Postoperative nausea and emesis

Efficacy of gastric aspiration to reduce postoperative vomiting after orthognathic surgery: double-blind randomised clinical trial

Orthognathic surgery is a treatment modality indicated to correct dentofacial deformities. Postoperative vomiting can be associated with multifactorial origin mainly correlated to patient-related symptoms, anaesthetic and surgical factors. Swallowed blood has been related to one of those multifactorial vomiting causes. This present study was to compare the efficacy of gastric aspiration after bimaxillary orthognathic surgery. A double blind randomised clinical trial was carried out and patients were divided in two groups (n = 44/39 respectively). There was statistically significant difference between the control and study groups in the overall incidence of vomiting (p = 0.031) A stratified analysis by sex between both groups was performed demonstrating a four-fold eduction in the odds for vomiting events independent of patient gender (OR = 0.24; 95% CI 0.07 to 0.72). Gastric aspiration after orthognathic surgery can reduce the effects of postoperative vomiting decreasing inpatient period and, consequently, hospitalisation costs.

Buclizine crystal forms: First Structural Determinations, counter-ion stoichiometry, hydration, and physicochemical properties of pharmaceutical relevance

Buclizine (BCZ) is a chiral synthetic piperazine derivative which has antihistaminic, anti-muscarinic and antiemetic properties, and has been reintroduced as an appetite stimulant, especially for pediatric patients. Structural information about this drug, as well as other buclizine crystalline forms (solvates, salts and co-crystals) including the BCZ free-base (BCZ-FB), is non-existent. Here, we present for the first time the crystal structure of the monohydrochloride monohydrate salt of BCZ (BCZHCl·H₂O), and of its anhydrous form, BCZHCl. Interestingly, BCZHCl·H₂O was obtained by recrystallization from the raw material (BCZH₂Cl₂) in ethanol:water solution showing that BCZ anhydrous dihydrochloride salt changes easily to a monohydrochloride monohydrate salt modification, which raise concerns about formulation quality control. BCZHCl·H₂O and BCZHCl crystallize in the orthorhombic space groups (Pna2₁ and Pca2₁) belonging to the mm2 point group and are thus classified as non-centrosymmetric achiral structures (NA). Intuitively, we expect these salts to crystallize in a space group with a center of symmetry, since less than 5% of the known racemic compounds crystallize in the NA type. The crystal structures of BCZH₂Cl₂ and BCZ-FB were not determined, but their existence was verified by other techniques (chloride ion analysis, PXRD, HPLC, FT-IR, DSC, TGA) and by comparison of the obtained results with those found for BCZHCl. Additionally, we have also performed an evaluation of the equilibrium solubility (at six different aqueous media) and the dissolution profile of the BCZHCl salt compared to the raw material and BCZ-FB. Different equilibrium solubility values were found comparing the three forms in acidic and neutral pH ranges and all of them were insoluble at pH > 7.0. Moreover, tablets prepared with BCZH₂Cl₂, BCZHCl or BCZ-FB show significant differences in terms of dissolution profile.

Predicting postoperative nausea and vomiting in patients undergoing oral and maxillofacial surgery

A common predictive measure of postoperative nausea and vomiting (PONV) is the Apfel score. Although tested in many different operations, it has not been tested extensively in oral and maxillofacial surgery (OMFS). This study was designed to determine whether it applied to OMFS and whether there were other factors in this population that would improve its accuracy. A retrospective chart review was carried out on a randomly selected group of patients who had OMFS during a 10-month period. In addition to the Apfel score risk factors, PONV data were collected in relation to type of anesthetic induction and maintenance, type of surgery, use of maxillomandibular fixation (MMF), use of opioids, and anesthesia and surgery times. One-hundred and sixty-seven patients were included in the analysis; 24% had nausea and 11% had nausea and vomiting. Patients who had orthognathic or temporomandibular joint surgery had the highest rate of PONV. Young age, anesthesia and operation time, and use of MMF were also associated with increased PONV. Adding age, MMF or limited postoperative mouth opening, and surgery type to the Apfel score should make it more predictive in OMFS.

Amisulpride Prevents Postoperative Nausea and Vomiting in Patients at High Risk

Background

Postoperative nausea and vomiting causes distress for patients and can prolong care requirements. Consensus guidelines recommend use of multiple antiemetics from different mechanistic classes as prophylaxis in patients at high risk of postoperative nausea and vomiting. The prophylactic efficacy of the dopamine D2/D3 antagonist amisulpride in combination with other antiemetics was investigated.

