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

Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery

PURPOSE

The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer.

DESIGN

This study used a prospective, cross-sectional, observational design.

METHODS

The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales.

FINDINGS

Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery.

CONCLUSIONS

Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.

Nausea and Vomiting After Laparoscopic Cholecystectomy: Analysis of Predictive Factors

PURPOSE

The purpose of this study was to identify the factors predictive of postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy.

DESIGN

This is a descriptive, cross-sectional study.

METHODS

In total, 172 patients completed the study. "The Questionnaire Form," "Visual Analog Scale," "Nausea Scale," and "Anxiety Specific to Surgery Questionnaire" created by the researchers were used for data collection.

FINDINGS

At the second postoperative hour, 55.8% of the patients had nausea, 20.3% had vomiting and 75% had severe pain. The severity of nausea, vomiting, and pain decreased with time. Age, gender, smoking, motion sickness, postoperative pain, opioid use, preoperative fasting time, time of first postoperative fluid intake and preoperative anxiety score were found to be among the factors predictive of PONV (P < .05).

CONCLUSIONS

High rates of postoperative nausea and vomiting were recorded.  The factors predictive of PONV can be evaluated in the preoperative period, and PONV can be controlled with early interventions and treatment of patients in the risk group.

Experience and Management of the Adverse Effects of Analgesics After Surgery: A Pediatric Patient Perspective

After surgery, the adverse effects (AEs) of analgesics are common and critical factors influencing the postoperative experience of pediatric patients. Inadequate management of AEs has been found to prolong hospital stay, increase readmission rates and decrease satisfaction with care. The aim of this qualitative descriptive study was to better understand the AEs of analgesics from the perspective of adolescent patients with idiopathic scoliosis after spinal surgery. A total of 7 patients participated in the study. Semistructured interviews were conducted at discharge and 1 week after discharge. Transcribed data were analyzed using qualitative content analysis and themes were identified. Overall, participants most frequently reported gastrointestinal and cognitive AEs, with constipation being the most persistent and bothersome. The pediatric participants used a combination of 3 strategies to mitigate analgesic AEs, namely pharmacologic, nonpharmacologic, and reduction of analgesic intake. Participants demonstrated a lack of understanding of AEs and involvement in their own care. Future studies should be conducted to evaluate the efficacy of nonpharmacological strategies in managing analgesic AEs for pediatric patients after surgery.

Prevalence of Nausea-Vomiting and Coping Strategies in Patients Undergoing Outpatient Surgery

PURPOSE

The present study aimed to determine the prevalence and coping strategies for postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) in patients undergoing outpatient surgery.

DESIGN

A descriptive research design was used.

METHODS

This descriptive study was carried out with 350 patients who were admitted within the scope of outpatient surgery of the ear, nose, and throat; orthopaedics, urology, and general surgery departments of a university hospital between July 3, 2017 and March 6, 2018. A patient diagnosis form consisting of 34 items developed by the researcher and nausea-vomiting diary were used to collect data.

FINDINGS

The results showed that 30.6% of the patients had PONV and 26.3% had PDNV. Of the 92 patients with postdischarge nausea, 26.1% experienced mild, 44.6% moderate, 20.7% high, and 8.7% severe nausea. Among the strategies for coping with PDNV, the patients preferred resting (49%), going outdoors (23.4%), eating something (17%), and drinking something (10.6%). A statistically significant difference was found between postdischarge nausea and risk factors for nausea-vomiting, such as female gender, history of nausea-vomiting, nausea in the postanesthesia care unit, and opioid use in the postanesthesia care unit (P < .05).

CONCLUSIONS

This study shows that approximately a quarter of patients who undergo outpatient surgery will experience nausea and vomiting immediately after surgery as well as at home after discharge. Assessment of risk factors for PONV/PDNV was discovered to be an important factor in the care of perioperative patients. Therefore, the risk scoring system is expected to contribute to reducing PONV/PDNV incidence and improving patient coping strategies and satisfaction.

Postoperative Nausea and Vomiting in Pediatric Patients

Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.

Perianesthesia Patient Education for the Promotion of Opioid Stewardship

Opioid overdose deaths and opioid use disorders are a crisis in the United States and other western countries around the globe. Opioid prescriptions more than doubled after the turn of the century, particularly for postoperative patients. Unfortunately, many who have abused opioids were able to obtain those opioids from friends or family who had held on to prescribed, but unused opioids. One method to manage and decrease the opportunity for unused opioids to become black-market opioids is to educate patients and families regarding the safe use, safe storage, and proper disposal of unused prescription opioids. Perianesthesia nurses, particularly those who educate patients before and after surgery, have an excellent opportunity to educate patients and families who are discharged to home after surgery.

