Postoperative nausea and vomiting "the little big problem" after surgery/anaesthesia is still a common side-effect compromising quality of care, delaying discharge and resumption of activities of daily living. A huge number of studies have been conducted in order to identify risk factors, preventive and therapeutic strategies. The Apfel risk score and a risk based multi-modal PONV prophylaxis is advocated by evidence based guidelines as standards of care but is not always followed. Tailored anaesthesia and pain management avoiding too liberal dosing of anaesthetics and opioid analgesics is also essential in order to reduce risk. Thus multi-modal opioid sparing analgesia and a risk based PONV prophylaxis should be provided in order to minimise the occurrence. There is however still no way to guarantee an individual patient that he or she should not experience any PONV. Further studies are needed trying to identify risk factors and ways to tailor the individual patient prevention/therapy are warranted. The present paper provides a review around prediction, factors influencing the occurrence and the management of PONV with a focus on the ambulatory surgical patient.

Transversus abdominal plane (TAP) block has a long history and there is currently extensive clinical experience around TAP blocks. The aim of this review is to provide a summary of the present evidence on the effects of TAP block and to provide suggestions for further studies. There are several approaches to performing abdominal wall blocks, with the rapid implementation of ultrasound-guided technique facilitating a major difference in TAP block performance. During surgery, an abdominal wall block may also be applied by the surgeon from inside the abdominal cavity. Today, there are more than 11 meta-analyses providing a compiled evidence base around the effects of TAP block. These analyses include different procedures, different techniques of TAP block administration and, importantly, they compare the TAP block with a variety of alternative analgesic regimes. The effects of TAP block during laparoscopic cholecystectomy seem to be equivalent to local infiltration analgesia and also seem to be beneficial during laparoscopic colon resection. The effects of TAP are more pronounced when it is provided prior to surgery and these effects are local anaesthesia dose-dependent. TAP block seems an interesting alternative in patients with, for example, severe obesity where epidural or spinal anaesthesia/analgesia is technically difficult and/or poses a risk. There is an obvious need for further high-quality studies comparing TAP block prior to surgery with local infiltration analgesia, single-shot spinal analgesia, and epidural analgesia. These studies should be procedure-specific and the effects should be evaluated, both regarding short-term pain and analgesic requirement and also including the effects on postoperative nausea and vomiting, recovery of bowel function, ambulation, discharge, and protracted recovery outcomes (assessed by e.g., postoperative quality of recovery scale).

Cognitive side-effects such as emergence agitation (EA), postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are not infrequently complicating the postoperative care especially in elderly and fragile patients. The aim of the present survey was to gain insight regarding concern and interest in prevention and treatment strategies for postoperative delirium and dysfunction, and the use of EEG-based depth-of-anaesthesia monitoring possibly reducing the risk for cognitive side effects among anaesthesia personnel. A web-based validated questionnaire was sent to all Swedish anaesthesiologists and nurse anaesthetists during summer 2013. The questionnaire consisted of 3 sections, subjective preferences, routines and practices related to the perioperative handling of EA, POD, POCD. The response rate was 52%. Cardiovascular/pulmonary risks where assessed as importance by 98, 97% of responders while 69% considered the risk of neurocognitive side-effects important. When asked explicitly around cognitive side-effects 89%, 37% and 44% assessed awareness, POC and POD respectively of importance. EEG-based depth-of-anaesthesia monitors were used in 50% of hospitals. The responders were not convinced about the benefits of such monitors even in at-risk patients. Structured protocols for the management of postoperative cognitive side-effects were available only in few hospitals. Swedish anaesthesia personnel are concerned about the risk of postoperative cognitive side-effects but are more concerned about cardiovascular/pulmonary risks, pain, PONV and the rare event of awareness. Most respondents were not convinced about the use of depth-of-anaesthesia monitors. There is a need to improve knowledge around risk factors, prevention and management of postoperative cognitive side effects.