Methods

This double-blind, randomized, placebo-controlled, international, multicenter trial was conducted in 1,147 adult surgical patients having three or four postoperative nausea and vomiting risk factors. Patients were randomized to receive either intravenous amisulpride (5 mg) or matching placebo at induction of general anesthesia, in addition to one standard, nondopaminergic antiemetic, most commonly ondansetron or dexamethasone. Vomiting/retching, nausea, and use of rescue medication were recorded for 24 h after wound closure. The primary endpoint was complete response, defined as no emesis or rescue medication use in the 24-h postoperative period.

Results

Complete response occurred in 330 of 572 (57.7%) of the amisulpride group and 268 of 575 (46.6%) of the control group (difference 11.1 percentage points; 95% CI, 5.3 to 16.8; P < 0.001). The incidences of emesis (13.8% vs. 20.0%, P = 0.003), any nausea (50.0% vs. 58.3%, P = 0.002), significant nausea (37.1% vs. 47.7%, P < 0.001), and rescue medication use (40.9% vs. 49.4%, P = 0.002) were significantly lower in the amisulpride group. Adverse events and laboratory and electrocardiogram abnormalities occurred no more frequently with amisulpride than with placebo.

Conclusions

Intravenous amisulpride was safe and effective as prophylaxis of postoperative nausea and vomiting when given in combination with an antiemetic from another class to adult patients at high risk for suffering postoperative nausea and vomiting undergoing elective surgery under inhalational general anesthesia.

Factors associated to post-operative nausea and vomiting following oral and maxillofacial surgery: a prospective study

AIM

This study aims to address and assess possible factors associated with nausea and vomiting (NV) following oral and maxillofacial surgery.

MATERIAL AND METHODS

A prospective study was carried out in the period from December 2013 to January 2016 targeting all attended cases in that period. For statistical analysis, Pearson chi-square and Fisher tests were used to verify association and ANOVA and Student's t tests to test for significant difference, p was defined as ≤0.05. The sample group consisted of 207 patients with an average age of 33.56 years (±13.23), and 70.5% of subjects were male.

RESULTS

Calculations based on the predictive model showed that a female patient with prior history of nausea and vomiting who used opioids and had intra-oral surgical access would have a 96% chance of experiencing a nausea and vomiting episode. Other factors like age, being overweight, anesthesia, surgery duration, and duration of hospital stay also contribute so that these aspects must be paid careful attention prior to surgery to ensure a suitably orientated treatment that will avoid disturbances caused by post-operative nausea and vomiting.

CONCLUSION

The occurrence of post-operative nausea and vomiting after oral and maxillofacial surgery was found to be more higher incidence associated to female patients who used opioids, who had a prior history of NV, whose surgery involved intra-oral access, who were in the second or third decades of their lives, who have above average weight, and who have long anesthesia when undergoing surgery, resulting in a long hospital stays.

Factors associated with postoperative nausea and vomiting in patients undergoing an ambulatory hand surgery

BACKGROUND

Patients undergoing ambulatory surgery under general anesthesia experience considerable levels of postoperative nausea and vomiting (N/V) after their discharge. However, those complications have not been thoroughly investigated in hand surgery patients yet. We investigated factors associated with postoperative N/V in patients undergoing an ambulatory hand surgery under general anesthesia and determined whether patients' satisfaction with this setting is associated with postoperative N/V levels.

METHODS

We prospectively evaluated 200 consecutive patients who underwent ambulatory hand surgeries under general anesthesia to assess their postoperative N/V visual analogue scale (VAS) levels during the first 24 hours after surgery and their satisfaction with an ambulatory surgery setting. Potential predictors of postoperative N/V were; age, sex, body mass index, smoking behavior, a history of postoperative N/V after previous anesthesia or motion sickness, preoperative anxiety level and the duration time of anesthesia. We conducted multivariate analyses to identify factors associated with postoperative N/V levels. We also conducted multivariate logistic regression analyses to determine whether the N/V levels are associated with the patients' satisfaction with this setting. Here, potential predictors for satisfaction were sex, age, postoperative pain and N/V.

RESULTS

Postoperative N/V were associated with a non-smoking history, a history of motion sickness and a high level of preoperative anxiety. Twenty-two patients (11%) were dissatisfied with the ambulatory setting and this dissatisfaction was independently associated with moderate (VAS 4-7) and high (VAS 8-10) levels of postoperative N/V and with a high level (VAS 8-10) of postoperative pain.

CONCLUSIONS

Although most of the patients were satisfied with the ambulatory surgery setting, moderate to high levels of N/V were associated with dissatisfaction of patients with this setting, suggesting a need for better identifying and managing those patients at risk. The information regarding risk factors for N/V could help in preoperative patient consultation regarding an ambulatory hand surgery under general anesthesia.

Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature

Lumbar spine surgery can be performed using different anesthetic techniques such as general endotracheal anesthesia (GA) or spinal-based regional anesthesia (RA). Several studies have been performed comparing these two anesthetic techniques and have revealed disparate results. As such, we set out to review the relevant literature. We performed a literature search for clinical articles comparing cohorts of patients who underwent RA versus GA for lumbar spine surgeries. We compared results of these studies between groups with respect to the following outcome variables: heart rate (HR), mean arterial pressure (MAP), blood loss, duration of surgery, time spent in the PACU, post-operative analgesic use or pain scores, urinary retention rates, and nausea or anti-emetic requirements. Eleven studies were identified that compared cohorts of patients who underwent GA or RA. Of these, 4 were randomized control trials, 3 were case control trials, 2 were prospective cohorts, and 2 retrospective analyses. Seven-out-of-seven studies reported reduced HRs and MAPs in the RA compared to GA group, and 7/9 studies reported a lower incidence of post-operative analgesic requirement and/or decreased pain scores for the RA group. Our review of the literature suggests that both RA and GA are safe and effective techniques for lumbar spine surgery and that RA may prove a better alternative than GA for healthy patients undergoing simple lumbar decompression procedures or for patients who are at high risk for general anesthetic complications.

Risk of severe and refractory postoperative nausea and vomiting in patients undergoing diep flap breast reconstruction

BACKGROUND

Postoperative nausea and vomiting (PONV) are commonly feared after general anesthesia and can impact results. The primary aim of our study was to examine incidence and severity of PONV by investigating complete response, or absence of PONV, to prophylaxis used in patients undergoing DIEP flaps. Our secondary aims were definition of the magnitude of risk, state of the art of interventions, clinical sequelae of PONV, and interaction between these variables, specifically for DIEP patients.

METHODS

A retrospective chart review occurred for 29 patients undergoing DIEP flap breast reconstruction from September 2007 to February 2008. We assessed known patient and procedure-specific risks for PONV after DIEPs, prophylactic antiemetic regimens, incidence, and severity of PONV, postoperative antiemetic rescues, and effects of risks and treatments on symptoms.

RESULTS

Three or more established risks existed in all patients, with up to seven risks per patient. Although 90% of patients received diverse prophylaxis, 76% of patients experienced PONV, and 66% experienced its severe form, emesis. Early PONV (73%) was frequent; symptoms were long lasting (average 20 hours for nausea and emesis); and multiple rescue medications were frequently required (55% for nausea, 58% for emesis). Length of surgery and nonsmoking statistically significantly impacted PONV.

CONCLUSION

We identify previously undocumented high risks for PONV in DIEP patients. High frequency, severity, and refractoriness of PONV occur despite standard prophylaxis. Plastic surgeons and anesthesiologists should further investigate methods to optimize PONV prophylaxis and treatment in DIEP flap patients.

Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis

Opioids are a key risk factor for postoperative nausea and vomiting (PONV). As intravenous (i.v.) acetaminophen reduces postoperative pain and opioid requirements, one would expect i.v. acetaminophen to be associated with a lower incidence of opioid-induced side effects, including PONV. We conducted a systematic search using Medline and Cochrane databases supplemented with hand search of abstract proceedings to identify randomized-controlled trials of i.v. acetaminophen. Inclusion criteria were (a) randomized for i.v. acetaminophen vs a placebo control, (b) general anesthesia, and (c) reported or obtainable PONV outcomes. Primary outcome was postoperative nausea and secondary outcome was postoperative vomiting. We included 30 studies with 2364 patients (1223 in the acetaminophen group, 1141 in the placebo group). The relative risk (95% confidence interval) was 0.73 (0.60-0.88) for nausea and 0.63 (0.45-0.88) for vomiting. Data showed significant heterogeneity for both nausea (P=0.02, I(2)=38%) and vomiting (P=0.006, I(2)=47%), but were homogeneous when studies were grouped according to timing of first administration: i.v. acetaminophen reduced nausea when given prophylactically either before surgery, 0.54 (0.40-0.74), or before arrival in the postanesthesia care unit, 0.67 (0.55-0.83); but not when given after the onset of pain, 1.12 (0.85-1.48). When i.v. acetaminophen was given prophylactically, the reduction of nausea correlated with the reduction of pain (odds ratio 0.66, 0.47-0.93), but not with reduction in postoperative opioids (odds ratio 0.89, 0.64-1.22). Prophylactically administered i.v. acetaminophen reduced PONV, mainly mediated through superior pain control.

