Postoperative nausea and vomiting (PONV) continues to be a major problem, because PONV is associated with delayed recovery and prolonged hospital stay. Although the PONV guidelines recommended the use of 5-hydroxy-tryptamine (5-HT3) receptor antagonists as the first-line prophylactic agents in patients categorized as high-risk, there are few studies comparing the efficacies of ondansetron, ramosetron, and palonosetron. The aim of present study was to compare the prophylactic antiemetic efficacies of three 5HT3 receptor antagonists in high-risk patients after laparoscopic surgery. In this prospective, randomized, double-blinded trial, 109 female nonsmokers scheduled for elective laparoscopic surgery were randomized to receive intravenous 4 mg ondansetron (n = 35), 0.3 mg ramosetron (n = 38), or 75 µg palonosetron (n = 36) before anesthesia. Fentanyl-based intravenous patient-controlled analgesia was administered for 48 h after surgery. Primary antiemetic efficacy variables were the incidence and severity of nausea, the frequency of emetic episodes during the first 48 h after surgery, and the need to use a rescue antiemetic medication. The overall incidence of nausea/retching/vomiting was lower in the palonosetron (22.2%/11.1%/5.6%) than in the ondansetron (77.1%/48.6%/28.6%) and ramosetron (60.5%/28.9%/18.4%) groups. The rescue antiemetic therapy was required less frequently in the palonosetron group than the other groups (P < 0.001). Kaplan-Meier analysis showed that the order of prophylactic efficacy in delaying the interval to use of a rescue emetic was palonosetron, ramosetron, and ondansetron. Single-dose palonosetron is the prophylactic antiemetics of choice in high-risk patients undergoing laparoscopic surgery.

Objectives: Although nicotine has an analgesic effect, the incidence and severity of chronic pain is higher in smokers than nonsmokers. Acute pain is more intense in smokers during the perioperative period. This study evaluated whether smokers require higher doses of opioid to reduce pain when they undergo surgery. Methods: A retrospective review of 236 patients who had intravenous patient-controlled analgesia after distal gastrectomy with gastroduodenostomy between October 2013 and September 2014 was performed to analyze the difference in postoperative opioid requirements between smokers and nonsmokers. Total opioid consumption was observed from the day of operation to postoperative day 2. Patients were grouped into smokers (N=117) and nonsmokers (N=119) for comparison. Simple and multiple regression analyses were performed to identify predictors of postoperative opioid requirements. Results: Opioid consumption by male smokers was higher than nonsmokers. Multiple regression analysis showed that age, smoking, and amount of intraoperative remifentanil were the only significant factors for postoperative opioid requirements. Discussion: Our results suggest that smokers undergoing distal gastrectomy with gastroduodenostomy required more opioid than nonsmokers for postoperative pain. Old age, smoking status, and increment of remifentanil use seemed to be predictors of postoperative opioid consumption.

Nam JS, et al. Korean J Pain. 2014 Oct;27(4):326-333. http://dx.doi.org/10.3344/kjp.2014.27.4.326

Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient’s underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.

Summary: When considering brachial plexus block as a practical alternative to general anaesthesia for upper limb surgery, the time to achieve complete sensory block is a clinically important variable. In this prospective randomised double‐blind controlled trial, we investigated the hypothesis that addition of hyaluronidase to ropivacaine may reduce the time to achieve complete sensory block after axillary brachial plexus block. The patients were randomly assigned into a hyaluronidase group (n = 24) and a control group (n = 24). The hyaluronidase group received ropivacaine 0.5% with 100 IU.ml ⁻¹ of hyaluronidase, and the control group received ropivacaine alone. The primary endpoint was the time to achieve complete sensory block. The hyaluronidase group demonstrated significantly shorter mean (SD) sensory block onset time (13.8 (6.0) min) compared with the control group (22.5 (6.3) min, p < 0.0001). Addition of hyaluronidase to ropivacaine resulted in a reduction in the time needed to achieve complete sensory block.