 0.13). Effect sizes decreased when the effect of expectation was statistically controlled. Logistic regression revealed that expectation was an independent predictor for the sensation of severe nausea (odds ratio OR 4.3] and intensive postoperative pain (OR 2.6). Regardless of gender, postoperative pain, nausea and dry mouth/thirst were symptoms with the highest affective load. CONCLUSIONS: Preoperative expectations increase gender differences in somatic complaints following surgery. Anesthesiological education of patients should influence dysfunctional expectations. Postoperative pain, nausea and thirst should be the main targets of interventions to improve patient complaints.

Patient's anxiety and fear of anesthesia: effect of gender, age, education, and previous experience of anesthesia. A survey of 400 patients.

PURPOSE: Patients express high anxiety preoperatively, because of fears related to anesthesia and its implications. The purpose of this survey was to gain insight into these fears and to study whether they are affected by patients' sex, age, education, or previous experience of anesthesia. METHODS: Questionnaires with fixed questions were distributed to consenting, consecutive surgical patients before the pre-anesthetic visit. The questionnaires included patients' demographics and questions related to their fears about anesthesia. RESULTS: Four-hundred questionnaires were collected and analyzed. Eighty-one percent of patients experience preoperative anxiety. The main sources of their anxiety were fear of postoperative pain (84 %), of not waking up after surgery (64.8 %), of being nauseous or vomiting (60.2 %), and of drains and needles (59.5 %). Patients are less concerned about being paralyzed because of anesthesia (33.5 %) or of revealing personal issues (18.8 %). Gender seems to affect patients fears, with women being more afraid (85.3 vs. 75.6 % of men, p = 0.014). The effects of patients' age, level of education, and previous experience of anesthesia are minor, except for individual questions. Sixty-three percent of our patients (mostly women 67.4 vs. 57.4 % of men, p = 0.039) talk about these fears with their relatives, although a vast majority of 95.5 % would prefer to talk with the anesthesiologist and be reassured by him. CONCLUSION: All patients, mostly women, express fears about anesthesia; this fear leads to preoperative anxiety. Slight differences are observed for some individual questions among patients of different sex, education level, and previous experience of anesthesia.

Simplified postoperative nausea and vomiting impact scale for audit and post-discharge review.

BACKGROUND: Postoperative nausea and vomiting (PONV) is common but many episodes may be trivial or transient. The aim of the study was to develop a simple-to-use measure of the intensity and clinical impact of PONV. METHODS: We re-analysed data from a study enrolling 163 patients recovering from surgery and anaesthesia that had experienced or were at increased risk of developing PONV. A range of measures of PONV characteristics and quality of recovery were collected. We devised a simplified nausea-vomiting impact scale based on patients' assessment of the impact of their nausea on their postoperative recovery and the number of times they experienced vomiting. We then undertook further tests of construct and discriminant validity, and reliability and responsiveness, of the impact scale using psychometric methodology. RESULTS: Around one in five patients with PONV had features that could classify them as having clinically important PONV. We found that patients with clinically important PONV had a much poorer quality of recovery (P<0.0005), needed more antiemetic administrations for treatment (P<0.0005), and were more likely to have consequences and complications of PONV (all P<0.01), when compared with those with lesser degrees of PONV. A change in clinically important PONV status can be reliably detected with the PONV impact scale. CONCLUSIONS: We have devised and validated a simplified PONV impact scale that can be used to identify those with clinically important PONV. The avoidance of clinically important PONV could be used as a quality indicator or outcome measure after surgery.

A time-motion economic analysis of postoperative nausea and vomiting in ambulatory surgery.