Perspectives on transdermal scopolamine for the treatment of postoperative nausea and vomiting

Transdermal scopolamine, a patch system that delivers 1.5 mg of scopolamine gradually over 72 hours following an initial bolus, was approved in the United States in 2001 for the prevention of postoperative nausea and vomiting (PONV) in adults. Scopolamine (hyoscine) is a selective competitive anatagonist of muscarinic cholinergic receptors. Low serum concentrations of scopolamine produce an antiemetic effect. Transdermal scopolamine is effective in preventing PONV versus placebo [relative risk (RR)=0.77, 95% confidence interval (CI), 0.61-0.98, P = 0.03] and a significantly reduced risk for postoperative nausea (RR=0.59, 95% CI, 0.48-0.73, P < 0.001), postoperative vomiting (RR=0.68, 95% CI, 0.61-0.76, P < 0.001), and PONV (RR 0.73, 95% CI, 0.60-0.88, P = 001) in the first 24 hours after the start of anesthesia.

Postoperative nausea and vomiting after myringoplasty under continuous sedation using midazolam with or without remifentanil

PURPOSE

This prospective study evaluated the effects of continuous sedation using midazolam, with or without remifentanil, on postoperative nausea and vomiting (PONV) in patients undergoing myringoplasty.

MATERIALS AND METHODS

Sixty patients undergoing myringoplasty were sedated with midazolam in the presence of remifentanil (group MR), or after saline injection instead of remifentanil (group M).

RESULTS

Three patients (10%) in group M complained of nausea; two vomited. Four patients (13%) in group MR complained of nausea and vomited within 24 h after surgery. Rescue drugs were given to the six patients who vomited. No significant difference was detected between the two groups regarding the incidence or severity of nausea, incidence of vomiting, or need for rescue drugs.

CONCLUSION

Midazolam-based continuous sedation can reduce PONV after myringoplasty. Compared with midazolam alone, midazolam with remifentanil produced no difference in the incidence or severity of nausea, incidence of vomiting, or need for rescue drugs.

[Evaluation of the efficiency of pharmacological antiemetic prophylaxis in different risk groups after general anaesthesia in the surgical population of Catalonia]

OBJECTIVE

To assess the efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthetic in different postoperative nausea and vomiting (NVPO) risk groups.

MATERIAL AND METHODS

A randomised, observational, prospective and multicentre cohort study was conducted. The study included 1239 patients from 26 hospitals who were subjected to elective surgery under general anaesthesia. The data collected included, demographic characteristics, the NVPO risk factors, anaesthetic technique, type of surgery, the duration, fluid therapy, antiemetic prophylaxis administered, and the incidence of NVPO in the first 24h after surgery. A stratified analysis (low, moderate and high risk) was performed with the intention of evaluating the relationship between prophylaxis and NVPO using a logistic regression model adjusted for propensity score. The number of patients needed to treat (NNT) to prevent an NVPO episode was then calculated for each of the strata.

RESULTS

The incidence of NVPO in the low risk stratum was 21.6% without prophylaxis and 8.6% with prophylaxis, 31.3% compared to 17.7% in the moderate risk, and 46.5% compared to 32.7% in the high risk group. There was a significant protective effect in the three strata (odds ratio between treated and untreated patients) and in the NNT (95% CI) was 7 (5-11) in the low risk stratum, 7 (5-13) in that of the moderate risk, and 6 (4-16) in the high risk.

CONCLUSIONS

The efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthesia was similar in all risk groups. Not providing antiemetic prophylaxis in low risk patients may not be justified due to the cost-effectiveness criteria. Future clinical guidelines to improve the quality of health care of patients operated on under general anaesthesia should consider the advantages of a universal NVPO prophylaxis.

Management of nausea, vomiting, and diarrhea during critical illness

Symptoms are subjective patient experiences that may negatively impact the patient's hospitalization, treatment plan, and quality of life. Critically ill patients frequently experience nausea, vomiting, and diarrhea related to underlying disease, procedures, and medical interventions (eg, medication, enteral feeding, surgery). Optimally, the nurse performs a subjective assessment that explores the patient's perception and impact of these symptoms to develop a comprehensive plan of care. Unfortunately, little evidence is available to guide assessment of nausea, vomiting, and diarrhea in critically ill nonverbal patients. Understanding the disease processes, medical treatments, and pathophysiology of these symptoms will assist the critical care nurse in the anticipation of symptoms and development of a proactive plan to alleviate the symptom-associated discomfort.

Efficacy and safety of aprepitant in the prevention of chemotherapy-induced nausea and vomiting: a pooled analysis

PURPOSE

A number of studies have reported that aprepitant has been used to prevent chemotherapy-induced nausea and vomiting. In this study, we aimed to analyze the efficacy and safety of aprepitant, which can provide evidence for aprepitant administration.

