The document discusses risk factors for postoperative nausea and vomiting (PONV). It describes studies that identified independent predictors of PONV including female sex, nonsmoking status, history of PONV, general anesthesia, longer surgery duration, and certain types of surgery. A simplified scoring system is presented to predict PONV risk based on the number of applicable risk factors, with a risk of 10-80% for scores of 0-4. Strategies to reduce baseline PONV risk include minimizing use of nitrous oxide, volatile anesthetics, and postoperative opioids.
Comparison of Ondansetron and Granisetron for Prevention of Nausea and Vomiti...Apollo Hospitals
The most common and distressing symptoms, which follow anaesthesia and surgery, are pain and emesis. The consequences of PONV are physical, surgical and anesthetic complications for patients as well as financial implications for the hospitals or institutions. Sometimes nausea and vomiting may be more distressing especially after minor and ambulatory surgery, delaying the hospital discharge. Laparoscopic surgery is one condition, where risk of PONV is particularly pronounced due to pneumo-peritoneum causing stimulation of mechanoreceptors in the gut. In spite of plenty of anti-emetic drugs available no single drug is 100% effective in prevention of PNV and combination therapy has got a lot of side effects.
CONCLUSION:
- For all agents, the ultimate condition of the patient
will be deternined by the sum of the effects of the
chosen agent on CBF, CMRO2, CO2 reactivity, MAP,
and CBV.
- The ultimate effects of volatile agents on ICP/CPP
are less predictable
- The effect of propofol on intracranial dynamics are
more predictable than volatile agents
Comparison of Ondansetron and Granisetron for Prevention of Nausea and Vomiti...Apollo Hospitals
The most common and distressing symptoms, which follow anaesthesia and surgery, are pain and emesis. The consequences of PONV are physical, surgical and anesthetic complications for patients as well as financial implications for the hospitals or institutions. Sometimes nausea and vomiting may be more distressing especially after minor and ambulatory surgery, delaying the hospital discharge. Laparoscopic surgery is one condition, where risk of PONV is particularly pronounced due to pneumo-peritoneum causing stimulation of mechanoreceptors in the gut. In spite of plenty of anti-emetic drugs available no single drug is 100% effective in prevention of PNV and combination therapy has got a lot of side effects.
CONCLUSION:
- For all agents, the ultimate condition of the patient
will be deternined by the sum of the effects of the
chosen agent on CBF, CMRO2, CO2 reactivity, MAP,
and CBV.
- The ultimate effects of volatile agents on ICP/CPP
are less predictable
- The effect of propofol on intracranial dynamics are
more predictable than volatile agents
Treatment Deintensification in HPV positive head and neck cancerDr Rushi Panchal
This ppt is providing detail of current status and future direction of treatment deintensification strategies of head and neck cancer in era of HPV positive sq cell carcinoma.
Transfusion and Postoperative Outcome in Pediatric Abdominal Surgeryasclepiuspdfs
Background: Intraoperative and post-operative morbimortality factors are multiple in pediatric patients. Studies in pediatric cardiac surgery and intensive care patients have identified transfusion as one independent factor among others. This study was undertaken to investigate whether transfusion was an independent factor of morbimortality in pediatric abdominal surgical patients. Objectives: The objective of the study is to identify morbimortality risk factors in intraoperatively transfused and not transfused pediatric abdominal surgical patients. Design: This was a retrospective observational descriptive pediatric cohort study. Setting: Monocentric pediatric tertiary center, Necker–Enfants Malades University Hospital, Paris, from January 1, 2014, to May 17, 2017. Patients: 193 patients with a median age of 27.5 months (1.0–100.5) were included in the study. Inclusion criteria were the presence or the absence of transfusion in the intraoperative period in abdominal surgery patients. Exclusion criterion was transfusion in the post-operative period until discharge from hospital and non-abdominal surgical patients.
La terapia medica e chirurgica della malattia perianale di Crohn - Gastrolear...Gastrolearning
Gastrolearning II modulo/21a lezione
La terapia medica e chirurgica della malattia perianale di Crohn
Relatore: Prof. Paolo Gionchetti (Università di Bologna)
Incisional Hernia, risk factors, management and relation to Surgical Abdomina...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
Non operating room anesthesia and reversal of muscle relaxation.Respiratory complications due to residual paralysis.Mechanism of action of residual paralysis .Sugammadex.Calabadion New discoveries.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
lowest heart rate
lowest mean arterial pressure
estimated blood loss
A score built from these 3 predictors has proved strongly predictive of the risk of major postoperative complications and death in general and vascular surgery
A new dantrolene formulation for the treatment of Malignant hyperthermia(MH).Receptors,pharmacokinetics,dosages,preparation of dantrolene,practical tips,advantages.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
1. Can PONV be predicted?
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Risk factor analysis
2. • Use of prophylactic antiemetics should be based on
valid assessment of the patients risk for POV or
PONV.