BACKGROUND: One-third of surgical outpatients experience postoperative nausea and vomiting (PONV) during their hospital stay or post-discharge nausea and vomiting (PDNV) after hospitalization. We determined the incremental costs of PONV/PDNV in ambulatory patients with this time-and-motion study. METHODS: In 100 ambulatory surgery patients, we evaluated the incidence of PONV, time staff spent with patients, use of PONV-related supplies, recovery duration, PONV rescue treatments, and quality-of-life through to the third postoperative morning. Patients with and without PONV/PDNV were compared in relation to PONV-related cost after adjusting for age, American Society of Anesthesiologists status, body mass index, and duration and complexity of surgery. RESULTS: Thirty-seven percent of the patients experienced PONV during hospitalization; this increased to 42% by the first postoperative morning and increased further to 49% by the third postoperative morning. Patients with PONV spent one hour longer in the postanesthesia care unit than patients without PONV (median [interquartile range] 234 [188-287] min vs 171 [144-212] min, respectively; P = 0.001). The amount of nursing time required for patients with PONV was significantly greater than that required for patients without PONV (82 [63-106] min vs 68 [57-79] min, respectively; P = 0.02). The total cost of postoperative recovery was significantly greater for patients with PONV/PDNV than for those without (US$730 vs $640, respectively; P = 0.006). Postoperative nausea and vomiting/PDNV was associated with an adjusted incremental total cost of $75 (95% confidence interval $67 to $86). Postoperative nausea and vomiting was also associated with worsened postoperative quality of life (49% of patients with PONV/PDNV rated quality high in four domains vs 94% of patients without PONV/PDNV; P < 0.001). CONCLUSION: Postoperative nausea and vomiting/PDNV were common; they impaired quality of life and imposed an incremental cost of $75 per patient. This incremental cost is comparable with the cost patients are willing to pay to avoid PONV.

[Realization of Fast track surgery principles during cesarean section].

The aim of the study was to evaluate the efficiency of Fast Track Surgery (FTS) program application and determine the role of the anesthesiologist in its realization during planned Cesarean section. There were 2 randomized groups formed (basic and control), which contained 22 patients each. The groups were identical by all anthropometrical indicators. The FTS was applied in the basic group while the control group was led in traditional postoperative mode. The level of postoperative pain was estimated by Visual Analogue Scale (VAS) in rest and during cough 6, 12 and 24 hours after surgery, cortisol and glucose level dynamics, Baevskiy index, nausea and vomiting frequency, defecation and urination delay, presence of anxiety and weakness were assessed. The VAS and Baevskiy index were lower in the basic group during 12th and 24th hour of investigation, p < 0.05. There was no difference in dynamic cortisol levels in both groups. The values of cortisol levels didn't exceed those of presurgical levels. The tendency of hypoglycemia in control group that testified the prevalence of ketabolic proccesses was accompanied by weakness and orthostatic reactions. In both groups urination delay, nausea and vomiting were present. The obtained data proved the efficacy and safety of FTS during Cesarean section. The study shows that the decision of FTS has to be made by the anesthesiologist. It can improve perioperative conduction of patients and result in the promt stabilization of mother's condition after surgical intervention and result to the optimized contact with the child as well as reduce the period of hospital stay and decrease the expenses.

Presurgery psychological factors predict pain, nausea, and fatigue one week after breast cancer surgery.

Before scheduled surgery, breast cancer surgical patients frequently experience high levels of distress and expect a variety of postsurgery symptoms. Previous literature has supported the view that presurgery distress and response expectancies are predictive of postsurgery outcomes. However, the contributions of distress and response expectancies to postsurgical side effect outcomes have rarely been examined together within the same study. Furthermore, studies on the effects of response expectancies in the surgical setting have typically focused on the immediate postsurgical setting rather than the longer-term setting. The purpose of the present study was to test the contribution of presurgery distress and response expectancies to common postsurgery side effects (pain, nausea, and fatigue). Female patients (n=101) undergoing breast cancer surgery were recruited to a prospective study. Results indicated that presurgery distress uniquely contributed to patients' postsurgery pain severity (P<0.05) and fatigue (P<0.003) one week after surgery. Response expectancies uniquely contributed to pain severity (P<0.001), nausea (P<0.012), and fatigue (P<0.010) one week after surgery. Sobel tests indicated that response expectancies partially mediated the effects of distress on pain severity (P<0.03) and fatigue (P<0.03). Response expectancies also mediated the effects of age on pain severity, nausea, and fatigue. Results highlight the contribution of presurgery psychological factors to postsurgery side effects, the importance of including both emotional and cognitive factors within studies as predictors of postsurgery side effects, and suggest presurgical clinical targets for improving patients' postoperative experiences of side effects.