Factors Influencing Satisfaction with Patient-Controlled Analgesia Among Postoperative Patients Using a Generalized Ordinal Logistic Regression Model

PURPOSE

The purpose of this study was to identify the factors affecting the satisfaction with patient-controlled analgesia (PCA) of patients using a generalized ordinal logistic regression model and to evaluate the difference in results of the ordinal regression from those of binary regression.

METHODS

The study design involved secondary analysis of electronic medical records from a single tertiary care hospital in Seoul, Korea. It included 2,409 patients treated with PCA for postoperative pain management after open or laparoscopic abdominal surgery. Binary logistic regression and generalized ordinal logistic regression were used to identify factors affecting satisfaction.

RESULTS

Binary logistic regression analysis showed that there was insufficient information for analysis. Generalized ordinal logistic regression revealed that sex, age, pain, PCA usage, and side-effects were common factors affecting PCA satisfaction. However, the effect of some factors affecting PCA satisfaction differed with the level of satisfaction. In open surgery patients, the effect of pain at 6 hours after surgery was significantly greater in the group with lower satisfaction. While, in the laparoscopic surgery patients, the effect of pain at 6-24 hours after surgery was significantly greater in the group with lower satisfaction.

CONCLUSION

Generalized logistic regression may be an appropriate statistical method for analyzing ordinal data. Degree of postoperative pain and assessment interval are the most important factors associated with PCA satisfaction. Because the factors affecting PCA satisfaction were different for the two types of abdominal surgeries, customizing PCA to individual patients may potentially improve pain management and consequently increase PCA satisfaction.

Incidence, Timing, and Factors Associated with Postoperative Nausea and Vomiting in the Ambulatory Surgery Setting

PURPOSE

To examine incidence, timing, and factors associated with postoperative nausea and vomiting (PONV) in patients recovering in the ambulatory postanesthesia care unit (PACU).

DESIGN

Descriptive correlational, cross-sectional.

METHODS

Data were collected prospectively, including patient, surgery, anesthesia, and postoperative factors associated with PONV. Independent predictors of nausea were determined using logistic regression.

FINDINGS

In 139 randomly selected patients, 10.8% had nausea and 2.9% vomited. On arrival to the PACU, 3 patients had nausea, which increased incrementally to 10 during the next 90 minutes, declining to 3 by 150 minutes. These patients had significantly more hydration and longer PACU stays. Fifty-three percent had nausea at discharge. Younger age and gastroesophageal reflux disease were significantly and independently associated with nausea.

CONCLUSIONS

PONV is relatively infrequent, but remains a distressing problem resulting in negative surgical experiences and increased cost. Future research is warranted to examine gastroesophageal reflux disease as a novel risk factor.

Postoperative Symptom Distress of Laparoscopic Cholecystectomy Ambulatory Surgery Patients

PURPOSE

The purposes of this study were to (1) identify symptoms that cause postoperative distress in ambulatory surgery patients; (2) identify symptom management techniques that effectively reduce distress of laparoscopic cholecystectomy (LC) postoperative symptoms at home after ambulatory surgery; and (3) identify facilitators and barriers to self-management of postoperative symptoms.

DESIGN

A qualitative descriptive study.

METHODS

Two focus groups of ambulatory surgery patients who had experienced a laparoscopic cholecystectomy procedure and their caregivers were queried to elicit understanding of postoperative symptoms and symptom management techniques.

FINDINGS

Themes identified included distressing symptoms and consequences of surgery, symptom management, and self-management facilitators and barriers. Pain was a major symptom after surgery and impacted mobility and sleep. Participants in our study wanted realistic information about symptoms and more specific information on symptom management. Caregivers were important to the success of symptom management but experienced their own stress.

CONCLUSIONS

Perianesthesia nurses should focus not only on the immediate recovery, but also prepare patients and their caregivers for the more prolonged issues of recovery at home.

Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment

Ambulatory surgery is common in plastic surgery, where many aesthetic and reconstructive procedures can be performed in hospitals, ambulatory surgery centers, or office-based surgery facilities. Outpatient surgery offers advantages to both the patient and the surgeon by increasing accessibility, flexibility, and convenience; lowering cost; and maintaining high-quality care. To optimize a patient's experience and comfort, postoperative nausea and vomiting (PONV) should be prevented. However, in those patients who develop PONV, it must be appropriately managed and treated. The incidence of PONV is variable. It is often difficult to accurately predict those patients who will develop PONV or how they will manifest symptoms. There are a variety of recommended "cocktails" for PONV prophylaxis and treatments that are potentially effective. The decision regarding the type of treatment given is often more related to provider preference and determination of side-effect profile, rather than targeted to specific patient characteristics, because of the absence of large volumes of reliable data to support specific practices over others. Fortunately, there are several tenets for the successful prevention and treatment of PONV we have extracted from the literature and summarize here. The following is a summary for the practicing plastic surgeon of the current state of the literature regarding PONV cause, risk factors, prophylaxis, and treatment that may serve as a guide for further study and practice management.

