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Concept: Postoperative nausea and vomiting

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Roughly one in three individuals is highly susceptible to motion sickness and yet the underlying causes of this condition are not well understood. Despite high heritability, no associated genetic factors have been discovered. Here, we conducted the first genome-wide association study on motion sickness in 80,494 individuals from the 23andMe database who were surveyed about car sickness. Thirty-five single-nucleotide polymorphisms (SNPs) were associated with motion sickness at a genome-wide-significant level (p<5×10-8). Many of these SNPs are near genes involved in balance, and eye, ear, and cranial development (e.g., PVRL3, TSHZ1, MUTED, HOXB3, HOXD3). Other SNPs may affect motion sickness through nearby genes with roles in the nervous system, glucose homeostasis, or hypoxia. We show that several of these SNPs display sex-specific effects, with up to three times stronger effects in women. We searched for comorbid phenotypes with motion sickness, confirming associations with known comorbidities including migraines, postoperative nausea and vomiting (PONV), vertigo, and morning sickness, and observing new associations with altitude sickness and many gastrointestinal conditions. We also show that two of these related phenotypes (PONV and migraines) share underlying genetic factors with motion sickness. These results point to the importance of the nervous system in motion sickness and suggest a role for glucose levels in motion-induced nausea and vomiting, a finding that may provide insight into other nausea-related phenotypes like PONV. They also highlight personal characteristics (e.g., being a poor sleeper) that correlate with motion sickness, findings that could help identify risk factors or treatments.

Concepts: Central nervous system, DNA, Genetics, Bioinformatics, Vomiting, Nausea, Metoclopramide, Postoperative nausea and vomiting

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Enhanced Recovery After Surgery (ERAS) pathways have been shown in multiple surgical disciplines to improve outcomes, including reduced opioid consumption, length of stay, and post-operative nausea and vomiting (PONV). However, very few studies describe the application of ERAS to breast surgery and even fewer describe ERAS for outpatient surgery. We describe the implementation and efficacy of an Enhanced Recovery After Surgery (ERAS) pathway for total skin-sparing mastectomy with immediate reconstruction in an outpatient setting.

Concepts: Surgery, Chemotherapy, Anesthesia, Opioid, Vomiting, Surgical oncology, Postoperative nausea and vomiting, Hypnosurgery

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Objectives To determine whether preoperative dexamethasone reduces postoperative vomiting in patients undergoing elective bowel surgery and whether it is associated with other measurable benefits during recovery from surgery, including quicker return to oral diet and reduced length of stay.Design Pragmatic two arm parallel group randomised trial with blinded postoperative care and outcome assessment.Setting 45 UK hospitals.Participants 1350 patients aged 18 or over undergoing elective open or laparoscopic bowel surgery for malignant or benign pathology.Interventions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia compared with standard care.Main outcome measures Primary outcome: reported vomiting within 24 hours reported by patient or clinician.

Concepts: Hospital, Randomized controlled trial, Surgery, Anesthesia, Vomiting, Laparoscopic surgery, Postoperative nausea and vomiting, Hypnosurgery

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A novel treatment, chewing gum, may be non-inferior to ondansetron in inhibiting postoperative nausea and vomiting (PONV) in female patients after laparoscopic or breast surgery. In this pilot study, we tested the feasibility of a large randomized controlled trial.

Concepts: Randomized controlled trial, Surgery, Chemotherapy, Anesthesia, Vomiting, Nausea, Metoclopramide, Postoperative nausea and vomiting

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To report a fuzzy logic mathematical model to predict postoperative vomiting (POV) in pediatric oncologic patients and compare with preexisting scores.

Concepts: Scientific method, Mathematics, Model theory, Set theory, Logic, Mathematical logic, Postoperative nausea and vomiting, Fuzzy logic

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BACKGROUND: Open thyroidectomy is associated with a high incidence of postoperative nausea and vomiting (PONV) in up to 70 % of cases. Use of the recently introduced robot-assisted endoscopic thyroidectomy using a gasless transaxillary approach has been increasing because of its several advantages over open thyroidectomy. This study compared the incidence of PONV in the women who underwent open or robot-assisted thyroidectomy. METHODS: This prospective, double-blinded study enrolled 170 women 20-60 years of age who were scheduled for conventional open thyroidectomy (group O) or robot-assisted thyroidectomy (group R). A standard anesthetic technique, including sevoflurane and air in oxygen, was used. During a 0-24-h postoperative period, the presence and severity of PONV (nausea, retching/vomiting), severity of pain, need for rescue antiemetics, and the degree of patient satisfaction were evaluated. RESULTS: During the 0-6-h postoperative period, the incidence of PONV and mean pain score (40.0 vs. 51.8 %and 4.2 vs. 4.8 in groups R and O, respectively) were not significantly different. At 6-24 h postoperatively, the incidence of PONV (18.8 vs. 44.7 %), severe emesis (11.8 vs. 29.4 %) and mean pain score (2.8 vs. 3.8) were significantly lower in group R compared to group O, respectively. Overall, the incidence of PONV (42.4 vs. 63.5 %) and severe emesis (20.0 vs. 43.5 %) were significantly lower in group R compared to group O, respectively. The incidence of satisfied patients 6 and 24 h after the end of anesthesia (55.3 vs. 28.2 and 82.4 vs. 58.8 %) were significantly higher in group R compared to group O, respectively. CONCLUSIONS: Robotic thyroidectomy reduces the incidence and severity of PONV compared to open thyroidectomy during a 0-24-h postoperative period.

