- Email: [email protected]
Enhanced recovery after general anaesthesia: A question of PONV prophylaxis?
302
| Correspondence
Enhanced recovery after general anaesthesia: A question of PONV prophylaxis? P. Kienbaum* and M. S. Schaefer Duesseldorf, Germany *E-mail: [email protected]
risk factors. Secondly, when comparing single drug (ramosetron) PONV prophylaxis to a combined antiemetic medication (ramosetron/TIVA), a lower PONV incidence in the latter study group can be expected.5 Of note, while the finding of similar preoperative and postoperative pain scores indicates effective postoperative analgesia, differences in postoperative nausea on day one might be caused by different dosages of postoperatively given opioids between groups. Therefore, the data presented do not support per se the conclusion that patients’ recovery can be generally enhanced with TIVA. In summary, anticipating a balanced baseline risk for PONV, the authors prove the common finding that in patients with high risk for PONV a combination of antiemetic drugs can be associated with a lower incidence of postoperative nausea compared with a single drug prophylaxis, which may in turn enhance patient quality of recovery from general anaesthesia.
Declaration of interest P.K. has received funding for research by Air Liquide Medical Germany and fees for lectures and traveling by Air Liquide Medical Germany and Baxter Germany.
References 1. Lee W-K, Kim M-S, Kang S-W, Kim S, Lee J-R. Type of anaesthesia and patient quality of recovery: a randomized trial comparing propofol- remifentanil total i.v. anaesthesia with desflurane anaesthesia. Br J Anaesth 2015; 114: 663–8 2. Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR40. Br J Anaesth 2000; 84: 11–5 3. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89: 652–8 4. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118: 85–113 5. Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004; 350: 2441–51 doi:10.1093/bja/aev468
Downloaded from http://bja.oxfordjournals.org/ at University of California, San Diego on February 3, 2016
Editor—We would like to congratulate Lee and coworkers1 for their study assessing the influence of type of anaesthesia on a patient-centred outcome as the quality of recovery (QoR). The authors randomized eighty female patients undergoing thyroid surgery to either effect-site target controlled infusion -total intravenous anaesthesia (TIVA) or general anaesthesia with desflurane/remifentanil. All patients received routine prophylactic i.v. ramosetron (0.3 mg) and ketorolac (0.5 mg kg−1) and antagonization of neuromuscular block by neostigmine/glycopyrrolate. QoR was determined by the well-validated QoR- 40 questionnaire.2 Standardized antiemetic (metoclopramide) and analgesic (fentanyl) rescue-medication was administered when the numeric rating scale exceeded four and was recorded during PACU stay. The authors found that TIVA significantly increased the QoR-40 on postoperative day one but not day two. Furthermore, while postoperative pain was comparable in both groups, patients in the TIVA group experienced less postoperative nausea only on day one but not immediately after anaesthesia in the PACU or on day two. The authors concluded, ‘that the quality of recovery in these patients is significantly better with TIVA compared with desflurane anaesthesia’. Absence of PONV is considered to be one major indicator for the quality of anaesthesia.3 Hence, risk factors (female gender, non-smoking, history of PONV/motion sickness, postoperative opioids and duration of anaesthesia) have been identified and a risk-adapted PONV-prophylaxis is recommended.4 Propofol administered for TIVA is considered to possess antiemetic properties itself so that it substitutes for one antiemetic drug.4 5 At the same time, if anaesthetists do not want to dispense with pharmacokinetic and clinical advantages of modern inhaled anaesthetics in patients at risk for PONV, the recommended combination of classic antiemetic drugs should be administered as a prophylaxis. In face of PONV incidences as high as 68% and comparable pain scores, we assume that PONV was the most influential event on the patients’ QoR in this study. To determine differences in treatment groups, it is essential that the authors provide the PONV-risk factor profile of their patients. Accordingly, the baseline risk to experience PONV can be calculated for each treatment group. Thus, ratios between observed to predicted PONV incidences can be compared and differences in values attributed to either treatment or uneven distribution of baseline
| Correspondence
Enhanced recovery after general anaesthesia: A question of PONV prophylaxis? P. Kienbaum* and M. S. Schaefer Duesseldorf, Germany *E-mail: [email protected]
risk factors. Secondly, when comparing single drug (ramosetron) PONV prophylaxis to a combined antiemetic medication (ramosetron/TIVA), a lower PONV incidence in the latter study group can be expected.5 Of note, while the finding of similar preoperative and postoperative pain scores indicates effective postoperative analgesia, differences in postoperative nausea on day one might be caused by different dosages of postoperatively given opioids between groups. Therefore, the data presented do not support per se the conclusion that patients’ recovery can be generally enhanced with TIVA. In summary, anticipating a balanced baseline risk for PONV, the authors prove the common finding that in patients with high risk for PONV a combination of antiemetic drugs can be associated with a lower incidence of postoperative nausea compared with a single drug prophylaxis, which may in turn enhance patient quality of recovery from general anaesthesia.