Psychometric Properties of the Ambulatory Surgery Index of Nausea, Vomiting, and Retching

BACKGROUND AND PURPOSE

At least one-third of ambulatory surgery patients will experience nausea or vomiting during the recovery period. The purpose of this study was to examine the psychometric properties of the Ambulatory Surgery Index of Nausea, Vomiting, and Retching (AS-INVR).

METHODS

Secondary analysis of longitudinal data from a study of 203 adult ambulatory surgery patients was conducted.

RESULTS

Based on the results of factor analysis, the retching item was eliminated and the 6-item, 2-dimensional AS-INV was formed. Cronbach's alphas for the AS-INV ranged from .83 to .87 across the 5 days postsurgery. Higher AS-INV scores were associated with self-reported presence of nausea and lower quality of life.

CONCLUSIONS

The shortened AS-INV provides a reliable and valid measure of the amount and distress because of nausea and vomiting in adult patients after ambulatory surgery and should be considered for use in future studies.

Measuring satisfaction and anesthesia related outcomes in a surgical day care centre: A three-year single-centre observational study

STUDY OBJECTIVE

To evaluate patient satisfaction and patient reported anaesthesia related outcome parameters after outpatient surgery.

DESIGN

A three-year (2013-2016) observational study.

SETTING

A surgical day care centre embedded in a tertiary care, university hospital.

PATIENTS

Adult Dutch-speaking patients who underwent surgery under general or regional anaesthesia on an outpatient basis (n=5424).

INTERVENTIONS

A questionnaire was developed to evaluate patients' satisfaction with care during their hospitalisation in the surgical day centre, as well as to assess their reports of anaesthesia related outcomes.

MEASUREMENTS

Various aspects of care were measured, including care by nurses, care by doctors, organisational and safety items. Variation in satisfaction and surgery and anaesthesia related outcomes as a function of different categories (gender, age, education, type of anaesthesia, discipline and era) were also investigated.

MAIN RESULTS

Confirmatory factor analysis showed an excellent fit to the hypothesized factors of the survey. Satisfaction scores were very high for different aspects of care, resulting in 98% of patients being (very) satisfied (59.1% very satisfied, 38.9% satisfied). Male (p=0.0003), higher educated (p<0.0001) and older patients (p<0.0001) were more likely to be very satisfied. Postoperative nausea and vomiting (PONV) were frequent (nausea: 13.9%, vomiting: 3.3%), and more present in female than in male patients (p<0.0001). Pain scores at the PACU differed among disciplines (p<0.0001) were higher in female patients compared to male patients (3.41% versus 2.54%, p<0.0001) and after general anaesthesia compared to regional anaesthesia (3.25% versus 0.39%, p<0.0001) and decreased with higher age (p=0.0001) and education level (p=0.0033).

CONCLUSIONS

Whereas satisfaction with all aspects of care is generally high, the results regarding pain and PONV should inspire quality improvement initiatives. The questionnaire developed in this study can be a vehicle to assess and improve the quality of care in surgical day care centres.

A Prospective Study of Nausea and Vomiting After Breast Cancer Surgery

PURPOSE

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) continue to be common and disturbing complications experienced after surgery, particularly in women and especially in women undergoing breast cancer surgery. The purpose of this study was to assess the incidence and risk factors associated with PONV and PDNV from preoperative to 48 hours postoperatively in 97 women scheduled for breast cancer surgery.

DESIGN

Prospective, comparative design.

METHODS

After informed consent was obtained, women scheduled for breast cancer surgery were evaluated for incidence of vomiting, as well as the presence and severity of nausea from the preoperative holding area for 48 hours following surgery. Vomiting was assessed as both a nominally scaled, binary variable (Yes/No) and as a continuous variable to measure separate emetic events. Nausea was measured on an 11point verbal numeric scale with 0 being the absence of nausea and 10 representing the highest level of nausea ever experienced.

RESULTS

Twenty-nine (29.8%) women experienced nausea, and nine (9%) women experienced nausea and vomiting while in the post-anesthesia care unit despite close attention to the need for prophylactic antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experience PONV. Women who received intravenous acetaminophen did not experience less PONV in this study. PDNV occurred more frequently than PONV, with 34 women (35%) reporting occurrence after discharge. About 13 women who did not experience PONV while in the PACU subsequently experienced PDNV after leaving the hospital, evidence for the importance of patient discharge teaching regarding these symptoms. Although clinical guidelines are necessary, our observation is that nurses in the PACU setting continuously challenge themselves to individualize the combination of medications and activities for each patient to reduce PONV after surgery.