MATERIALS AND METHODS

Fifteen trials involving patients who received moderately or highly emetogenic chemotherapy were included in this pooled analysis. Antiemetic drugs in these studies included aprepitant, dexamethasone, and 5-HT3 receptor antagonists.

RESULTS

A total of 4,798 cases were investigated in these clinical trials. Compared with placebo or the standard antiemetic therapy, the cumulative incidence of emesis was significantly reduced in the patients treated with aprepitant-based (125 mg/80 mg) therapy on the first day [relative risk (RR) = 1.13, 95% confidence interval (CI) 1.10-1.16], from 2 to 5 days (RR = 1.35, 95% CI 1.22-1.48) and in the overall 5 days (RR = 1.30, 95% CI 1.22-1.39). In terms of drug safety, there was no significant difference between aprepitant-based regimens and non-aprepitant regimens.

CONCLUSION

Results from the analysis suggest that aprepitant with 5-HT3 receptor antagonists and dexamethasone is highly effective in preventing nausea and vomiting in the days after administration of moderately or highly emetogenic chemotherapy (MEC or HEC) agents.

Propofol vs isoflurane anesthesia-incidence of PONV in patients at maxillofacial surgery

PURPOSE

Prophylaxis of PONV (postoperative nausea and vomiting) is important for maxillofacial surgery. Vomiting is particularly unpleasant for the patient and undesirable as it may be detrimental to the operative area. The aim of this study is to compare the incidence of PONV after propofol with that after isoflurane anesthesia.

MATERIALS AND METHODS

84 patients age 15-50, ASA I-II, undergoing maxillofacial surgery were randomly allocated in two groups. Group P n=42 -using TIVA (Total Intravenous Anesthesia) with propofol and Group I n=42- using isoflurane anesthesia. The incidence and severity of PONV was evaluated for 24 hours postoperatively based on scoring system: 0=no emetic symptoms, 1=nausea, 2=vomiting. Whereas the severity of nausea was assessed using a four-point Likert scale, with 0=none, 1=mild, 2=moderate, 3=severe.

RESULTS

There were no significant differences between the groups with respect to demographic data and duration of anesthesia. The incidence of nausea (2-3 Likert scale) in the propofol group was 11.9% compared to the isoflurane group 38.1% during early post-operative period (0-6 hrs) (p=0.011), whereas during late post-operative period 7.1% in group P compared with 11.9% in group I (p=0.712).Incidence of vomiting in early post-operative period in-group P was 4.8%, whereas in-group I 11.9% (p=0.432). In late postoperative period in-group P no patient suffered from vomiting or retching, whereas in-group I 4.8% (p=0.494).

CONCLUSIONS

TIVA with propofol reduces the postoperative incidence of nausea and vomiting after maxillofacial surgery, compared with isoflurane anesthesia, and also reduces requirements of antiemetic medications.

DISCONTINUATION OF DROPERIDOL FOR THE CONTROL OF ACUTELY AGITATED OUT-OF-HOSPITAL PATIENTS

OBJECTIVE

To identify the effects of the removal of droperidol as a treatment option for sedation of agitated out-of-hospital patients.

METHODS

This was a retrospective review conducted January 1, 2001, through December 5, 2002, of patients with an out-of-hospital diagnosis of agitation who received either droperidol or midazolam prior to arrival in the emergency department (ED). The need for continuous cardiac or pulse oximetry monitoring, intubation, critical care ED management, intensive care unit admission, and mortality was reviewed.

RESULTS

Seventy-one patients received droperidol or midazolam for acute agitation in the out-of-hospital setting. Forty-one patients received droperidol in 2001 (D2001); three patients received midazolam in 2001 (M2001). No patients received droperidol in 2002, and 27 patients received midazolam (M2002). Comparing the D2001 and M2002 groups, the need for continuous pulse oximetry monitoring in the ED [14/41 (34.1%) versus 18/27 (66.7%)], intubations [4/41 (9.8%) versus 10/27 (37.0%)], critical emergency medical services transports [5/41 (12.2%) versus 11/27 (40.7%)], critical ED care cases [6/41 (14.6%) versus 11/27 (40.7%)], and intensive care unit admissions [6/13 (46.2%) versus 14/15 (93.3%)] were increased in the M2002 group. No difference was found in the frequencies of ED cardiac monitoring, hospital admission, complications, or death.

CONCLUSIONS

Since the removal of droperidol as a treatment option for out-of-hospital agitated patients, the authors have observed an increased frequency of continuous pulse oximetry monitoring, intubation, ED critical care management, and intensive care unit admission in patients requiring chemical sedation for control of agitation in the out-of-hospital setting.

Do current antiemetic practices result in positive patient outcomes? Results of a new study

PURPOSE

The problem of perioperative nausea and vomiting (including postoperative and postdischarge nausea and vomiting [PONV/PDNV]) among people undergoing general anesthesia is discussed.

SUMMARY

Nausea and vomiting are not limited to the postanesthesia care unit (PACU) or the hospital, but can persist long after the patient has been discharged and has returned home. This underscores the need for new antiemetic agents that not only offer greater efficacy and proven safety, but also provide an extended duration of action. The Prospective Observational Study of Treatments, Outcomes and Patterns of Care (POSTOP), was designed to assess the impact that current antiemetic practices have on patient outcomes in the postoperative and postdischarge settings. The investigation assessed the treatments, outcomes, and patterns of care for PONV and PDNV in high-risk patients over the course of 72 hours following surgery. Based on this observational study, despite the availability of current guidelines there is no current standard of care for managing PONV and PDNV.

CONCLUSION

Increasing the adherence to guidelines and the rational use of prophylaxis based on patient stratification will reduce the incidence of PONV, as will the development of new antiemetic agents with greater efficacies and longer durations of action that can provide extended protection from nausea and vomiting throughout the 72-hour postsurgical period.

Identification of risk factors for postoperative nausea and vomiting in the perianesthesia adult patient

Postoperative nausea and vomiting (PONV) is a common and potentially debilitating complication of surgery. The preoperative assessment of PONV using established risk assessment tools enables the identification of patients at risk and potentially decreases the incidence of PONV in adult surgical patients. The identification of risk factors associated with PONV and the factors that are independent predictors of PONV preoperatively can facilitate the effective prophylactic treatment and management of PONV in adult surgical patients.

Patients' willingness to pay for anti-emetic treatment

BACKGROUND

Post-operative nausea and vomiting (PONV) is a common complication of anaesthesia. This study was conducted in 100 German and 100 Turkish patients scheduled for elective surgery under general anaesthesia to assess the amount patients were willing to pay for an anti-emetic that completely prevented PONV.

METHODS

Post-operatively, using Dixon's up and down method, patients completed an interactive computer questionnaire with a random starting point to determine how much of their own money they were willing to pay for a totally effective anti-emetic treatment.

RESULTS

On average, participants were willing to pay 65 euro in Germany and 68 euro in Turkey to avoid PONV. However, patients who actually experienced PONV were willing to pay larger amounts: 96 euro in Germany and 99 euro in Turkey. The amount patients were willing to pay was related to female sex, history of motion sickness, non-smoking status and better education.

CONCLUSIONS

Despite differences in political and cultural origin, health care system and financial background, the amount patients were willing to pay for an effective anti-emetic was similar in both Germany and Turkey to that reported previously for the USA.

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.

Isopropyl alcohol inhalation as treatment for nausea and vomiting

In my practice as a recovery room nurse, I had observed anesthesiologists and nurse anesthetists wave an opened alcohol preparation pad under a patient's nose when he or she complained of nausea. When asked, "Why?'' the response often was, "Because it works.'' The following article describes the use of inhalation of isopropyl alcohol as a treatment for postoperative nausea and vomiting. Because alcohol swabs are so readily available, and certainly less expensive than some of the newer antiemetics on the market, this simple nursing intervention was worth investigating.

Postoperative nausea and vomiting

Nausea and vomiting following surgery may either occur as postoperative nausea and vomiting, which is a condition that is mainly related to anesthesia, or as secondary to postoperative ileus, which denotes inhibition of gastrointestinal motility following surgery. Postoperative ileus is a multifactorial event with several contributing mechanisms. Although postoperative nausea and vomiting pathophysiology has been quite well-studied little is known about it. There are multiple targets for treatment, prevention, and its successful empirical management e.g. by 5-HT(3) receptor antagonists. This review describes different aspects of the pathophysiology of postoperative ileus and postoperative nausea and vomiting, their relevance to postoperative care, and the standardized approach to manage postoperative nausea and vomiting that was established by Apfel and coworkers. Despite the recent advances in the understanding and treatment of conditions that trigger nausea and vomiting in the postoperative period, these symptoms remain a significant problem that affects patients' recovery, comfort, and treatment cost.

