Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was conducted to identify the independent predictive factors for postoperative pain and analgesic consumption. The authors identified 48 eligible studies with 23,037 patients included in the final analysis. Preoperative pain, anxiety, age, and type of surgery were four significant predictors for postoperative pain. Type of surgery, age, and psychological distress were the significant predictors for analgesic consumption. Gender was not found to be a consistent predictor as traditionally believed. Early identification of the predictors in patients at risk of postoperative pain will allow more effective intervention and better management. The coefficient of determination of the predictive models was less than 54%. More vigorous studies with robust statistics and validated designs are needed to investigate this field of interest.

This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. The guidelines are established by an international panel of experts under the auspices of the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. The guidelines provide recommendation on identifying high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatment of PONV as well as recommendations for the institutional implementation of a PONV protocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-generation 5-hydroxytryptamine 3 [5-HT3] receptor antagonists, neurokinin 1 (NK1) receptor antagonists, and dopamine antagonists), discussion regarding the use of general multimodal PONV prophylaxis, and PONV management as part of enhanced recovery pathways. This set of guidelines have been endorsed by 23 professional societies and organizations from different disciplines (Appendix 1). What Other Guidelines Are Available on This Topic? Guidelines currently available include the 3 iterations of the consensus guideline we previously published, which was last updated 6 years ago 1–3 ; a guideline published by American Society of Health System Pharmacists in 1999 4 ; a brief discussion on PONV management as part of a comprehensive postoperative care guidelines 5 ; focused guidelines published by the Society of Obstetricians and Gynecologists of Canada, 6 the Association of Paediatric Anaesthetists of Great Britain & Ireland 7 and the Association of Perianesthesia Nursing 8 ; and several guidelines published in other languages. 9–12 Why Was This Guideline Developed? The current guideline was developed to provide perioperative practitioners with a comprehensive and up-to-date, evidence-based guidance on the risk stratification, prevention, and treatment of PONV in both adults and children. The guideline also provides guidance on the management of PONV within enhanced recovery pathways. How Does This Guideline Differ From Existing Guidelines? The previous consensus guideline was published 6 years ago with a literature search updated to October 2011. Several guidelines, which have been published since, are either limited to a specific populations 7 or do not address all aspects of PONV management. 13 The current guideline was developed based on a systematic review of the literature published up through September 2019. This includes recent studies of newer pharmacological agents such as the second-generation 5-hydroxytryptamine 3 (5-HT3) receptor antagonists, a dopamine antagonist, neurokinin 1 (NK1) receptor antagonists as well as several novel combination therapies. In addition, it also contains an evidence-based discussion on the management of PONV in enhanced recovery pathways. We have also discussed the implementation of a general multimodal PONV prophylaxis in all at-risk surgical patients based on the consensus of the expert panel.

Similar to the STOP questionnaire, the Berlin questionnaire and ASA checklist demonstrated a moderately high level of sensitivity for OSA screening. The STOP questionnaire and the ASA checklist were able to identify the patients who were likely to develop postoperative complications.

A lthough obstructive sleep apnea (OSA) is common, up to 82% of men and 92% of women with moderate-to-severe sleep apnea have not been diagnosed. The use of preoperative screening instruments may help identify these undiagnosed patients. The STOP-Bang questionnaire has 8 questions and is scored on the basis of yes/no answers. Scores range from a value of 0 to 8, with a score of 3 or greater having a high sensitivity for detecting OSA, 93% and 100% for moderate and severe OSA, respectively. Because the specificity is 47% and 37% for moderate and severe OSA, the false-positive rate of the questionnaire is high. This study was performed to evaluate the predictive probabilities for OSA at different scores on the STOP-Bang questionnaire.Patients older than 18 years undergoing elective procedures were included in the screening process and approached for consent for the preoperative polysomnography (PSG), either portable at home or in the laboratory. All patients were asked to complete the STOP questionnaire. Information on the patient_s body mass index, age, neck circumference, and sex were collected. Manual scoring of PSG was performed according to the Manual of the American Academy of Sleep Medicine. The PSG recordings were scored by a sleep physician. The sleep stages and apnea-hypopnea index (AHI) were scored. The diagnosis of OSA was based on an AHI greater than 5 with fragmented sleep and daytime sleepiness. The severity of OSA with laboratory and portable PSG was classified based on the AHI values: greater than 5 to 15 as mild OSA, greater than 15 to 30 as moderate OSA, and greater than 30 as severe OSA.Over 4 years, 6469 patients were approached, and 1312 consented. Of these, 930 completed PSG, and 746 patients with complete data on PSG and the STOP-Bang questionnaire were included in the final analysis. Their median age was 60 years, 49% were male, body mass index was 30 kg/m 2 , and neck circumference was 39 cm. Of the 746 patients, 510 (68.4%) had OSA, with 287 (38.5%) and 134 (18.0%), respectively, having moderate/severe OSA and severe OSA. Most patients had a STOP-Bang score of 3 and 4 (22.9% and 22.3%, respectively). The area under the receiver operating curves was 0.65, 0.67, and 0.71 for all OSA, moderate/severe OSA, and severe OSA, respectively. For STOP-Bang scores of 5 and 6, the odds ratios (ORs) for moderate/severe OSA were 4.8 and 6.3, respectively, and for severe OSA, 10.4 and 11.6, respectively. For STOPBang scores of 7 and 8, the ORs were 6.9 for moderate/severe OSA and 14.9 for severe OSA. As the STOP-Bang score increased from 3 to 8, sensitivity decreased from 68.4% to 0.4% for patients with moderate/severe OSA and from 94.8% to 0% for those with severe OSA. When the STOP-Bang score was 5, the specificity for moderate/severe and severe OSA was 56.1% and 74.2%, respectively. The probabilities of having OSA were greater and the STOP-Bang score increased, a trend that was the same for the groups of all OSA, moderate/severe OSA, and severe OSA. As the STOP-Bang score increased from 0 to 2 to 7 an...

The scores on the PQRS demonstrated an improvement over time, consistent with an expected recovery after surgery and anesthesia, and an ability to discriminate between individuals. Many patients had incomplete recovery by the third postoperative day.

This study has identified the more painful common ambulatory surgical procedures which will allow take home analgesia to be tailored according to individual procedures. Further improvement in analgesic instructions may help in better pain management of ambulatory surgery patients.

This review suggests ways to screen for OSA in the preoperative setting and proposes perioperative management strategies. The ultimate goal is to reduce the perioperative risk of OSA patients but, to realize that goal, research will be needed to determine whether screening for OSA and/or adapting specific perioperative management approaches translates into a lessening of adverse events in surgical patients with undiagnosed OSA.

; for the Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) Study Investigators IMPORTANCE Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain. OBJECTIVES To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations. EXPOSURES Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications. RESULTS Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome