Strategies for postoperative nausea and vomiting

Effect of Intermittent Thoracic Paravertebral Block on Postoperative Nausea and Vomiting Following Thoracoscopic Radical Resection of the Lung Cancer: A Prospective Randomized Trial

Purpose

To explore the benefits of ultrasound-guided intermittent thoracic paravertebral block (TPVB) combined with intravenous analgesia (PCIA) in alleviating postoperative nausea and vomiting (PONV) during video-assisted thoracic surgery (VATS).

Patients and Methods

120 patients with lung carcinoma undergoing VATS were included and divided into three groups: group S (single TPVB+PCIA), group I (intermittent TPVB+PCIA), and group P (PCIA). The patients' NRS scores, postoperative hydromorphone hydrochloride consumption, and intramuscular injection of bucinnazine hydrochloride were recorded. The incidence of PONV and complications were documented.

Results

Compared with the group P, both group I and group S had significantly lower static NRS scores from 1-48 hours after the operation (P <0.05), and the dynamic NRS score of group I at the 1-48 hours after the operation were significantly decreased (P <0.05). Compared with the group P, the proportion of patients with PONV in group I was significantly lower (P <0.05), while there was no significant difference in group S. Moreover, the hospitalization period of patients in group I was significantly reduced compared with the other two groups (P <0.01), and the patient satisfaction was significantly increased compared with the group P (P <0.05).

Conclusion

Intermittent TPVB combined with PCIA can reduce the postoperative pain and the occurrence of PONV.

Effect of Preoperative Carbohydrate Drink and Postoperative Chewing Gum on Postoperative Nausea and Vomiting in Patients Undergoing Day Care Laparoscopic Cholecystectomy: A Randomized Controlled Trial

BACKGROUND

Postoperative nausea and vomiting (PONV) causes an unexpected prolonged hospital stay after ambulatory surgery. Novel measures such as preoperative loading of oral carbohydrates and postoperative chewing gum have recently gained momentum for postoperative recovery. This study evaluated the effects of preoperative carbohydrate loading and postoperative chewing gum (CG) on PONV after daycare laparoscopic cholecystectomy (LC).

METHODS

A total of 100 patients were randomized to group A (preoperative carbohydrate loading with 200 ml of water with 25 g of carbohydrate and postoperative chewing gum (CG) when the patient responded to his/her name) and group B (standard care). The incidence of PONV and pain was assessed by using visual analogue scale. Quality of recovery (QoR-15) was assessed by using QoR15 questionnaire at 6 h, 24 h and 48 h after surgery.

RESULTS

The incidence of PONV and pain was lower in group A; however, it was not significant (p > 0.05). The severity of PONV, pain and the need for rescue antiemetic was significantly lower in group A (p < 0.05). The episodes of PONV and required dose of antiemetic were less in group A. Group A also had a significantly higher QoR-15 score at all time points (p < 0.001). Preoperative dyspepsia was also noticed as a significant confounding predictor for postoperative vomiting.

CONCLUSION

Preoperative carbohydrate drinks and early postoperative CG reduces the severity of PONV and requirement of antiemetics in patients undergoing LC. Hence, these simple measures can be used as a standard of care to optimize perioperative care in patients undergoing daycare surgery.

Comparing the effects of continuous infusion of esmolol and ramosetron alone and in combination on nausea and vomiting after laparoscopic cholecystectomy: A prospective, randomized, double-blind study

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication of laparoscopic cholecystectomy. Although PONV is usually mild, severe thing can delay recovery and prolong hospitalization. We aimed to investigate the effects of ramosetron and esmolol, alone and in combination, on PONV, and pain.

METHODS

We enrolled 165 patients in their 20s to 50s who had an American Society of Anesthesiology physical status score of 1 or 2 and were scheduled to undergo laparoscopic cholecystectomy. They were randomly allocated into 3 groups: groups R, E, and E+R. Patients in group R received 0.3 mg of ramosetron following surgery. Those in group E were intravenously administered a bolus of esmolol (1.0 mg/kg) before endotracheal intubation. They were continuously infused with esmolol during the surgery to maintain their heart rate at 60 to 100 beats per minute and mean blood pressure at 60 to 100 mm Hg, followed by a bolus of esmolol (1.0 mg/kg) following surgery. Patients in group E+R were intravenously administered a bolus of esmolol (1.0 mg/kg) before endotracheal intubation, infused esmolol during surgery, and administered 0.3 mg of ramosetron and a bolus of esmolol (1.0 mg/kg) following surgery. We monitored the PONV stages (none, nausea, retching, and vomiting) and symptom severity in 3 postoperative stages (0-30 minutes, 30 minutes to 6 hours, and 6-24 hours), the latter by using the visual analog scale (VAS). We conducted an analysis of variance to compare VAS scores between groups.

RESULTS

Patients in groups E (mean ± standard deviation VAS score, 3.62 ± 1.00) and E+R (3.66 ± 0.71) exhibited less pain (P < .05) until 30 minutes following surgery compared to group R (5.72 ± 1.41). More patients in group E (28/50, 56%) experienced nausea compared to those in groups R (15/50, 30%) and E+R (8/50, 16%) until 30 minutes after surgery (P < .05). However, there were no differences in the severity of retching and vomiting between the groups in any of the phases (P > .05).

CONCLUSION

Despite reducing pain after laparoscopic cholecystectomy, esmolol did not prevent PONV, whether used alone or in combination with ramosetron.

Effects of perioperative dextrose infusion on preventing postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

Objective

The aim of this study was to systematically examine the literature and assess the effects of perioperative dextrose infusion on the prevention of postoperative nausea and vomiting (PONV) in patients following laparoscopic surgery under general anesthesia.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Studies were eligible for inclusion if they evaluated the prevention of PONV with perioperative intravenous dextrose. Studies listed in PUBMED, Web of Science, and EMBASE databases published up to December 2020 were identified. Data were extracted and analyzed independently using a fixed-effects or random-effects model according to the heterogeneity.

Results

Six RCTs involving 526 patients were included. Our results showed that perioperative dextrose infusion not only reduced the incidence of PONV (risk ratio [RR] = 0.61, 95% confidence interval [CI]: 0.39–0.95; I² = 59%) but also decreased the requirement for antiemetics compared with the control (RR = 0.53, 95% CI: 0.42–0.66; I² = 32%). Furthermore, perioperative glucose infusion did not increase blood glucose levels compared with the control (mean difference [95% CI] = 74.55 [−20.64 to 169.73] mg/dL; I² = 100%).

Conclusion

Our study reveals that perioperative dextrose infusion may reduce the risk of PONV after laparoscopic surgery. However, additional population-based RCTs are needed to confirm this finding.

The Impact of Acupuncture on Postoperative Nausea and Vomiting in Obese Adult Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial

Objectives: We wanted to research the effect of acupuncture on postoperative nausea and vomiting (PONV) in morbidly obese adult patients who were scheduled for laparoscopic sleeve gastrectomy. Design: This prospective randomized controlled study included 62 American Society of Anesthesiologists physical status I-III, 18- to 60-year-old morbidly obese patients undergoing laparoscopic sleeve gastrectomy. Patients were assigned using a closed envelope method to both groups equally. Group I consisted of acupuncture and metoclopramide; Group II consisted of metoclopramide. Setting: The study was carried out in Kecioren Educational Research Hospital, University of Health Sciences, Ankara, Turkey. Interventions: Acupuncture was performed by needling PC6, LI4 acupoints bilaterally and Yin Tang acupoint in Group I. Metoclopramide was administered as an antiemetic drug in both groups. Measurements: Demographic parameters, SAMBA PONV risk, first analgesic requirement time and PONV of the patients at the recovery 0-1, 1-6, 6-12, and 12-24 hours after operation were recorded. We used the simplified PONV impact scale to determine the intensity of nausea and its effects on the patient. Results: Nausea was observed in 37.5% of patients in Group I and 63.3% of patients in Group II at the recovery. Nausea intensity was not different between the groups at the postoperative 1-6 hours, but vomiting count was found higher in Group II at the postoperative 12-24 hours. Apfel score of the patients were similar between the groups. PONV impact scale was found higher in Group II. First analgesic requirement time was found shorter and demand for additional analgesic treatment was found significantly higher in Group II. Conclusions: Combining acupuncture with antiemetic treatment reduced nausea intensity and vomiting in the postoperative follow-up period. Also, patient's first analgesic demand time was found longer and the requirement for additional analgesic treatment was found lower in the acupuncture group.

Dexamethasone versus placebo for prevention of nausea, vomiting and pain after open total abdominal hysterectomy

Post-operative nausea and vomiting (PONV) is a disturbing issue. Dexamethasone has been suggested for the prevention of PONV. The aim of the present study was to evaluate the efficacy of dexamethasone as an anti-emetic and analgesic following total abdominal hysterectomy. The study was performed as a double blind, placebo-controlled randomised clinical trial on 102 women undergoing an open total abdominal hysterectomy. The intervention group received 8 mg dexamethasone 1 h before surgery, and the control group received a placebo. The total number of emesis episodes during the 24 h after surgery did not show significant difference between the two groups, however, the number of emesis episodes in hours 2 and 4 after the surgery were less in the intervention group, but not in hours 0, 6, 12 and 24. The nausea severity in hours 0, 2, 4, 6 and 12 after the surgery, was less in the intervention group. The severity of pain was not different between the two groups.IMPACT STATEMENTWhat is already known on this subject? Post-operative nausea and vomiting (PONV) is an important and disturbing issue. It is one of the most common problems following gynaecological surgeries including open total abdominal hysterectomy (TAH). Dexamethasone has been suggested as a prophylaxis for the prevention of PONV.What do the results of this study add? Dexamethasone 8 mg is effective for the prevention of late onset PONV (after 2 h of surgery) in the cases of open total abdominal hysterectomy. However, it has no effect on PONV immediately following surgery (hour 0) and pain.What are the implications of these findings for clinical practice and/or further research? Dexamethasone can be considered as an effective prophylaxis for PONV for the first 24 h after an open total abdominal hysterectomy, but it has limited effects on the management of early onset of PONV; between 0 and 2 h after surgery. Since the highest rates of emesis episodes and nausea severity are at this time, it is suggested to combine another rapid onset medication with dexamethasone. Also, dexamethasone, 8 mg, cannot be considered for pain relief after an open total abdominal hysterectomy. Higher amounts of dexamethasone should be evaluated for this purpose, in order to find appropriate dosages.

Preoperative oral carbohydrate loading: Effects on intraoperative blood glucose levels, post-operative nausea and vomiting, and intensive care unit stay

Background and Aims:

Material and Methods:

Results:

Conclusion:

Evidence-based prophylaxis strategies for postoperative nausea and vomiting when considering ethnicity factor

In most western countries, postoperative nausea and vomiting (PONV) is an important issue and prophylaxis guideline for PONV will be followed in clinical practice. We tried to conduct a review study and a local study to elucidate the incidence and severity of PONV to see if considering ethnicity factor, should we still need to follow those prophylaxis guidelines from western countries. The PubMed, and MEDLINE were consulted from January 2000 to 2018 and also Cochrane Central Register of Controlled Trials (CENTRAL 2010). The key word for searching is PONV (incidence, severity and prevention strategy), without language limitation and focus on Asian countries. The results showed that the overall incidence and severity of PONV in Asian countries was less significant than in western countries. PONV in western countries could be a serious issue and prophylaxis strategy adjusted by Apfel score could be adopted in routine practice. After this review consultation, the issue of PONV in different ethnic countries (including Taiwan) might be over emphasized and we may suggest not to follow west countries PONV prophylaxis guideline as our routine practice.

Comparison of ramosetron and ondansetron for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

Objective

We conducted a systematic literature search and meta-analysis to identify randomized controlled trials (RCTs) comparing the efficacy and safety of ramosetron versus ondansetron for the prevention of postoperative nausea and vomiting (PONV; PON and POV, respectively) in patients undergoing laparoscopic surgery.

Methods

The electronic databases PubMed, EMBASE, Web of Science, and Cochrane Library were searched up to March 2019 to identify relevant studies.

Results

The final pooled analysis included 6 RCTs and revealed that postoperative treatment with ramosetron at 24 to 48 hours after surgery significantly reduced the incidence of PON and POV relative to treatment with ondansetron. In a subgroup analysis, ramosetron 0.3 mg tended to reduce PON (0–2 hours) and POV (24–48 hours) more effectively than ondansetron 4 mg. However, no statistical difference was observed between ramosetron 0.3 mg and ondansetron 8 mg in terms of the reduction of PON or POV during any time interval within the first 48 hours after surgery.

Conclusions

Our results indicate that ramosetron 0.3 mg is superior to ondansetron 4 mg and comparable to ondansetron 8 mg for PONV prophylaxis after laparoscopic surgery.

Efficacy and Safety of Ramosetron Injection for Nausea and Vomiting in Colorectal-Cancer Patients Undergoing a Laparoscopic Colectomy: A Randomized, Double-Blind, Comparative Study

Purpose

A laparoscopic colectomy in colorectal-cancer patients is usually associated with a high risk of postoperative nausea and vomiting (PONV). The purpose of this study is to evaluate the efficacy of injection of long-acting 5-hydroxytryptamine type 3 (5-HT₃) receptor antagonist for the reduction of PONV in patients with colorectal cancer.

Methods

A total of 48 patients scheduled to undergo a laparoscopic colectomy for colorectal cancer were randomized in a double-blinded fashion. Patients were randomly allocated to 1 of 2 groups and assigned to receive either 0.3 mg of ramosetron intravenously (group A, n = 25) or 2 mL of normal saline (placebo) (group B, n = 22) immediately after the operation. The incidence of PONV, the nausea severity scale score, the visual analogue scale (VAS) score for pain, the total amount of patient-controlled analgesia used, the recovery of bowel function, and morbidities were assessed at 1 hour and at 24, 48, and 72 hours after surgery.

Results

The baseline and the operative characteristics were similar between the groups (P > 0.05). The number of cases without PONV (complete response) was higher for group A (ramosetron) than group B (normal saline): 24 hours after surgery, 92.0% (23 of 25) for group A versus 54.5% (12 of 22) for group B; 48 hours after surgery, 92% (23 of 25) for group A versus 81.8% (18 of 22) for group B (both P < 0.05). No serious adverse events occurred.

Conclusion

Postoperative ramosetron injection is effective for the prevention of PONV after a laparoscopic colectomy in colorectal-cancer patients.

Prevention of Postoperative Nausea and Vomiting

Objective:

To review the literature on the prevention of postoperative nausea and vomiting (PONV) in adults.

Data Sources:

Literature retrieval was accessed through MEDLINE (1966–December 2006) using the terms postoperative nausea and vomiting, prevention and treatment. Article references were hand-searched for additional relevant articles and abstracts.

Study Selection And Data Extraction:

All studies published in English were evaluated. Those dealing with prevention and treatment of PONV in adults were included in the review.

Data Synthesis:

Evidence suggests that providing prophylactic antiemetic medications in high-risk surgical patients is warranted. 5-HT3 receptor antagonists are widely used, with no one agent being clearly superior. However, studies have shown other types of agents to ho more cost-effective.

Conclusions:

The first step in the prevention of PONV is assessment and reduction of risk factors. Although nonpharmacologic therapies may play a role in the treatment of PONV, the mainstay of therapy for PONV is pharmacologic modalities. Patients at moderate to high risk for PONV need prophylactic antiemetic therapy. High-risk patients may require combination therapy with 2 or 3 agents from different antiemetic classes. Rescue antiemetic therapy is needed by patients who actually develop PONV. The agents of choice in such cases should be from antiemetic classes different from those used for prophylaxis of PONV.

Postdischarge nausea and vomiting: management strategies and outcomes over 7 days

PURPOSE

The purpose of this study is to determine patient management strategies and outcomes for self-care of postdischarge nausea and vomiting (PDNV).

DESIGN

Prospective, comparative, descriptive, and longitudinal study.

METHODS

The sample consisted of 248 patients aged 18 years or older undergoing a procedure requiring general anesthesia. Patients recorded incidence and severity of nausea and vomiting, the impact of symptoms, and actions taken to alleviate symptoms for 7 days postdischarge.

FINDINGS

The prevalence of PDNV was 56.9%. The methods used to relieve symptoms included antiemetic use by a minority and nonpharmacologic techniques of self-management by some. The effect of nausea on QOL, patient functioning, and patient satisfaction was significantly worse for those who experienced postdischarge nausea on all days.

CONCLUSION

Patients with PDNV use minor self-care strategies to manage symptoms. The presence of PDNV affects overall quality of life, patient functioning, and patient satisfaction.

Prophylactic antiemetic effects of Midazolam, Ondansetron, and their combination after middle ear surgery

Objective:

The purpose of the present study was to evaluate the efficacy of midazolam-ondansetron combination in prevention of postoperative nausea and vomiting (PONV) after middle ear surgery and its comparison with using midazolam or ondansetron alone.

Methods:

One hundred and forty patients were enrolled in four groups to receive midazolam 0.75 mg/kg in group M, ondansetron 4 mg in group O, midazolam 0.75 mg/kg and ondansetron 4 mg in group MO, and saline 0.90% in group S intravenously just before anesthesia. Assessment of nausea, vomiting, rescue antiemetic, and side effects of study drugs such as headache and dizziness was carried out postoperatively for 24 h.

Findings:

The incidence of PONV was significantly smaller in group MO than group M and group O, while there was no significant difference between group M and group O during the first 24 h postoperatively. Requirement to the additional antiemetic was significantly more in group S (71.4%) compared to other groups, while in group MO (11.4%) was lower than group M (31.4%) and group O (34.3%).

Conclusion:

Our study showed that prophylactic administration of midazolam 0.75 mg/kg combined with ondansetron 4 mg was more effective than using midazolam or ondansetron alone in prevention of PONV after middle ear surgery.

Postoperative nausea and vomiting: A simple yet complex problem

Postoperative nausea and vomiting (PONV) is one of the complex and significant problems in anesthesia practice, with growing trend toward ambulatory and day care surgeries. This review focuses on pathophysiology, pharmacological prophylaxis, and rescue therapy for PONV. We searched the Medline and PubMed database for articles published in English from 1991 to 2014 while writing this review using “postoperative nausea and vomiting, PONV, nausea-vomiting, PONV prophylaxis, and rescue” as keywords. PONV is influenced by multiple factors which are related to the patient, surgery, and pre-, intra-, and post-operative anesthesia factors. The risk of PONV can be assessed using a scoring system such as Apfel simplified scoring system which is based on four independent risk predictors. PONV prophylaxis is administered to patients with medium and high risks based on this scoring system. Newer drugs such as neurokinin-1 receptor antagonist (aprepitant) are used along with serotonin (5-hydroxytryptamine subtype 3) receptor antagonist, corticosteroids, anticholinergics, antihistaminics, and butyrophenones for PONV prophylaxis. Combination of drugs from different classes with different mechanism of action are administered for optimized efficacy in adults with moderate risk for PONV. Multimodal approach with combination of pharmacological and nonpharmacological prophylaxis along with interventions that reduce baseline risk is employed in patients with high PONV risk.

Effective Dose of Ramosetron for Prophylaxis of Postoperative Nausea and Vomiting in High-Risk Patients

BACKGROUND

Postoperative nausea and vomiting (PONV) are common adverse events with an incidence of up to 80% in high-risk patients. Ramosetron, a selective 5-HT3 receptor antagonist, is widely used to prevent PONV. The purpose of this study was to evaluate the effective dose of ramosetron for the prevention of PONV in high-risk patients.

METHODS

Fifty-one patients were randomly allocated to 3 groups and were administered ramosetron 0.3 mg (group A), 0.45 mg (group B), or 0.6 mg (group C), at the end of their surgery. The episodes of PONV were assessed 1, 6, 24, and 48 hours after the injection and all the adverse events were observed.

RESULTS

The complete response rate in the postoperative period 6-24 hours after the anesthesia was higher in group C than in group A: 93% versus 44%. Group C's experience score of Rhodes index was lower than group A's: 0.81 ± 2.56 versus 3.94 ± 5.25. No adverse drug reaction could be observed in all groups.

CONCLUSIONS

The effective dose of ramosetron to be injected for the near-complete prophylaxis of PONV 6 to 24 hours after surgery in high-risk patients is a 0.6 mg bolus injection at the end of the surgery.

Incidence and risk factors of postoperative nausea and vomiting in patients with fentanyl-based intravenous patient-controlled analgesia and single antiemetic prophylaxis

PURPOSE

We evaluated the incidence and risk factors of postoperative nausea and vomiting (PONV) in patients with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) and single antiemetic prophylaxis of 5-hydroxytryptamine type 3 (5 HT₃)-receptor antagonist after the general anesthesia.

MATERIALS AND METHODS

In this retrospective study, incidence and risk factors for PONV were evaluated with fentanyl IV-PCA during postoperative 48 hours after various surgeries.

RESULTS

Four hundred-forty patients (23%) of 1878 had showed PONV. PCA was discontinued temporarily in 268 patients (14%), mostly due to PONV (88% of 268 patients). In multivariate analysis, female, non-smoker, history of motion sickness or PONV, long duration of anesthesia (>180 min), use of desflurane and intraoperative remifentanil infusion were independent risk factors for PONV. If one, two, three, four, five, or six of these risk factors were present, the incidences of PONV were 18%, 19%, 22%, 31%, 42%, or 50%. Laparoscopic surgery and higher dose of fentanyl were not risk factors for PONV.

CONCLUSION

Despite antiemetic prophylaxis with 5 HT₃-receptor antagonist, 23% of patients with fentanyl-based IV-PCA after general anesthesia showed PONV. Long duration of anesthesia and use of desflurane were identified as risk factors, in addition to risk factors of Apfel's score (female, non-smoker, history of motion sickness or PONV). Also, intraoperative remifentanil infusion was risk factor independent of postoperative opioid use. As the incidence of PONV was up to 50% according to the number of risk factors, risk-adapted, multimodal or combination therapy should be applied.

A prospective, randomized, double-blind, multicenter trial to evaluate the therapeutic efficacy and safety of palonosetron in the treatment of postoperative nausea and vomiting over a 72-h period

PURPOSE

We performed a multicenter, randomized, double-blind trial to assess the efficacy and safety of a single, fixed, intravenous dose of palonosetron (0.075 mg) in the treatment of established postoperative nausea and vomiting (PONV).

METHODS

Three hundred and eighty-four patients who had at least one risk factors of PONV and underwent surgery under general anesthesia were screened. Those who developed PONV were randomized to receive either 0.075 mg intravenous palonosetron or a placebo. The incidence of nausea and vomiting, severity of nausea, requirements for rescue anti-emetics, and adverse effects at 2, 24, and 72 h after drug administration were evaluated. Complete response (CR) and complete control (CC) rate were compared for 24 and 72 h.