Postoperative nausea and vomiting and pain after transsphenoidal surgery: a review of 877 patients

Although postoperative nausea and vomiting and pain after supra- and infratentorial craniotomy have been evaluated in multiple studies, there are few data regarding pain or postoperative nausea and vomiting after transsphenoidal procedures. Therefore, we reviewed the perioperative records of 877 patients undergoing transsphenoidal surgery by the same surgeon. The overall incidence of postoperative emesis was 7.5%, significantly less than most studies of neurosurgical patients. An intraoperative cerebrospinal fluid leak and subsequent fat grafting, the use of lumbar intrathecal catheter, and patients presenting for the resection of a craniopharyngiomas all had a significantly increased incidence of postoperative emesis (11.4%, 17.1%, and 18%, respectively). Interestingly, antiemetic prophylaxis did not decrease the risk of vomiting overall or in any cohort of patients; however, both droperidol and ondansetron decreased the incidence of nausea in the postanesthesia care unit (PACU). Regarding pain and morphine consumption, patients who later developed diabetes insipidus had a significant increase in morphine requirements in the PACU. No other disease state was associated with increased pain or morphine consumption in the PACU.

Prevention of nausea and vomiting following breast surgery

BACKGROUND

The purpose of this study was to determine the rate of nausea and vomiting in women following breast surgery (PONV) under general anesthesia (GA), before and after the introduction of a standardized prophylactic anti-emetic (AE) regimen.

METHODS

We performed a retrospective review of eligible patients, between July 2001 and March 2003. Patients operated on before September 2002 had standard preoperative care (old cohort [OC]); patients operated on after September 2002 were treated prophylactically with oral dronabinol 5 mg and rectal prochlorperazine 25 mg (new cohort [NC]). Data were collected from hospital records regarding age, diagnosis, comorbid conditions, previous anesthesia history, anesthesia and operative details, episodes PONV, and use of AE. The rate and severity of PONV was calculated for both cohorts.

RESULTS

Two hundred forty-two patients were studied: 127 patients in the OC and 115 patients in the NC. The median age was 56 years (range 32 to 65). The rate of nausea and vomiting were significantly better in the patients treated prophylactically with dronabinol and prochlorperazine (59% vs. 15%, P < .0001 and 29% vs. 3%, P < .0001). Twenty patients in the OC were given some prophylactic AE treatment and 12 (60%) of them required further treatment; only 12 of 109 patients (11%) in the NC required further AE treatment (P < .0001).

CONCLUSION

PONV is a significant problem in breast surgical patients. Preoperative treatment with dronabinol and prochlorperazine significantly reduced the number and severity of episodes of PONV.

Prevention, Recognition, and Management of Nursing Complications in the Intraoperative and Postoperative Surgical Patient

A review of the literature focusing on postoperative complications reveals that the best available tools to the medical and surgical teams are recognition and prevention. This article highlights the more common postsurgical adverse events and discusses methods for preventing and treating these occurrences.

What postoperative outcomes matter to pediatric patients?

Children are often excluded from making decisions related to their medical treatment, and parents' proxy reports are often used. This approach fails to consider that parents and children may differ in their perception of the child's health. In this study, we assessed children's decision-making processes related to postoperative pain management. Forty-five children who underwent an anterior cruciate ligament repair or Nuss procedure for pectus excavatum repair were studied. A standard gamble technique was used to assess children's perceptions of the utility of a hypothetical treatment that would provide them with perfect pain control, with respect to different rates of risk for vomiting during the postoperative period. The maximum risk of vomiting that the overall study population was willing to accept to decrease the pain level to zero was 32% +/- 24%. Girls were willing to take a significantly higher risk (41% +/- 24%) compared to boys (25% +/- 22%) (P = 0.02). Children who actually experienced vomiting before they were questioned were willing to take a higher risk (46% +/- 26%) compared to those who did not (23% +/- 17%) (P = 0.035). Children can express opinions about preferred postoperative outcomes and provide useful input about their care. Girls, more than boys, seem to perceive vomiting as less important than improved pain control in the postoperative period.

Therapeutic options for the prevention and treatment of postoperative nausea and vomiting: a pharmacoeconomic review

Even with the development of the serotonin 5-HT(3) receptor antagonists in recent years, postoperative nausea and vomiting (PONV) remains a significant concern for clinicians and patients. For the selection of an appropriate antiemetic strategy for PONV, economic considerations should be taken into account. A literature search covering the period from September 1996 to August 2005 yielded 16 economic evaluations on antiemetics used for the prevention or treatment of PONV. In these studies, a variety of different antiemetic regimens were evaluated, with different doses and timing of administration, in many different populations, for various types of surgery, and in different settings. In addition, there were many differences in the design of these economic evaluations in terms of the extent of the costs considered and the decision rules used when forming conclusions. Therefore, despite the availability of economic evaluations on antiemetics in PONV, it is difficult to draw clear conclusions with such disparate information. In spite of these limitations, key learning can be drawn from these economic evaluations. From studies where a placebo was used as a comparator, we can conclude that there is clinical benefit in using an antiemetic for the prevention of PONV versus no therapy. The dose of the 5-HT(3) receptor antagonist seems more important in determining cost effectiveness than the selection of the agent itself, and less expensive agents such as droperidol, dexamethasone and prochlorperazine may also represent cost-effective alternatives to 5-HT(3) receptor antagonists. In an additional six studies where a willingness to pay (WTP) to avoid or reduce the incidence of PONV was estimated, the average WTP amounts varied from $US29 to $US117. Many questions remain unanswered about the cost effectiveness of existing antiemetics and their regimens, and little is known about the impact of new agents, such as the neurokinin-1 receptor antagonists, in the control of PONV.

