EVIDENCE BEHIND THIS PROTOCOL

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The OPMC TIVA protocol is adapted from the 2014 RCT "Opioid-free TIVA reduces PONV in bariatric surgery beyond triple prophylaxis" conducted at Flagler Hospital in St. Augustine, FL. Similar versions of this protocol exist in literature and in hospital facilities, however few have the gold standard of an RCT to support it. The full article is attached, so we won't bore you with details. But here are the highlights:

• Opioid-free TIVA resulted in an absolute risk reduction of 17.3% for PONV. For patient's that did experience PONV, there was a decrease in the severity of nausea and vomiting.
• 119 patients were randomized to the TIVA group (n=60) or classic group (n=59) with volatile anesthetics and opioids.  
• The severity of PONV was assessed using a graded-Likert scale. Patients were interviewed in the morning on the first POD. 
•  22 (37.3%) in the classic group and 12 patients (20.0%) in the TIVA group reported PONV. This is a statistically significant reduction in PONV (P=0.04), with a RR reduction of 46.4%.  

This systematic review identified 22 studies with a total of 95,154 patients to evaluate the biggest independent predictors of PONV. See the full article in attachments if interested. Here are the highlights:

•  The use of volatile anesthetics was the strongest anesthesia-related predictor for PONV, followed by the duration of anesthesia, postoperative opioid use, and nitrous oxide.
• Female gender was the strongest patient specific predictor, followed by a history of PONV/motion sickness, non-smoking status, and age.

Do we really need to use Precedex? 

           No. But this December 2021 article from the AANA Journal makes the argument for the use of this alpha-2 adrenergic drug for early recovery and improved outcomes. The full reference is below. Here are the highlights:

• Administration of an alpha-2 adrenergic agonist can enhance pain management, decrease adverse effects, and promote surgical recovery. 
• a2-adrenergic drugs decrease opioid consumption. The nociceptive effective works independent of the opioid receptor, and actually can enhance the effects of opioids.
• a2-adrenergic drugs reduce post-operative nausea and vomiting, anxiety, perioperative stress, inflammation shivering and cognitive dysfunction.

Ziemann-Gimmel, P., Goldfarb, A. A., Koppman, J., & Marema, R. T. (2014). Opioid-free total intravenous anaesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis.British Journal of Anaesthesia: BJA, 112(5), 906-911. doi:10.1093/bja/aet551

Zhang, X., & Bai, X. (2014). New therapeutic uses for an alpha2 adrenergic receptor agonist – dexmedetomidine in pain management. Neuroscience Letters, 561, 7-12. doi:10.1016/j.neulet.2013.12.039 

Apfel, C., Heidrich, F., Jukar-Rao, S., Jalota, L., Hornuss, C., Whelan, R., Zhang, K., & Cakmakkaya, S. (2012). Evidence-based analysis of risk factors for postoperative nausea and vomiting. British Journal of Anaesthesia, 109 (5), 742-53. http://doi.org/10.1093/bja/aes276

Demirel, I., Yildiz Altun, A., Bolat, E., Kilinc, M., Deniz, A., Aksu, A., & Bestas, A. (2021). Effect of patient state index monitoring on the recovery characteristics in morbidly obese patients: Comparison of inhalation anesthesia and total intravenous anesthesia. Journal of Perianesthesia Nursing, 36(1), 69-74. https://10.1016/j.jopan.2020.07.005

 Elbakry, A., Sultan, W., & Ibrahim, E. (2017). A comparison between inhalational (Desflurane) and total intravenous anaesthesia (propofol and dexmedetomidine) in improving postoperative recovery for morbidly obese patients undergoing laparoscopic sleeve gastrectomy: A double-blinded randomized controlled trial. Journal of Clinical Anesthesia, 45(2018), 6-11. http://doi.org/10.1016/j.jclinane.2017.12.001

 Elsayed, M. (2019). Comparative study between total intravenous anesthesia versus volatile induction and maintenance anesthesia with sevoflurane for bariatric operations some of the authors of this publication are also working on these related projects: Effect of dexmedetomidine on post spinal anesthesia shivering view project effect of TIVA versus VIMA in bariatric surgery view project. The Egyptian Journal of Hospital Medicine, 76(6), 4319-4324. doi:10.12816/EJHM.2019.43986

Groene, P., Eisenlohr, J., Zeuzem, C., Dudok, S., Karcz, K., & Hofmann-Kiefer, K. (2019). Postoperative nausea and vomiting in bariatric surgery in comparison to non-bariatric gastric surgery Termedia Sp. z.o.o. doi:10.5114/wiitm.2018.77629