• In other words....antiemetic prophylaxis shouild be
used only when the patient individual risk is
sufficiently high.
• Estimate:baseline risk * baseline risk reduction
resulting from prophylaxisUse of prophylactic
antiemetics should be based on
• This approach produces a clinically meaningful
decrease in the risk of PONV
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3. Simplified Scoring System
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Risk Factors
• Female
• Nonsmoking history
• Hx of motion sickness or PONV
• Use of postoperative opioids
Incidence of PONV
Risk Factors Incidence
0 10%
1 21%
2 39%
3 61%
4 79% Apfel CC et al. Anesthesiology 1999;91:693-700.
4. Simplified scoring system from Apfel for
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adults
• For every risk factor the sum is additive:
• Point 0 risk 10%
• Point 1 risk 20%
• Point 2 risk 40%
• Point 3 risk 60%
• Point 4 risk 80%
5. Simplified risk score from Apfel et al. to predict the
patients risk for PONVin adults . When 0, 1, 2, 3, or 4 of the depicted independent
predictors are present, the corresponding riskfor PONV is approximately 10%, 20%,
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40%, 60%, or 80%.
Figure 1
6. Simplified scoring system from Eberhardt
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39 di Samba for children
• Surgery> 30 min
• Age> 3
• Strabismus surgery
• Hx of POV or POnv in relatives
• Sum 0......4
• Risk 10%,10%,30%,55%,70%
7. Simplified risk score from Eberhart et al. (39) to predict the
risk for POV in children. When 0, 1, 2, 3, or 4 of the depicted
independent predictors are present, the corresponding risk
for PONV is approximately 10%, 10%, 30%, 55%, or 70%.
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8. Particular medical risk
• more liberal prophylaxis is appropriate for patients in
whom vomiting poses a particular medical risk:
• wired jaws
• increased intracranial pressure
• gastric or esophageal surgery
• when the anesthesia care provider determines the
need
• or the patient has a strong preference to avoid PONV
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9. Servizio di Anestesia e
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Sinclair et al.Can PONV be
predicted?Anesthesiology 1999;91:109-18
• 17,638 consecutive ambulatory surgical patients;>90% ASA I /II
• 5,812 men and 11,826 women
• mean (± SD) age of 46.7 ± 21.2 yr.
• prospectively studied during a 3-yr period
• ASU of The Toronto Hospital, Western Division
• telephone interview 24 h after operation was obtained.
• Preoperative patient characteristics and intraoperative variables were
documented on specifically designed, standardized adverse-outcome
check-off forms.
• i.v.2—4 mg morphine for pain relief and 25—50 mg dimenhydrinate
for nausea or vomiting.
• Overall PONV incidence 4.6%:9.1 % at 24 hrs interview.
10. Independent predictors of PONV
Sinclair et al.Can PONV be predicted?Anesthesiology 1999;91:109-18
• age A 10-yr increase in age was associated with a 13% decrease in the likelihood of PONV.
• sex Men had one third the risk for PONV compared with women.
• smoking status Smokers had two thirds the risk for PONV compared with nonsmokers
• history of previous PONV, had a threefold increase in the likelihood PONV compared with patients with no
previous PONV.
• type of anesthesia: General anesthesia increased the likelihood of PONV 11 times compared with other types of
anesthesia.
• duration of anesthesia, direct association between the duration of anesthesia and the risk for PONV. A 30-min
increase in duration predicted a 59% increase in the incidence of PONV
• type of surgery :
– plastic surgery had a sevenfold increase in the risk for PONV.
– orthopedic shoulder surgery, ophthalmologic, or ENT procedures had a four- to sixfold increase.
– orthopedic (nonshoulder) and gynecologic (non-D&C) procedures had a threefold
increase in the risk for PONV. Compared with the reference group, which includes
general surgery, gynecologic dilation and curettage (D&C), urologic surgery,
neurosurgery, and chronic pain blockENT
– dental surgery 14.3%, orthopedic 7.6%,plastic surgery 7.4%.Urologic, gynecologic,
neurologic, or general surgery had an incidence of PONV corresponding to the overall
average 4%
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•
11. Logistic regression da:Sinclair et al.Can PONV be
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predicted?Anesthesiology 1999;91:109-18
• P=1/1+e esponente
• con il segno neg. all’esponente la probabilità aumenta perché e elevato
ad esp negativo diminuisce sempre + con il risultato che 1+e tende a 1 e
dunque P=1/1,ossia 100%
• Con il segno positivo all’esponente e aumenta sempre + e allora 1+e
aumenta e dunque il denominatorer dell’equazione aumenta e dunque
1/un numero in aumento fa scendere la probabilità perché viene
1/5,cioè 20%,1/10=10%,ecc…..