Concepts: Chemotherapy, Anesthesia, Opioid, Vomiting, Nausea, Metoclopramide, Postoperative nausea and vomiting, Hypnosurgery

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INTRODUCTION: Our objective was to evaluate the contribution of bilateral inferior alveolar nerve block (BIANB) in patients before mandibular sagittal osteotomy for postoperative pain management, consumption of opioids, treatment of nausea and vomiting. MATERIALS AND METHODS: We included 30 patients undergoing mandibular sagittal osteotomy in a prospective, randomized, double blind study. The first group of patients (n=14) underwent a standard procedure (general anesthesia with postoperative morphine treatment). The second group of patients (n=16) underwent BIANB before surgery, in addition to the standard procedure. The postsurgical management was evaluated every four hours for the first 24hours, according to the following criteria: postoperative nausea and vomiting (PONV), visual analogue scale (VAS) assessment of pain, consumption of morphine (cumulative dose) and antiemetic drugs, and need for releasing inter-maxillary blockage. RESULTS: PONV was significantly less frequent in the second group (6.3 % versus 42.9 %, P=0.031). The frequency of releasing inter-maxillary blockage and the consumption of antiemetic drugs were not significantly different in the two groups. The mean VAS pain score was significantly lower in the second group (1.6 versus 0.9 avec P=0.045). There was no significant difference in cumulative morphine requirements between the two groups at 24hours. DISCUSSION: BIANB during mandibular osteotomy increases the patient comfort by decreasing PONV and improving postsurgical analgesia.

Concepts: Pharmacology, Anesthesia, Opioid, Analgesic, Vomiting, Metoclopramide, Postoperative nausea and vomiting, Blind experiment

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Background: Dexmedetomidine is a highly selective α2 agonist with analgesic, anxiolytic, and anti-inflammatory properties. We investigated the effect of a single dose of dexmedetomidine on patient-perceived quality of recovery and clinical recovery variables after modified radical mastectomy under general anesthesia in this randomized, double-blind, placebo-controlled study. Methods: After Institutional Review Board approval, ninety two female patients were randomly allocated to receive intravenously either saline (Group C, N.=46) or 0.5 μg/kg of dexmedetomidine (Group D, N.=46) five min before the end of surgery. The quality of recovery was assessed using a 40-item quality-of-recovery scoring system (QoR-40) preoperatively and 24 h after surgery. Pain intensity, rescue analgesics, and postoperative nausea and vomiting (PONV) were assessed at postanesthesia care unit (PACU), 1-6 h, and 6-24 h after surgery. Results: Postoperative global QoR-40 scores were higher in Group D compared with Group C (181 [175-187] vs. 174 [154.5-181.5], P=0.004); postoperative QoR-40 scores were improved in the dimensions of emotional state, physical comfort, and psychological support. Total amount of tramadol during 24 h after surgery was significantly lower in Group D than in Group C (54 vs. 76 mg, P=0.006). The incidence of PONV was lower in Group D than in Group C in PACU (21% vs. 43%, P=0.026) and 6-24 h period after surgery (10% vs. 41%, P=0.012). Heart rate and mean blood pressure were significantly lower in Group D as compared with Group C at 5 min after administration of dexmedetomidine, 1 min after extubation, and 20 min after arrival in PACU. Conclusion: The use of a single dose dexmedetomidine improved the quality of recovery and reduced analgesic requirements and the incidence of PONV in the early postoperative period after modified radical mastectomy.

Concepts: Randomized controlled trial, Anesthesia, Opioid, Analgesic, Vomiting, Mastectomy, Postoperative nausea and vomiting, Post anesthesia care unit

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The postoperative course of surgical patients can have a tremendous impact on the surgical outcome and on patient satisfaction. One of the most significant issues is postoperative nausea and vomiting (PONV) which, despite being a common side effect of general anesthesia, has received little attention in the plastic surgery literature. The incidence and potential consequences of PONV are frequently underestimated and consequently the need for prophylaxis is often overlooked. There are significant consequences to this seemingly minor morbidity that extend beyond patient discomfort and dissatisfaction. In addition to being considered a significant undesirable outcome by patients, severe cases of PONV may result in postoperative complications and unplanned hospital admissions. In this article we overview the mechanism, pathophysiology, and risk factors for PONV and provide a comprehensive algorithmic approach to its management. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Concepts: Hospital, The Canon of Medicine, Evidence-based medicine, Surgery, Avicenna, Anesthesia, Vomiting, Postoperative nausea and vomiting

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Acupuncture therapy for preventive and treatment of postoperative nausea and vomiting(PONV), a condition which commonly present after anaesthesia and surgery is a subject of growing interest.

Concepts: Medicine, Chemotherapy, Anesthesia, Acupuncture, Vomiting, Nausea, Postoperative nausea and vomiting, Hypnosurgery