This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. The guidelines are established by an international panel of experts under the auspices of the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. The guidelines provide recommendation on identifying high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatment of PONV as well as recommendations for the institutional implementation of a PONV protocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-generation 5-hydroxytryptamine 3 [5-HT3] receptor antagonists, neurokinin 1 (NK1) receptor antagonists, and dopamine antagonists), discussion regarding the use of general multimodal PONV prophylaxis, and PONV management as part of enhanced recovery pathways. This set of guidelines have been endorsed by 23 professional societies and organizations from different disciplines (Appendix 1).Guidelines currently available include the 3 iterations of the consensus guideline we previously published, which was last updated 6 years ago; a guideline published by American Society of Health System Pharmacists in 1999; a brief discussion on PONV management as part of a comprehensive postoperative care guidelines; focused guidelines published by the Society of Obstetricians and Gynecologists of Canada, the Association of Paediatric Anaesthetists of Great Britain & Ireland and the Association of Perianesthesia Nursing; and several guidelines published in other languages.The current guideline was developed to provide perioperative practitioners with a comprehensive and up-to-date, evidence-based guidance on the risk stratification, prevention, and treatment of PONV in both adults and children. The guideline also provides guidance on the management of PONV within enhanced recovery pathways.The previous consensus guideline was published 6 years ago with a literature search updated to October 2011. Several guidelines, which have been published since, are either limited to a specific populations or do not address all aspects of PONV management. The current guideline was developed based on a systematic review of the literature published up through September 2019. This includes recent studies of newer pharmacological agents such as the second-generation 5-hydroxytryptamine 3 (5-HT3) receptor antagonists, a dopamine antagonist, neurokinin 1 (NK1) receptor antagonists as well as several novel combination therapies. In addition, it also contains an evidence-based discussion on the management of PONV in enhanced recovery pathways. We have also discussed the implementation of a general multimodal PONV prophylaxis in all at-risk surgical patients based on the consensus of the expert panel.

Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.

https://rapm.bmj.com/content/rapm/34/2/134-170.full.pdf

Lower extremity regional anesthesia: essentials of our current understanding.

Background Hip fractures are common in the elderly and have a high 30 day postoperative mortality. The ability to recognize patients at high risk of poor outcomes before operation would be an important clinical advance. This study has determined key prognostic factors predicting 30 day mortality in a hip fracture population, and incorporated them into a scoring system to be used on admission. Methods A cohort study was conducted at the Queen's Medical Centre, Nottingham, over a period of 7 yr. Complete data were collected from 4967 patients and analysed. Forward univariate logistic regression was used to select the independent predictor variables of 30 day mortality, and then multivariate logistic regression was applied to the data to construct and validate the scoring system. Results The variables found to be independent predictors of mortality at 30 days were: age (66–85 yr, ≥86 yr), sex (male), number of co-morbidities (≥2), mini-mental test score (≤6 out of 10), admission haemoglobin concentration (≤10 g dl−1), living in an institution, and presence of malignant disease. These variables were subsequently incorporated into a risk score, the Nottingham Hip Fracture Score. The number of deaths observed at 30 days, and the number of deaths predicted by the scoring system, indicated good concordance (χ2 test, P=0.79). The area ( se ) under the receiver operating characteristic curve was 0.719 (0.018), which demonstrated a reasonable predictive value for the score. Conclusions We have developed and validated a scoring system that reliably predicts the probability of mortality at 30 days for patients after hip fracture.

Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery

https://rapm.bmj.com/content/rapm/29/4/333.full.pdf

Local anesthetic myotoxicity.

This study explored whether estimates of treatment effect differ between single-center and multicenter randomized, controlled trials (RCTs). The researchers examined 48 meta-analyses that included ...

