J Clin Anesth

Evaluation of simethicone for the treatment of postoperative abdominal discomfort in infants.

Year 1998
Voepel-Lewis TD. Malviya S. Burke C. D'Agostino R. Hadden SM. Siewert M. Tait AR.
Department of Anesthesiology, University of Michigan Health Care Center, Ann Arbor 48109-0211, USA.
STUDY OBJECTIVE: To determine whether abdominal discomfort is a cause for distress symptoms in infants following administration of inhalational anesthesia, and to evaluate the effectiveness of simethicone in treating this discomfort. DESIGN: Randomized, double-blinded study. SETTING: Large tertiary care, university-based medical center. PATIENTS: 175 ASA physical status I and II infants under 28 months of age who underwent an inhalational anesthetic for a variety of procedures that were expected to cause relatively little pain. INTERVENTIONS: Children were assessed for the presence of postoperative abdominal discomfort, and, if evident, were randomly given either simethicone or placebo in a double-blinded fashion. MEASUREMENTS AND MAIN RESULTS: Abdominal discomfort was measured using the Faces Legs Activity Cry and Consolability (FLACC) Behavioral Pain Scale. Scores were recorded pre-drug; at 10, 20, and 30 minutes following drug administration; and at discharge. If discomfort had not resolved within 15 minutes after the drug was given, routine analgesics or other medications were administered. Abdominal girth was measured preoperatively, on admission into the postanesthesia care unit (PACU), and at discharge. 21% of infants exhibited symptoms of abdominal discomfort postoperatively. Younger infants were at greater risk for this condition. 36 infants were given either placebo or simethicone, and of these, infants who received simethicone were comfortable earlier and required fewer rescue medications compared with placebo. There were no differences in ability to tolerate oral fluids prior to discharge or in the length of stay in the PACU. CONCLUSIONS: Simethicone is a safe and inexpensive medication that may provide anesthesiologists with an effective treatment choice for suspected postoperative abdominal discomfort in infants.

Oral dolasetron mesylate for prevention of postoperative nausea and vomiting: a multicenter, double-blind, placebo-controlled study. The Oral Dolasetron PONV Prevention Study Group.

Year 1998
Diemunsch P. Korttila K. Leeser J. Helmers JH. Wilkey B. Nave S. Radke AJ. Hahne WF. Brown RA.
Department of Anesthesiology, Les Hopitaux Universitaires de Strasbourg, France.
STUDY OBJECTIVE: To examine the safety and effectiveness of a range of single oral doses of dolasetron mesylate for the prevention of postoperative nausea and vomiting. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: 32 hospitals. PATIENTS: 789 female ASA physical status I, II, and III patients, ages 18 to 60 years, weighing between 45 and 100 kg, scheduled for major gynecologic surgery (including abdominal hysterectomy, gynecologic laparotomy, or vaginal hysterectomy) with general anesthesia. INTERVENTIONS: 25, 50, 100, or 200 mg oral doses of dolasetron mesylate or placebo were administered 1 to 2 hours before induction of anesthesia. Efficacy was assessed for 24 hours postrecovery by measuring complete response (no emetic episodes, no rescue medication), total response (complete response with no nausea), time to first emetic episode or rescue, and patient visual analog scale evaluations of nausea severity and satisfaction with antiemetic therapy. MEASUREMENTS AND MAIN RESULTS: Complete response rates for the 50, 100, and 200 mg dose groups were statistically greater than placebo (p < or = 0.018). Likewise, total response rates were statistically greater in the 50, 100, and 200 mg dose groups than in the placebo group (p = 0.012). Percentage of patients with no nausea and patient satisfaction scores were significantly higher for each dolasetron dose group than placebo (p < or = 0.047 and p < or = 0.004, respectively). Efficacy peaked at the 50 mg dose. The incidence of adverse events was similar in the placebo (30.1%) and dolasetron groups (29.4%). Headache was the most frequent treatment-related adverse event, with 2% to 5% incidence across groups. Incidence of adverse events did not increase with increasing dolasetron doses. Dose-related decreases in blood pressure at acute time points were not clinically significant. CONCLUSION: Single oral doses of dolasetron, administered 1 to 2 hours before induction of anesthesia, are safe and effective for preventing postoperative nausea and vomiting in this patient sample. Maximal antiemetic response was seen with the 50 mg oral dolasetron dose.

Droperidol-ondansetron combination versus droperidol alone for postoperative control of emesis after total abdominal hysterectomy.