Declaration of interest P.K. has received funding for research by Air Liquide Medical Germany and fees for lectures and traveling by Air Liquide Medical Germany and Baxter Germany.
References 1. Lee W-K, Kim M-S, Kang S-W, Kim S, Lee J-R. Type of anaesthesia and patient quality of recovery: a randomized trial comparing propofol- remifentanil total i.v. anaesthesia with desflurane anaesthesia. Br J Anaesth 2015; 114: 663–8 2. Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR40. Br J Anaesth 2000; 84: 11–5 3. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89: 652–8 4. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118: 85–113 5. Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004; 350: 2441–51 doi:10.1093/bja/aev468
Downloaded from http://bja.oxfordjournals.org/ at University of California, San Diego on February 3, 2016
Editor—We would like to congratulate Lee and coworkers1 for their study assessing the influence of type of anaesthesia on a patient-centred outcome as the quality of recovery (QoR). The authors randomized eighty female patients undergoing thyroid surgery to either effect-site target controlled infusion -total intravenous anaesthesia (TIVA) or general anaesthesia with desflurane/remifentanil. All patients received routine prophylactic i.v. ramosetron (0.3 mg) and ketorolac (0.5 mg kg−1) and antagonization of neuromuscular block by neostigmine/glycopyrrolate. QoR was determined by the well-validated QoR- 40 questionnaire.2 Standardized antiemetic (metoclopramide) and analgesic (fentanyl) rescue-medication was administered when the numeric rating scale exceeded four and was recorded during PACU stay. The authors found that TIVA significantly increased the QoR-40 on postoperative day one but not day two. Furthermore, while postoperative pain was comparable in both groups, patients in the TIVA group experienced less postoperative nausea only on day one but not immediately after anaesthesia in the PACU or on day two. The authors concluded, ‘that the quality of recovery in these patients is significantly better with TIVA compared with desflurane anaesthesia’. Absence of PONV is considered to be one major indicator for the quality of anaesthesia.3 Hence, risk factors (female gender, non-smoking, history of PONV/motion sickness, postoperative opioids and duration of anaesthesia) have been identified and a risk-adapted PONV-prophylaxis is recommended.4 Propofol administered for TIVA is considered to possess antiemetic properties itself so that it substitutes for one antiemetic drug.4 5 At the same time, if anaesthetists do not want to dispense with pharmacokinetic and clinical advantages of modern inhaled anaesthetics in patients at risk for PONV, the recommended combination of classic antiemetic drugs should be administered as a prophylaxis. In face of PONV incidences as high as 68% and comparable pain scores, we assume that PONV was the most influential event on the patients’ QoR in this study. To determine differences in treatment groups, it is essential that the authors provide the PONV-risk factor profile of their patients. Accordingly, the baseline risk to experience PONV can be calculated for each treatment group. Thus, ratios between observed to predicted PONV incidences can be compared and differences in values attributed to either treatment or uneven distribution of baseline