• Esponente=-5,97+(-0,14 *age)+(-1,03*sex)+
(-0,42*smoke)+(1,14*PONV history)+
(0,46*duration)+(2,36*GA)+(1,48*ENT)+
(1,77*ophtalm)+(1,90*plastic)+(1,20 Gynecol non DC)+(1,04 ort knee)+(1,78*ortshoulder)+(0.94
ort other)
• where Age = age in years/10; Sex = 1 if male and 0 if female; Smoke = 1 if smoker and 0 if nonsmoker; PONV
History = 1 if previous PONV and 0 if no previous PONV; Duration = duration of surgery in 30-min increments;
GA = 1 if general anesthesia and 0 if other type of anesthesia; ENT = 1 if ENT and 0 if other type of surgery;
Ophthalm = 1 if ophthalmology and 0 if other type of surgery; Plastic = 1 if plastic surgery and 0 if other type
of surgery; GynNonDC = 1 if gynecologic non D&C procedure and 0 if other type of surgery; OrtKnee = 1 if
orthopedic procedure involving knee and 0 if other type of surgery; OrtShoulder = 1 if orthopedic procedure
involving the shoulder and 0 if other type of surgery; OrtOther = 1 if orthopedic procedure involving neither
knee nor shoulder and 0 if other type of surgery.
12. Importance of the work by Sinclair et
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al…
• Fitting the model to the data, we can obtain the
maximum likelihood estimate of the parameters for
each variable. Based on the maximum likelihood
estimates from the final models, it is possible to
calculate an expected risk of occurrence of the
specific adverse event for any patient.
•
13. • Appendix 1
• Logistic regression is used to model the relation between explanatory variables and binary outcome variables. The logistic regression
modeling assumes that the probability of an event (i.e., the occurrence of the outcome) is associated with the values of the explanatory
variables in the following way:
•
• where
•
• where p = probability of the occurrence of the outcome, xi = value of the ith independent variable, and bi events for any patient =
parameter estimates for the ith variable.
• Fitting the model to the data, we can obtain the maximum likelihood estimate of the parameters for each variable. Based on the
maximum likelihood estimates from the final models, it is possible to calculate an expected risk of occurrence of the specific adverse
event for any patient.
• Examples
• The risk for patient 1, a 30-yr-old woman with a history of smoking and previous PONV undergoing a 1-h shoulder (orthopedic)
operation with general anesthesia is 35.2%.
•
• The risk for patient 2, a 40-yr-old nonsmoking man with no previous PONV undergoing a 1-h knee arthroscopy (orthopedic) without
general anesthesia is 0.4%.
•
• The risk for patient 3, a 70-yr-old smoking man with no previous PONV undergoing a 1-h cataract surgery (ophthalmologic) without
general anesthesia is 0.3%.
•
• The risk for patient 4, a 32-yr-old nonsmoking woman with previous PONV undergoing a 30-min laparoscopy (gynecologic) with general
anesthesia is 22.1%
•
• The risk for patient 5, a 22-yr-old woman with a history of smoking and previous PONV undergoing a 90-min bilateral breast
augmentation (plastic surgery) with general anesthesia is 52%.
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14. Strategies to Reduce Baseline
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Risk
• Avoidance of general anesthesia by the use of regional
anesthesia (11,16) (randomized, controlled trial, RCT)
• Use of propofol for induction and maintenance of
Anesthesia(4,14,41,42) (RCT/systematic review, SR)
• Avoidance of nitrous oxide (3,4,43,44) (RCT/SR)
• Avoidance of volatile anesthetics (15,28) (RCT)
• Minimization of intraoperative (SR) and postoperative
• opioids (3,13,15,17,18,20,28,43) (RCT/SR)
• Minimization of neostigmine (19,45) (SR)
• Adequate hydration (46) (RCT)
15. Servizio di Anestesia e
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Risk Factors
• Non-anesthetic factors
• Anesthetic related
factors
• Postoperative factors
16. Risk factors da Samba 2007:1
• Patient specific
– Female gender
– Non smoking status
– Hx of ponv/motion sickness
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17. Risk factors da Samba 2007:2
• Anesthetic risk factors
– Use on intraop volatile anesth
– Use on intraop and postop opioids
– Use of intraop N2O
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18. Risk factors da Samba 2007:3
• Surgical risk factors
– Duration of surgery
– Each 30 min increase in duration of surgery oncreases the
risk by 60%,so thyat a baseline risk of 10% increases to
16% after 30 min
– Type of surgery
Laparoscopy;,laparotomy;breast,strabismus,plastic,maxi
llofacial,gynecological,abdominal,neurologic
,opthalmologic,urologic
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19. Non-anesthetic Factors
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Risk Factors
• Age
• Gender
• Body habitus
• Hx motion sickness
• Hx PONV
• Anxiety
• Concomitant disease
• Operative procedure
• Duration of surgery
20. Anesthetic Related Factors
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Risk Factors
• Preanesthetic medication
• Gastric distension
• Gastric suctioning
• Anesthetic technique
• Anesthetic agents
21. Postoperative Factors
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Risk Factors
• Pain
• Dizziness
• Ambulation
• Oral intake
• Opioids
22. Postoperative Nausea and Vomiting:
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Anesthetic Related Factors
• Nitrous oxide
• Volatile anesthetics
• NMB reversal
• Propofol
23. Omitting nitrous oxide from general anesthesia:
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Risk Factors
Nitrous Oxide and PONV
• Decreases POV significantly only if the baseline
risk is high
• Does not affect nausea or complete control of
emesis
• Increases the incidence of intraoperative
awareness
Tramer et al. BJA 1996;76:186-193
24. IS PONV incidence different between
Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
LMA and ETT?
