Volume 6 Number 2

Promethazine in the treatment of postoperative nausea and vomiting: a systematic review (Views : 7569 times)


Postoperative nausea and vomiting (PONV) is among the most important concerns of patients undergoing surgery. The incidence ranges  from 30% to 70%. The incidence of PONV correlates with a number of risk factors a patient possesses. Patient-related risk factors in adults are: female gender, history of PONV, duration of surgery > 60 min, nonsmoking status, history of motion sickness, and postoperative use of opioids. Risk factors in children are: duration of surgery ≥ 30 minutes, age ≥ 3 years, strabismus surgery, and a history of PONV in the patient, parent or sibling. Treatment of PONV includes various classes of medications and none of them is entirely effective. If it is necessary to use combination therapy, then  medicines with different sites of activity should be used. Promethazine is a phenothiazine derivate available as a medicine since its introduction in 1946. In this article, a search was performed to identify all published papers and reports evaluating the effectiveness of promethazine for the management of postoperative nausea and vomiting in adults and children. The results of this review support the finding that promethazine is not recommended as a first-line agent  in the treatment of PONV, but can be considered for use as a rescue antiemetic.

Key words: promethazine, postoperative nausea and vomiting, treatment


Nesiritide and clinically relevant outcomes in cardiac surgery: a meta-analysis of randomized studies (Views : 2737 times)


B-type natriuretic peptide is a cardiac hormone that relaxes vascular smooth muscle and causes arterial dilatation. Nesiritide has been  associated with increased urine output; reduced diuretic requirements; and suppression of aldosterone, endothelin, and norepinephrine. We have independently conducted the first systematic review and meta-analysis of randomized trials to determine the impact of nesiritide on renal replacement therapy and death in patients undergoing cardiac surgery. We performed a meta-analysis of 6 randomized controlled studies including 560 patients (280 receiving nesiritide and 280 assigned to the control group). Two unblinded reviewers selected randomized trials studying  nesiritide  in patients undergoing cardiac surgery. Nesiritide doses ranged from 0.005 mcg/kg/min to 0.01 mcg/kg/min. Nesiritide did not reduce postoperative creatinine peak values: -0.16 [-0.42, 0.10], p for effect=0.23, p for heterogeneity<0.01, I2=90.5%) or the need for  renal replacement therapy (1/177 in the nesiritide group vs 4/176 in the control group OR 0.39 [0.07, 2.06], p for effect=0.27, p for heterogeneity=0.70, I2=0%). We observed an interesting trend toward a reduction in mortality in the nesiritide group:13/280 (4.6%) vs 22/280 (7.8%) OR 0.57 [0.28, 1.15], p for effect=0.12, p for heterogeneity=0.43, I2=0%. Nesiritide did not reduce time of mechanical ventilation -8.77 hours [-21.42, 3.88], p=0.17, length of hospital stay -2.67 days [-6.50, 1.16], p=0.17 or intensive care unit (ICU) stay -0.94 days [-2.83, 0.95], p=0.33. In conclusion, further randomized controlled trials are needed to support the hypothesis that nesiritide improves clinically relevant outcomes in cardiac surgery.

Key words: Nesiritide, meta-analysis, cardiac surgery, renal replacement therapy, mortality.


Targeting out-of-hospital cardiac arrest: the effect of heparin administered during cardiopulmonary resuscitation (T-ARREST) (Views : 2843 times)


Introduction. Heparin administration during cardiopulmonary resuscitation (CPR) may prevent activation of coagulation after successful resuscitation for out-of-hospital cardiac arrest (OHCA). We hypothesize that such an approach is not associated with an increased rate of bleeding, but it has not been evaluated. We performed a pilot randomized clinical study assessing the safety of intra-arrest heparin administration in OHCA patients with suspected acute myocardial infarction (AMI) and its impact on their prognosis.
Materials and Methods.  OHCA patients were randomized during CPR to 10 000 units of intra-arrest intravenous heparin (Group H) or to treatment without heparin (Group C). The occurrence of major bleeding and the presence of a favourable neurological result 3 months after OHCA, were analyzed.
Results. Out of 88 randomized patients, AMI was subsequently confirmed in 63 of them (71.6 %). There were 30 patients in group H and 33 in group C. No major bleeding event was observed in either group. Return of spontaneous circulation (ROSC, Group H: 40.0%, Group C: 45.4%, p=0.662) and a good neurological result 3 months after OHCA (Group H: 6.7 %, Group C: 9.1 %, p=0.921) did not differ between groups.
Conclusions. Intravenous administration of 10 000 units of heparin during CPR for OHCA in patients with supposed AMI was safe. We did not find any improvement in prognosis for our sample of limited size. Though the procedure proved safe, we recommend postponing the administration of heparin until ROSC, assessment of  clinical state and  recording of a  twelve-lead ECG.

