Intraoperative respiratory and hemodynamic strategies for reducing nausea, vomiting, and pain after surgery: Systematic review and meta-analysis

Johanne M Holst, Maibritt P Klitholm, Jeppe Henriksen, Mikael F Vallentin, Marie K Jessen, Maria Bolther, Mathias J Holmberg, Maria Høybye, Peter Carøe Lind, Asger Granfeldt, Lars W Andersen, Johanne M Holst, Maibritt P Klitholm, Jeppe Henriksen, Mikael F Vallentin, Marie K Jessen, Maria Bolther, Mathias J Holmberg, Maria Høybye, Peter Carøe Lind, Asger Granfeldt, Lars W Andersen

Abstract

Background: Despite improved medical treatment strategies, postoperative pain, nausea, and vomiting remain major challenges. This systematic review investigated the relationship between perioperative respiratory and hemodynamic interventions and postoperative pain, nausea, and vomiting.

Methods: PubMed and Embase were searched on March 8, 2021 for randomized clinical trials investigating the effect of perioperative respiratory or hemodynamic interventions in adults undergoing non-cardiac surgery. Investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed when feasible. GRADE was used to assess the certainty of the evidence.

Results: This review included 65 original trials; of these 48% had pain, nausea, and/or vomiting as the primary focus. No reduction of postoperative pain was found in meta-analyses when comparing recruitment maneuvers with no recruitment, high (80%) to low (30%) fraction of oxygen, low (5-7 ml/kg) to high (9-12 ml/kg) tidal volume, or goal-directed hemodynamic therapy to standard care. In the meta-analysis comparing recruitment maneuvers with no recruitment maneuvers, patients undergoing laparoscopic gynecological surgery had less shoulder pain 24 h postoperatively (mean difference in the numeric rating scale from 0 to 10: -1.1, 95% CI: -1.7, -0.5). In meta-analyses, comparing high to low fraction of inspired oxygen and goal-directed hemodynamic therapy to standard care in patients undergoing abdominal surgery, the risk of postoperative nausea and vomiting was reduced (odds ratio: 0.45, 95% CI: 0.24, 0.87 and 0.48, 95% CI: 0.27, 0.85). The certainty in the evidence was mostly very low to low. The results should be considered exploratory given the lack of prespecified hypotheses and corresponding risk of Type 1 errors.

Conclusion: There is limited evidence regarding the impact of intraoperative respiratory and hemodynamic interventions on postoperative pain or nausea and vomiting. More definitive trials are needed to guide clinical care within this area.

Keywords: PONV; anesthesia; hemodynamic; nausea; pain; respiratory; review; vomiting.

Conflict of interest statement

The authors declare no conflicts of interest.

© 2022 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.

Figures

FIGURE 1
FIGURE 1
Fraction of inspired oxygen and postoperative nausea and vomiting. Results from random‐effects meta‐analyses of trials assessing fraction of inspired oxygen. Results are displayed as odds ratios (dots) with 95% confidence intervals (error bars). Values below 1 indicate reduced postoperative nausea and vomiting with 80% inspired oxygen. Subgroup analysis by abdominal surgeries, gynecological surgeries, and various surgeries.
FIGURE 2
FIGURE 2
Recruitment maneuvers and pain 24 h postoperatively. Results from random‐effects meta‐analyses of trials assessing recruitment maneuvers. Results are displayed as mean differences (dots) with 95% confidence intervals (error bars). Values below 0 indicate reduced pain 24 h postoperatively with recruitment maneuvers.
FIGURE 3
FIGURE 3
Recruitment maneuvers and shoulder pain 24 h postoperatively. Results from random‐effects meta‐analyses of trials assessing recruitment maneuvers. Results are displayed as mean differences (dots) with 95% confidence intervals (error bars). Values below 0 indicate reduced shoulder pain 24 h postoperatively with recruitment maneuvers.
FIGURE 4
FIGURE 4
Goal‐directed hemodynamic therapy and postoperative nausea and vomiting. Results from random‐effects meta‐analyses of trials assessing goal‐directed hemodynamic therapy. Results are displayed as odds ratios (dots) with 95% confidence intervals (error bars). Values below 1 indicate reduced postoperative nausea and vomiting with goal‐directed hemodynamic therapy.

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