Single-Center Trials Show Larger Treatment Effects Than Multicenter Trials: Evidence From a Meta-epidemiologic Study

Background We studied the incidence and clinical characteristics of persistent diplopia related to anaesthesia for cataract surgery in a general hospital. Methods This was a retrospective review of anaesthesia for 3587 cataract surgeries. Of all the cases of diplopia referred to the ocular motility clinic after cataract surgery, those involving anaesthesia-related diplopia lasting longer than 1 month were studied. Results During the study period, 3450 cataract surgeries were performed by phacoemulsification and 137 by extracapsular extraction. Retrobulbar block was used in 2024 cases, peribulbar block in 98, topical anaesthesia in 1420 and general anaesthesia in 43. Twenty-six cases of persistent diplopia were found (0.72% incidence), nine of which (0.25%) were considered to be related to anaesthetic factors; five of the latter involved the left eye. Five were caused by paresis of the inferior rectus muscle and three by fibrosis. In one patient, the inferior oblique muscle was affected. Anaesthesia was by retrobulbar block in eight cases (0.39%) and by peribulbar block in one. No diplopia was found in patients who had topical or general anaesthesia. Treatment was with surgery in two patients and with prisms in six. One patient continues to be studied. Conclusions Persistent diplopia can occur after cataract surgery using retrobulbar block predominantly through direct damage to the inferior rectus muscle. The overall incidence of anaesthesia-related diplopia in this series was 0.25%.

Anaesthesia‐related diplopia after cataract surgery

Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a 'nitrous oxide group' (total 2297 patients) vs a 'no-nitrous oxide group' (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71-0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In subgroup analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60-0.96). When nitrous oxide was used in combination with propofol, the antiemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77-1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.2010.06249.x

Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis

Background: Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly.



Methods: We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve.



Results: The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality.



Conclusions: A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients

The use of adverse incident reporting systems has provided key information for improving safety in medical and nonmedical settings. Although the characteristics of the ideal reporting system are controversial, for this type of system to work, a culture of safety in the organization is required. Reporting systems gather information on adverse events, errors, or incidents with the aim of analyzing the causes and implementing changes in the system to prevent their repetition. One of the most important limitations of these systems is under-reporting, caused by fear of disciplinary or legal repercussions and lack of belief in the effectiveness of reporting. We present our experience of the use of a computerized system for reporting and analyzing critical incidents in an anesthesiology department. Over a period of 6 years, with 52,259 anesthesiology procedures performed, 513 critical incidents were reported (0.98%). The most frequently registered incidents were related to equipment, communication, and drugs. The factors most frequently associated with adverse incidents were failure to check equipment and drugs, communication problems, and inability to put knowledge into practice. Most (81.8%) of the incidents had no effect on the patient or produced only minor morbidity. In 78.9% of cases, the incident was considered avoidable. As a result of systematic analysis of the incidents, various corrective measures were adopted, some of which produced a statistically significant reduction in equipment-and drug-related incidents.

Seguridad del paciente y sistemas de comunicación de incidentes

This report deals with the case of a patient who presented persistence of left superior vena cava (LSVC). This disorder was discovered following placement of a catheter in pulmonary artery via the left subclavian vein. The patient was a 67-yr-old woman who, while in the intensive care unit after undergoing coronary revascularization with extracorporeal circulation, required pulmonary artery catheterization to guide resuscitation. Placement of the catheter proved to be difficult as the advance of the catheter was impeded. A normal pulmonary artery pressure wave was eventually detected at a distance of approximately 70 cm. Chest x-ray showed a catheter route suggestive of persistent LSVC. A diagnosis of persistent LSVC should be considered whenever there appears to be some obstacle to central venous or pulmonary artery catheterization, especially in patients with congenital heart disease, since this disorder can have important clinical consequences.

/pdf/left-superior-vena-cava-a-vascular-abnormality-discovered-54au8wi9oo.pdf

J. I. Gómez-Arnau

Papers

Anaesthesia‐related diplopia after cataract surgery

Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients

Seguridad del paciente y sistemas de comunicación de incidentes

Left superior vena cava: a vascular abnormality discovered following pulmonary artery catheterization.