Intrathecal Morphine in Laparoscopic Bowel Surgery

Pain is by no means minimal after laparoscopic colonic resection and a study using intrathecal Morphine with Bupivacaine (0.3/12.5 with age adjustment) showed better analgesia and faster recovery. There was increased pruritus and nausea, and respiratory depression was curiously not studied on the first night. Overall patient satisfaction was similar as was actual length of stay. Benefits appear confined to the first day.  The study was not a convincing win for intrathecal morphine but may have application in selected patients, or need further study in ERAS protocols.  link

An earlier study was less enthusiastic about the benefits  link

 

Amisulpride for PONV

A study on postoperative nausea and vomiting found this dopamine antagonist atypical anti-psychotic effective in combination with either ondansetron or dexamethasone. All 1,100+ participants were female and at high risk of nausea and vomiting. Side effects were infrequent and no Q-T  prolongation reported. Further study is needed to compare with other combination therapies. Amisulpride has not been approved in the US.

link

 

Phenylephrine vs. Ephedrine in OB

Phenylephrine has largely supplanted Ephedrine for neuraxial anesthesia related hypotension during Cesarean due to the latter’s association with fetal acidosis, despite an unclear clinical significance. A current study in a more defined population of pre-eclampsia with non-reassuring fetal heart rate finds fetal pH and other blood gas parameters, as well as Apgar Scores to be no different between the two agents.

They conclude that maternal hemodynamics and heart rate etc should determine best (or both) vasopressors. link

Atrial Fibrillation After Surgery

1 in 10 patients develop post-op atrial fibrillation after general abdominal surgery. Identified risk factors included: increasing age; history of cardiac disease; postoperative complications, particularly sepsis, pneumonia and pleural effusions. Esophagectomy had a higher incidence. We of course know it’s also common after thoracic surgery

Risk stratification and prophylaxis, as often done in cardiothoracic surgery, is an area for further delineation. The most commonly used strategies have been Magnesium, B-Blockers and Amiodarone. After 48 hours, evaluation of stroke risk and balancing bleeding vs embolism risk is necessary.

Most studies show an increased cardiac and stroke risk, although some question whether it is causal or a marker for underlying disease. Often considered a transient event, it may also be a target for stroke prevention and anticoagulation in the longer term at hospital discharge.

link

earlier review

Also of note is the association between OSA ad AFib and the benefits of  CPAP link

 

 

Dexamethasone, Neuraxial Opioids and PONV

The effect of Dexamethasone on nausea and vomiting after long acting neuraxial opioids was studied in a meta-analysis. While such a generic and potentially disparate group can make conclusions difficult, important reduction in nausea and vomiting was found without increase in complications like infection or restlessness, with blood sugar not being reported. It seems reasonable to add Dexamethasone to facilitate enhanced recovery.  link