Key words: out-of-hospital cardiac arrest, heparin, major bleeding


Near-death experiences and electrocardiogram patterns in out-of-hospital cardiac arrest survivors: a prospective observational study (Views : 2715 times)


Aim. To determine the effect of several factors, that are a part of cardiac arrest and resuscitation, on the incidence of near-death experiences (NDEs).
Methods. We conducted a prospective observational study in the three largest hospitals in Slovenia in a consecutive sample of patients after out-of-hospital primary cardiac arrest. The presence of NDE was assessed with the  self-administered Greyson’s near-death experiences scale. The electrocardiogram pattern at the beginning of  resuscitation was recorded. Main outcome measure was the presence of near-death experiences. Univariate analysis was used.
Results. The study included 52 patients. There were 42 (80.8%) males in the sample; median age ± standard deviation of the patients was 53.1 ± 14.5 years. Near-death experiences were reported by 11 (21.2%) patients. Patients with ventricular fibrillation had significantly less NDEs than other patients (12.2% vs. 54.5%, P = 0.006). Patients with pulseless electrical activity had significantly more NDEs than others (60.0% vs. 11.9%, P = 0.003). Patients with asystole  and pulseless electrical fibrillation had significantly more NDEs than patients who had ventricular fibrillation and ventricular tachycardia (60.0% vs. 11.9%, P = 0.003). Patients with at least one defibrillation attempt had significantly less near-death experiences than others (62.5% vs. 13.6%, P = 0.007).
Conclusion. Our study found a possible correlation between electrocardiogram pattern in cardiac arrest patients and the incidence of near-death experiences. Further studies should address this problem in larger  samples.

Key words: near-death experiences, electrocardiogram, heart arrest, incidence, prospective study, resuscitation


A prospective randomized high fidelity simulation center based side-by-side comparison analyzing the success and ease of conventional versus new generation video laryngoscope technology by inexperienced laryngoscopists (Views : 2424 times)


Introduction. Indirect video laryngoscopes are altering the landscape of airway management.  The primary aim of this prospective randomized patient simulator analysis was to objectively compare video laryngoscopes to standard airway management techniques in novice users.
Methods.  "First year medical students were exposed to high-fidelity simulated normal and difficult airway scenarios while using an array of indirect video laryngoscopes (e.g., the GlideScope, McGRATH or Pentax AWS-100) that were compared to Macintosh laryngoscope and fiberoptic bronchoscope (i.e., historic gold standards for normal and difficult airways, respectively)."
Results.  In the normal airway scenario, the best glottic view (both subjective and objective) was obtained with the video laryngoscopes and intubation success rates were highest with the video laryngoscopes (100% success rate for each device) and Macintosh (80%).  In the difficult airway scenario, the best glottic view was achieved with all video laryngoscopes and the fiberoptic bronchoscope; however, tracheal intubation was best achieved with the video laryngoscopes (100% success rate for each device) whereas the success rate with the bronchoscope was only 36%.
Discussion.  Our findings support the use of the GlideScope, McGRATH, or Macintosh laryngoscopes for novice users managing a normal airway.  When managing the difficult airway, there was no difference between any video or Macintosh laryngoscope in the time to successfully intubate the trachea.  Over time, study participants demonstrated learned behavior as they became more facile with all devices.  When comparing the video laryngoscopes, all three performed similarly overall and proved useful in the hands of novice users.  Regardless of airway difficulty, the fiberoptic bronchoscope yielded the worst results.

Key words: airway, airway management, airway equipment, patient simulation, success, tracheal intubation




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