RESULTS

Among the 384 patients, 152 (39.6 %) developed PONV and were randomized to either the palonosetron (n = 75) or placebo (n = 77) group. The number of patients with CR at 24 and 72 h was higher in the palonosetron group than the placebo group [0-24 h: n = 49 (68.1 %) vs. n = 30 (40.5 %), p < 0.001; 0-72 h: n = 47 (65.3 %) vs. n = 28 (37.8 %), p < 0.001]. The incidence of PONV at 2, 24, and 72 h periods was lower in the palonosetron group than the placebo group (29.2, 45.8, and 50.0 % in the palonosetron group vs. 50.0, 62.2, and 66.2 % in the placebo group, p = 0.010, 0.048, 0.047, respectively). The incidence of adverse events was not different between the groups.

CONCLUSION

A single 0.075 mg IV dose of palonosetron effectively increased the CR rates at 24 and 72 h in these moderate-risk patients with established PONV.

Preventing postoperative nausea and vomiting after laparoscopic cholecystectomy: a prospective, randomized, double-blind study

BACKGROUND

Postoperative nausea and vomiting (PONV) are potential complications in patients after laparoscopic cholecystectomy (LC). Combination antiemetic therapy often is effective for preventing PONV in patients undergoing LC, and combinations of antiemetics targeting different sites of activity may be more effective than monotherapy.

OBJECTIVE

The aim of this study was to compare the administration of a subhypnotic dose of propofol combined with dexamethasone with one of propofol combined with metoclopramide to prevent PONV after LC.

METHODS

Sixty adult patients scheduled for LC were randomly assigned to 1 of 2 treatment groups. The patients in group 1 received 0.5 mg/kg propofol plus 8 mg dexamethasone, and those in group 2 received 0.5 mg/kg propofol plus 0.2 mg/kg metoclopramide. The number of patients experiencing nausea and vomiting at 0 to 4, 4 to 12, and 12 to 24 hours postoperatively and as well as additional use of rescue antiemetics were recorded.

RESULTS

The total PONV rates up to 24 hours postanesthesia were 23.3% and 50% for group 1 and group 2, respectively. Comparisons of the data revealed that at 0 to 4 hours, the number of patients experiencing vomiting was 6 (20%) in group 1 and14 (46.7%) in group 2 (P = 0.028). The frequency of vomiting in group 1 was significantly lower than that for group 2 (P = 0.028), and the rate of rescue antiemetic use in group 2 was higher than that in group 1 (20% vs 46.7%; P = 0.028). In the evaluation of PONV based on the nausea and vomiting scale scores, the mean PONV score was 0.4 (0.2) in group 1 compared with 1.0 (0.2) in group 2 (P = 0.017). There were no significant differences between the values at 4 to 12 hours and at 12 to 24 hours. The frequency of adverse reactions (respiratory depression: 1.3%, 1.3%; laryngospasm: 1.3%, 0%; cough: 1.3%, 0%; hiccup: 1.3%, 0%;) was not significantly different in the 2 groups.

CONCLUSIONS

Administration of a subhypnotic dose of 0.5 mg/kg propofol plus 8 mg dexamethasone at the end of surgery was more effective than administration of 0.5 mg/kg propofol plus metoclopramide in preventing PONV in the early postoperative period in adult patients undergoing LC.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

PONV in Ambulatory surgery: A comparison between Ramosetron and Ondansetron: a prospective, double-blinded, and randomized controlled study

BACKGROUND

postoperative nausea and vomiting (PONV) frequently hampers implementation of ambulatory surgery in spite of so many antiemetic drugs and regimens.

AIMS

the study was carried out to compare the efficacy of Ramosetron and Ondansetron in preventing PONV after ambulatory surgery.

SETTING AND DESIGN

it was a prospective, double blinded, and randomized controlled study.

METHODS

124 adult patients of either sex, aged 25-55, of ASA physical status I and II, scheduled for day care surgery, were randomly allocated into Group A [(n=62) receiving (IV) Ondansetron (4 mg)] and Group B [(n=62) receiving IV Ramosetron (0.3 mg)] prior to the induction of general anesthesia in a double-blind manner. Episodes of PONV were noted at 0.5, 1, 2, 4 h, 6, 12, and 18 h postoperatively.

STATISTICAL ANALYSIS AND RESULTS

statistically significant difference between Groups A and B (P <0.05) was found showing that Ramosetron was superior to Ondansetron as antiemetic both regarding frequency and severity.

CONCLUSION

it was evident that preoperative prophylactic administration of single dose IV Ramosetron (0.3 mg) has better efficacy than single dose IV Ondansetron (4 mg) in reducing the episodes of PONV over 18 h postoperatively in patients undergoing day-care surgery under general anesthesia.

The efficacy of ginger added to ondansetron for preventing postoperative nausea and vomiting in ambulatory surgery

BACKGROUND

Post-operative nausea and vomiting (PONV) frequently hampers implementation of ambulatory surgery in spite of so many costly antiemetic drugs and regimens.

OBJECTIVE

The study was carried out to compare the efficacy of ginger (Zingiber officinale) added to Ondansetron in preventing PONV after ambulatory surgery.

MATERIALS AND METHODS

It was a prospective, double blinded, and randomized controlled study. From March 2008 to July 2010, 100 adult patients of either sex, aged 20-45, of ASA physical status I and II, scheduled for day care surgery, were randomly allocated into Group A[(n = 50) receiving (IV) Ondansetron (4 mg) and two capsules of placebo] and Group B[(n = 50) receiving IV Ondansetron (4 mg) and two capsules of ginger] simultaneously one hour prior to induction of general anaesthesia (GA) in a double-blind manner. One ginger capsule contains 0.5 gm of ginger powder. Episodes of PONV were noted at 0.5h, 1h, 2h, 4h, 6h, 12h and 18h post- operatively.

STATISTICAL ANALYSIS AND RESULTS

Statistically significant difference between groups A and B (P < 0.05), was found showing that ginger ondansetron combination was superior to plain Ondansetron as antiemetic regimen for both regarding frequency and severity.