Year 1998
Riley TJ. McKenzie R. Trantisira BR. Hamilton DL.
Department of Anesthesia, Magee-Womens Hospital, Pittsburgh, PA 15213-3180, USA.
STUDY OBJECTIVES: To investigate the hypothesis that the combination of ondansetron and droperidol would be more effective than droperidol alone in reducing nausea and vomiting. DESIGN: Randomized, doubleblind study. SETTING: Magee-Womens Hospital, Pittsburgh, Pennsylvania. PATIENTS: 160 healthy, ASA physical status I and II, female patients scheduled for total abdominal hysterectomy. INTERVENTIONS: After induction of anesthesia with propofol, Group 1 received intravenous (i.v.) droperidol 1.25 mg plus i.v. ondansetron 4 mg. Group 2 received i.v. droperidol plus i.v. saline. MEASUREMENTS AND MAIN RESULTS: The complete response (no emesis, no rescue) for Group 1 was 36 of 80 patients (45%) versus 30 of 80 patients (38%) in Group 2 (p = 0.21). In Group 1, 42 of 80 patients (53%) required rescue antiemetic as compared with 44 of 80 patients (55%) in Group 2 (p = 0.43). There were 72 total rescues in Group 1 versus 73 in Group 2, (p = 0.24). Mean time until first rescue was 578 +/- 429 minutes in Group 1 and 418 +/- 354 minutes in Group 2, (p = 0.03). In Group 1, 81 % (34/42) were rescued for nausea only versus 90% (39/44) of Group 2 (p = 0.16). In Group 1, 21% of patients (17/80) had at least one emetic episode versus 34% (27/80) of Group 2 patients (p = 0.05). There were 31 emetic episodes in Group 1 versus 72 episodes in Group 2. (p = 0.02). Mean time to the first emetic episode was 699 +/- 403 minutes in Group 1 and 616 +/- 376 minutes in Group 2, (p = 0.23). CONCLUSION: For patients undergoing total abdominal hysterectomies, the addition of ondansetron to droperidol increases the time until first rescue and reduces the number of emetic episodes, as well as the percentage of patients, having at least one emetic episode.

Ondansetron in the prophylaxis of postoperative vomiting: a meta-analysis.

Year 1998
Figueredo ED. Canosa LG.
Department of Anesthesia, Torrecardenas Hospital, Almeria, Spain.
STUDY OBJECTIVES: To assess the efficacy of ondansetron and the incidence of headache when used as prophylaxis for postoperative vomiting. DATA SOURCES: Studies were identified using MEDLINE (January 1990 to July 1997) with the key words: "vomiting," "ondansetron," and "surgery" and/or "anesthesia." STUDY SELECTION: All prospectively randomized trials in which ondansetron and placebo had been administered for prevention of postoperative vomiting. DATA EXTRACTION: Data on patient numbers, gender and ages, drug dosage, outcomes (incidence of vomiting and incidence of headache), time of outcome (up to 8 hrs or up to 48 hrs postoperatively), and baseline risk for vomiting according to type of surgical intervention were extracted. MAIN RESULTS: 48 trials involving 12,078 patients (10,390 adults and 1688 children) met the selection criteria. No evidence was found that the drug became more effective at doses larger than 4 mg. The dose of 8 mg was not statistically demonstrated to be superior (p = 0.558), while that of 1 mg was barely effective. The meta-analysis indicated that when the incidence of vomiting is elevated (e.g., the combined average of the placebo groups of 48%), on the statistical (i.e., hypothetical) grounds of six patients being treated with 4 mg of ondansetron, one will not vomit due to the treatment and, of the rest, two patients would have vomited despite the treatment and three patients would not have vomited anyway. The overall incidence of headache was 7.05% in ondansetron groups versus 6.16% in placebo groups. CONCLUSIONS: While ondansetron is an effective antiemetic with minimal adverse effects, the data obtained on the numbers needed to be treated calculation for prophylaxis of postoperative vomiting should be considered in future cost-effective strategies of postoperative management.

Difficult intubation from gastroesophageal reflux disease in adults.

Year 1998
Cantillo J. Cypel D. Schaffer SR. Goldberg ME.
Department of Anesthesiology, The Cooper Health System, Camden, NJ 08103, USA.
Two cases of difficult intubation are presented. Both cases presented with red swollen arytenoids, swollen false vocal cords, and subglottic stenosis. Tracheal intubation could not be achieved for these reasons. Both patients were placed on gastrointestinal prokinetic drugs and histamine-two blocker, as a diagnosis of gastroesophageal reflux disease (GERD) was made. In one case, follow-up by an otolaryngotic surgeon showed reversal of the above findings. In the other case, one tracheal intubation was achieved eventually. GERD occurs frequently. Clinicians need to maintain a high index of suspicion for GERD-related airway changes so as to avoid potential difficult intubations.

Aortic stenosis with end-stage liver disease: prioritizing surgical and anesthetic therapies.

Year 1998
Pollard RJ. Sidi A. Gibby GL. Lobato EB. Gabrielli A.
Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA.
A 48-year-old man with end-stage liver disease and aortic stenosis (AS), was being evaluated for liver transplantation. This report focuses on the question of which medical problem to correct first, the end-stage liver disease or the AS. Risk factors for surgical correction of AS and liver transplantation are reviewed and discussed, and the surgical and anesthetic management strategies for this patient are outlined.