• Joshi GP, Inagaki Y, White PF, Taylor-Kennedy
L, Wat LI, Gevirtz C, McCraney JM, McCulloch
DA: Use of the laryngeal mask airway as an
alternative to the tracheal tube during
ambulatory anesthesia. Anesth Analg 85:573–
7, 199
25. Risk Factors
Volatile anesthetics
Risk Factors OR* CI
Volatile
anesthetics
isoflurane 3.41 2.18; 5.37
sevoflurane 2.78 1.79; 4.31
enflurane 3.11 1.98; 4.88
Apfel et al. BJA 2002;88:659-668
* Compared to propofol
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
26. Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
Risk Factors
Reversal of Neuromuscular Block
• Omitting neostigmine may have a clinically
relevant antiemetic effect when high doses
are used
• Omitting NMB antagonism introduces a
non-negligent risk of residual paralysis
even when short acting NMB agents are
used
Tramer MR, Fuchs-Buder T. BJA 1999;82:379-386
27. Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
Risk Factors
Propofol and PONV
All Control Event Rates
Early Late
NauseaVomitingAnyNauseaVomitingAny
Induction 9.3* 13.7* 20.9 50.114.9NA
Maintenance 8* 9.2* 6.2* 5.8* 10.1* 10
20% - 60% Control Event Rate
Early Late
NauseaVomitingAnyNauseaVomitingAny
Induction 5.0* 7.0* 14 28 10 NA
Maintenance 4.7* 4.9* 4.9* 6.1* 8.3* 7.1
Tramer et al. BJA 1997;78:247-255
Analysis by NNT
28. Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
Risk Factors
Antiemetic Effects of Propofol
Investigations Randomized Double-Blind Placebo-Controlled Effective
Chemotherapy Induced Emesis
Scher 1992 no no no yes
Borgeat 1993 no no no yes
Borgeat 1994 no no no yes
PONV
Campbell 1991 yes yes yes no
Borgeat 1992 yes yes yes yes
Ewalenko 1996 yes yes yes yes
Montgomery 1996 yes yes yes no
Scuderi 1996 yes yes yes no
Gan 1997 no no no yes
Gan 1999 yes yes yes yes
29. Logistic Regression
Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
Risk Factors
Palazzo M, Evans R. Logistic regression analysis of fixed patient
factors for postoperative sickness: a model for risk assessment. Br J
Anaesth 1993;70:135-40.
Koivuranta M, Läärä E, Snåre L, Alahuhta S. A survey of postoperative
nausea and vomiting. Anaesthesia 1997;52:443-49.
Apfel CC, Greim CA, Haubitz I, et al. A risk score to predict the
probability of postoperative vomiting in adults. Acta Anaesthesiol Scand
1998;42:495-501.
30. Logistic Regression
Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
Risk Factors
• Younger age
• Nonsmoking history
• Female
• Hx of motion sickness
• Hx of PONV
• Increased duration of operation
31. Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
Problems............
• to separate independent factors vs dependent
factors................
• No risk model can actually predict the
likelihood of an individual having PONV;risk
models only allow clinicians to etimate the risk
of PONV among patients groups
32. Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
PPOONNVV
ffattttorrii dii rriischiio
ddoonnnnee
ggiioovvaannii
età
fer tile
ggrraavviiddee
post
partum
iinntteerrvveennttii
mus coli
ex traocular i
orecc hio
medio
pelv i
femm.in
laparoscopia
deambulazione
precoce
bbaambbiinnii
soggetti
a
cinetos i
pregres so
PONV
ffaarrmaaccii
ooppppiiooiiddii
anestetici
inalatori
Neurosurg N2O
Breast surg
Laparotomy
Plastic surg.
Non
smokers
Editor's Notes
Patients received thiopental for induction, opioid and potent inhalation anesthetic plus nitrous oxide for maintenance. Type of surgical procedure seems to not be an independent risk factor.