CONCLUSION

Prophylactic administration of ginger and ondansetron significantly reduced the incidence of postoperative nausea and vomiting compared to ondansetron alone in patients undergoing day care surgery under general anaesthesia.

Incidence and predictors of postdischarge nausea and vomiting in a 7-day population

STUDY OBJECTIVE

1) To quantify the incidence and severity of postdischarge nausea and vomiting (PDNV) for 7 days in adults undergoing outpatient surgeries with general anesthesia; 2) to evaluate whether a risk model previously developed for the first two postoperative days may be used to predict the patient's risk of PDNV for 7 days; and 3) to verify whether the same risk factors are applicable in the 3 to 7 day period.

DESIGN

Prospective study.

SETTING

Two university-affiliated centers.

PATIENTS

248 adult (>18 years) surgical outpatients undergoing ambulatory surgical procedures with general anesthesia between 2007 and 2008.

MEASUREMENTS

The incidence and severity of PDNV and a simplified risk score for PDNV was assessed prospectively from discharge up to 7 postoperative days.

MAIN RESULTS

The overall incidence of nausea was 56.9% and of emesis was 19.4%. The incidence of PDNV was highest on the day of surgery (DOS), with PDNV of 44.8% and decreasing over time to 6.0% on day 7. Using the simplified risk score for PDNV the area under the receiver operating characteristic (ROC) curve was 0.766 (0.707, 0.825). A previous history of postoperative nausea and vomiting (PONV; OR 3.51, CI 1.70 - 7.27), operating room time (odds ratio [OR] 2.19, 95% CI 1.34 - 3.60), use of ondansetron in the Postanesthesia Care Unit (PACU; OR 6.39, CI 1.65-24.79), and pain during days 3-7 (OR 1.67, CI 1.30 - 2.14) were the strongest predictors of PDNV on days 3-7.

CONCLUSIONS

PDNV affects a significant number of patients after ambulatory surgery, and our simplified PDNV score may be applied to a 7-day population. Pain appears to be a factor in late PDNV. It is possible that the presence of PDNV during days 3-7 has different origins from the PDNV that resolved over the first 48 hours.

Day-case stapedotomy: is it a viable option?

CONCLUSIONS

Stapedotomy is, in our opinion, the technique of choice in stapes surgery. The precision of this technique allows clinicians to perform the surgical procedure in day surgery under local anesthesia.

OBJECTIVES

There is a strong emphasis on increasing the number of elective day surgery cases, especially in the patients' best interest, as it decreases the likelihood of late cancellation and hospital-acquired morbidity. A prospective study was performed to determine whether stapes surgery for otosclerosis could be performed safely in an outpatient setting.

METHODS

We present a series of stapes surgery cases for otosclerosis performed on a day-case basis. We performed a classic stapedotomy in 9 patients, a reverse classic step stapedotomy in 2 patients, a partial reverse classic step stapedotomy in 11 patients, and a hemi-stapedectomy in two patients.

RESULTS

Three of 24 patients (12.5%) treated with classic stapedotomy, 1 patient with partial reverse classic step stapedotomy, and 1 patient with hemi-stapedectomy were formally admitted to the hospital after surgery (length of stay, 23 h). The indications were vertigo (two patients) and asthenia (one patient). These patients were treated under general anesthesia. Two of these patients resided more than 250 km away from the hospital.

Dexamethasone has additive effect when combined with ondansetron and droperidol for treatment of established PONV

BACKGROUND

Prophylactic dexamethasone, ondansetron and droperidol have a documented effect on post-operative nausea and vomiting (PONV). Still, there is a lack of studies investigating the effect of adding dexamethasone to ondansetron and droperidol in order to treat established PONV.

METHODS

In this double-blind randomised, controlled trial, we compared triple prophylaxis for PONV consisting of dexamethasone 8 mg intravenous (IV), ondansetron 4 mg IV and droperidol 0.625 mg IV (n = 157) with placebo (n = 156) given before gynaecological day-case surgery. Subsequently, in those having PONV despite triple prophylaxis or placebo, a dose of ondansetron and droperidol plus dexamethasone was compared with the combination of ondansetron and droperidol.

RESULTS

Triple prophylaxis reduced acute PONV (0-6 h) (P = 0.0003) and post-discharge PONV (6-24 h) (P = 0.001) when compared with placebo. Among those suffering from PONV despite placebo or active prophylaxis (n = 80), adding dexamethasone to ondansetron and droperidol reduced acute PONV (0-6 h) (P = 0.025) as well as post-discharge nausea (6-24 h) (P = 0.04) compared with duo treatment comprising ondansetron and droperidol. In those reporting PONV despite prophylaxis (n = 12), the treatment comprising ondansetron and droperidol, with or without dexamethasone, gave a 91.7% reduction in acute PONV and an 83.6% reduction in post-discharge PONV.

CONCLUSION

Treatment of established PONV comprising ondansetron and droperidol, with or without dexamethasone, reduced PONV in both treatment groups. In those reporting PONV without active prophylaxis, the addition of dexamethasone resulted in a significant amplification of the PONV-reducing [corrected] effects of ondansetron and droperidol.

The Postoperative Recovery Profile (PRP) - a multidimensional questionnaire for evaluation of recovery profiles

AIMS AND OBJECTIVES

The previously developed Postoperative Recovery Profile (PRP) questionnaire is intended for self-assessment of general recovery after surgery. The aim of this study was to further evaluate the questionnaire regarding the construct validity and ability to discriminate recovery profiles between groups. Furthermore, the item variables of greatest importance during the progress of recovery were investigated.

METHODS

Post-operative recovery was assessed during the period from discharge to 12 months after lower abdominal and orthopaedic surgery. Construct validity was evaluated by comparing the assessments from the PRP questionnaire and a global recovery scale. Recovery profiles of the diagnose groups were displayed by the cumulative proportion recovered participants over time. The importance of item variables was investigated by ranking ordering.

RESULTS

A total of 158 patients were included. Support was given for good construct validity. The result showed that 7.6% of all possible pairs were disordered when comparing the assessments from the PRP questionnaire and the global recovery scale. Twelve months after discharge the PRP assessments discriminated significantly the recovery profiles of the abdominal and orthopaedic groups. The variable pain was one of the top five most important issues at each follow-up occasion in both study groups. The importance of the item variables was thereby emphasized.

CONCLUSIONS

The PRP questionnaire allows for evaluation of the progress of post-operative recovery, and can be useful to assess patient-reported recovery after surgical treatment both on individual and group levels. Knowledge about recovery profiles can assist clinicians in determining the critical time points for measuring change.

Comparison of the prophylactic anti-emetic efficacy of ramosetron and ondansetron in patients at high-risk for postoperative nausea and vomiting after total knee replacement

We compared the prophylactic anti-emetic efficacy of ramosetron, a newly developed 5-HT(3) antagonist, and ondansetron in patients at high-risk for postoperative nausea and vomiting after total knee replacement. Eighty-four patients with three risk factors for postoperative nausea and vomiting (female, non-smoking and use of postoperative opioid use (ropivacaine and hydromorphone patient controlled epidural analgesia)) undergoing unilateral total knee replacement were randomly allocated to ramosetron 0.3 mg (n = 42) or ondansetron 4 mg (n = 42) groups. A complete response (no postoperative nausea and vomiting and no rescue anti-emetic) and the incidence of postoperative nausea and vomiting were assessed for 48 h after surgery at 0-2 h, 2-6 h, 6-24 h, and 24-48 h. More patients in the ramosetron group had a complete response between 2 and 48 h. The incidence of nausea between 2 and 24 h and the severity of nausea between 2 and 48 h were also less in the ramosetron group. Ramosetron was more effective than ondansetron in preventing postoperative nausea and vomiting in patients at high risk undergoing unilateral total knee replacement.

[Effects of nitrous oxide on middle ear pressure]

INTRODUCTION

Recent literature data suggest that permanent or reversible hearing loss may occur after general anesthesia. The etiology varies, while hearing loss following middle ear surgery is attributed to exposure to nitrous oxide (N,0). The objective of our study was to measure, using tympanometry, the middle air pressure change caused by nitrous oxide during general anesthesia and to establish its emetogenic effects during the postoperative period.

MATERIAL AND METHODS

This academic (non-commercial) prospective study included two groups of patients (a total of 58), with ASA status I, II and III. The study group (n 30) consisted of patients undergoing unilateral ear surgery. In this group, the intratympanic pressure was measured in the unoperated (healthy) ear before and during the surgery. The control group (n 28) patients underwent nose, throat or neck surgical interventions. This group underwent measurement of bilateral intratympanic pressure in healthy ears, before and during the surgery. Both groups were operated under general balanced anesthesia. Pain, nausea and antiemetics were monitored during the first 24 postoperative hours. Statistical analysis was performed using the Mann-Whitney-Wilcoxon test.

RESULTS

This perioperative study confirmed the following: highly significant (p < 0.001) increase in intratympanic pressure in nonoperated ears in the study group and significant (p < 0.05) in controls. However, there was no statistical significance (p > 0.05) between groups. Pain was more freguent in controls, and nausea in the study group, but without significant difference (p > 0.05).

CONCLUSIONS

Postoperative audiometry findings showed no conductive or sensorineural hearing loss after interventions. Nitrous oxide can be used in general balanced anesthesia with discontinuation 15 to 45 minutes before insertion of the tvmpanic membrane and completion of middle ear surgery.

Combination of antiemetics for the prevention of postoperative nausea and vomiting in high-risk patients

It was previously reported that the Korean predictive model could be used to identify patients at high risk of postoperative nausea and vomiting (PONV). This study investigated whether PONV in the high-risk and very high-risk patients identified by the Korean predictive model could be prevented by multiple prophylactic antiemetics. A total of 2,456 patients were selected from our previous PONV study and assigned to the control group, and 374 new patients were recruited consecutively to the treatment group. Patients in each group were subdivided into two risk groups according to the Korean predictive model: high-risk group and very high-risk group. Patients in the treatment group received an antiemetic combination of dexamethasone 5 mg (minutes after induction) and ondansetron 4 mg (30 min before the end of surgery). The incidences of PONV were examined at two hours after the surgery in the postanesthetic care unit and, additionally, at 24 hr after the surgery in the ward, and were analyzed for any differences between the control and treatment groups. The overall incidence of PONV decreased significantly from 52.1% to 23.0% (p< or =0.001) after antiemetic prophylaxis. Specifically, the incidence decreased from 47.3% to 19.4% (p< or =0.001) in the high-risk group and from 61.3% to 28.3% (p< or =0.001) in the very high-risk group. Both groups showed a similar degree of relative risk reductions: 59.0% vs. 53.8% in the high-risk and very high-risk groups, respectively. The results of our study showed that the antiemetic prophylaxis with the combination of dexamethasone and ondansetron was effective in reducing the occurrence of PONV in both high-risk and very high-risk patients.

Predictive models for post-operative nausea and vomiting in patients using patient-controlled analgesia

This study identified predictive factors for post-operative nausea and vomiting (PONV) in patients using patient-controlled analgesia (PCA) and developed five predictive model pathways to calculate the probability of PONV using decision tree analysis. The sample consisted of 1181 patients using PCA. Data were collected using: a specifically designed check-off form to collect patient-, surgery-, anaesthesia- and post-operation-related data; the Beck Anxiety Inventory to measure pre-operative anxiety; and a visual analogue scale, to measure post-operative pain. The incidence of PONV was 27.7%. Nine factors were highly predictive of PONV in our five model pathways: gender, obesity, anxiety, history of previous PONV, history of motion sickness, inhalation of nitrous oxide during operation, use of inhalational agents, starting oral fluid/food intake after operation, and post-operative pain. With these five predictive model pathways, we can predict the probability of PONV in an individual patient according to their individual characteristics.

Algorithms for the prevention of postoperative nausea and vomiting: an efficacy and efficiency simulation

BACKGROUND AND OBJECTIVE

A number of algorithms for the prevention of postoperative nausea and vomiting have been proposed. Their efficacy and efficiency remains unclear.

METHODS

We assumed that four antiemetic interventions were similarly effective and achieved additive effects when combined. We applied published and hypothetical algorithms for the prevention of postoperative nausea and vomiting to patient populations with different baseline risks. As indicators of efficacy and efficiency we computed for each baseline risk and each algorithm the total number of patients receiving prophylaxis, the total number of administered interventions, the cumulative 24 h incidence of postoperative nausea and vomiting, and an Efficiency Index (i.e. the number of administered interventions divided by the achieved absolute risk reduction). This was done for cohorts of 100 patients.

RESULTS

Ten algorithms were tested in seven populations with different baseline risks. Algorithms were fixed (> or = 1 intervention given to all patients, independent of baseline risk) or risk-adapted (> or = 1 intervention administered depending on the presumed baseline risk). Risk-adapted algorithms were escalating (the greater the baseline risk, the more interventions are given) or dichotomous (a fixed number of interventions is given to high-risk patients only). With some algorithms, when applied to selected patient populations, the average postoperative nausea and vomiting incidence could be decreased below 15%; however, none produced consistent postoperative nausea and vomiting incidences below 20% across all populations. With all, the number of administered antiemetic interventions was the major factor for improved efficacy. Depending on the baseline risk, some algorithms offered potential towards improved efficiency.

CONCLUSIONS

Despite improved knowledge on risk factors and antiemetic strategies, none of the tested algorithms completely prevents postoperative nausea and vomiting and none is universally applicable. Anesthesiologists should try to identify the most useful antiemetic strategy for a specific setting. That strategy may be prophylactic or therapeutic or a combination of both, and it should consider institutional policies and individual baseline risks.

Outcomes in day surgery

PURPOSE OF REVIEW

To summarize and examine the updated published results on the outcome measures that can be used to assess the quality of ambulatory surgery and anesthesia.

RECENT FINDINGS

Major morbidity and mortality following ambulatory surgery is exceedingly low. Cancellations and delays may have a negative impact on the patients, healthcare personnel and the organizations. Minor cardiovascular adverse events are the most common intraoperatively and are associated with preexisting cardiovascular diseases and elderly patients. Respiratory events postoperatively are associated with obesity, smoking and asthma. Also, pain is a common cause for longer postoperative stay, unanticipated admission and readmission. Postoperative nausea and vomiting occurs in 30% of patients and strongly affects patient satisfaction. Furthermore, prolonged stays are mainly caused by surgical factors, or minor symptoms like pain or nausea. Surgical factors are also the main causes of unanticipated hospital admission. The type of surgery and the 24 h postoperative symptoms may affect the degree of return to daily living function. Also, patient satisfaction affects the outcome of healthcare and the use of healthcare services.

SUMMARY

Ambulatory surgery, as currently practiced, provides quality care that is cost-effective. Minor adverse events such as pain and postoperative nausea and vomiting are still common, and improvement could be targeted in these areas.

Evidence-Based Interventions for Post Discharge Nausea and Vomiting: A Review of the Literature

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) continue to be a problem for one third of all patients who require surgery and anesthesia. Very few studies have been reported that specifically target PDNV in the outpatient surgery population for interventions after discharge home. Twenty studies were identified that specifically addressed the effect of an intervention for the purpose of preventing PDNV or rescuing the patient who develops PDNV. This article presents an integrative review of the research literature to determine the best evidence for prevention of PDNV in adults or for the rescue of patients who suffer from PDNV.

Postoperative pain, nausea and vomiting in neurosurgical patients

PURPOSE OF REVIEW

Postoperative pain and postoperative nausea and vomiting are significant problems for neurosurgical patients and their carers. The treatment of these problems is widely perceived to be inadequate, however, especially in patients undergoing craniotomy, and there are few large, randomized controlled trials. The main issue has been fear of side effects, especially those masking neurological signs. A review of the recent literature therefore is justified.

RECENT FINDINGS

Very little new information has been added to the literature about pain management in craniotomy patients, and postoperative nausea and vomiting management in neurosurgery patients as a whole. The main themes in the literature have been the introduction of multimodal analgesia for craniotomy patients, using simple analgesics as adjuvants to opioids, and innovative neuroaxial analgesia techniques in spinal surgery patients.

SUMMARY

There is still a lot of scope to research and refine pain and postoperative nausea and vomiting management in cranial and spinal neurosurgical patients. Large-scale studies are required to define the current state of practice, determine effective treatments and define the incidence of side-effects.

A korean predictive model for postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after surgery. An identification of risk factors associated with PONV would make it easier to select specific patients for effective antiemetic therapy. We designed a case-controlled study to identify the risk factors for PONV in 5,272 surgical patients. At postoperative 2 and 24 hr, patients were visited and interviewed on the presence and severity of PONV. Thirty nine percent of patients experienced one or more episodes of nausea or vomiting. Five risk factors were highly predictive of PONV: 1) female, 2) history of previous PONV or motion sickness, 3) duration of anesthesia more than 1 hour, 4) non-smoking status, and 5) use of opioid in the form of patient controlled analgesia (PCA), in the order of relevance. The formula to calculate the probability of PONV using the multiple regression analysis was as follows: P (probability of PONV)=1/1+e(-Z), Z=-1.885+0.894 (gender)+0.661 (history)+0.584 (duration of anesthesia)+0.196 (smoking status)+0.186 (use of PCA-based opioid) where gender: female=1, male=0; history of previous PONV or motion sickness: yes=1, no=0; duration of anesthesia:more than 1 hr=1, less than or 1 hr=0; smoking status: no=1, yes=0; use of PCA-based opioid: yes=1, no=0.