PONV: a problem of inhalational anaesthesia?

Even nowadays every third or fourth patient suffers from postoperative nausea and vomiting (PONV) after general anaesthesia with volatile anaesthetics. There is now strong evidence that volatile anaesthetics are emetogenic and that there are no meaningful differences between halothane, enflurane, isoflurane, sevoflurane, and desflurane in this respect. However, when propofol is substituted for volatile anaesthetics the risk for PONV is reduced by only about one fifth, indicating that there are other even more important causes for PONV following general anaesthesia. A main causative factor might be the use of perioperative opioids, but their impact--relative to other factors including volatile anaesthetics--has never been quantified. Patient-specific risk factors have also been shown to be clinically relevant; they are therefore included in the calculation of simplified risk scores that allow prediction of a patient's risk independent of the type of surgery. Although controversial, the well-known different incidences following certain types of surgery are most likely caused by patient-specific and anaesthesia-related risk factors. There is a common consensus that prophylaxis with anti-emetic strategies is rarely justified when the risk of PONV is low, while it is warranted in case of imminent medical risk associated with vomiting or in a patient with a high risk for PONV. A recently published large multicentre trial of factorial design, IMPACT, has demonstrated that various anti-emetic strategies are associated with a very similar and constant relative reduction rate of about 25-30% and that the main predictor for the efficacy of prophylaxis is the patient's risk for PONV. Interestingly, all anti-emetics (dexamethasone, droperidol and ondansetron) work independently, so that their combined benefit can be derived directly from the single effects. The effectiveness of the anti-emetics was also independent of a variety of risk factors, including volatile anaesthetics. This means that any anti-emetic prophylaxis for PONV induced by volatile anaesthetics is equally effective. Of course, the most logical approach for prevention would be the omission of volatile anaesthetics and nitrous oxide using a total intravenous anaesthesia with propofol. However, since volatile anaesthetics are probably not the most important risk factors, it might be even better--if appropriate--to avoid general anaesthesia by using a regional, opioid-free anaesthesia if PONV is a serious problem.

Intraoperative nausea and vomiting during cesarean section under regional anesthesia

Nausea and vomiting during regional anesthesia for cesarean section are very common and unpleasant events. They cause significant distress to the patient and also interfere with the surgical procedure. They have multiple etiologies, which include hypotension, vagal hyperactivity, visceral pain, i.v. opioid supplementation, uterotonic agents and motion. The obstetric anesthesia literature has addressed these causative factors for nausea and vomiting individually, making it difficult for the anesthesiologists to have a comprehensive understanding of these important complications. This review highlights the anesthetic and non-anesthetic causes of intraoperative nausea and vomiting during regional anesthesia for cesarean section and the appropriate prophylactic and therapeutic management. Intraoperative nausea and vomiting can be best prevented by controlling hypotension, optimizing the use of neuraxial and i.v. opioids, improving the quality of block, minimizing surgical stimuli and judicious administration of uterotonic agents. Although prophylactic antiemetics have been advocated during cesarean sections, strict adherence to these practices can effectively lower the incidence of intraoperative nausea and vomiting without the requirement of antiemetic agents. Antiemetics, therefore, should be reserved for the prevention of intraoperative nausea and vomiting in high-risk patients and for the treatment of nausea and vomiting not responding to routine measures.

Eine faktorielle Studie von 6 Interventionen zur Vermeidung von �belkeit und Erbrechen nach Narkosen

BACKGROUND

Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown.

METHODS

In a randomized, controlled trial of factorial design, 5,199 patients at high risk for postoperative nausea and vomiting were randomly assigned to 1 of 64 possible combinations of 6 prophylactic interventions: 1) 4 mg of ondansetron or no ondansetron; 2) 4 mg of dexamethasone or no dexamethasone; 3) 1.25 mg of droperidol or no droperidol; 4) propofol or a volatile anesthetic; 5) nitrogen or nitrous oxide; 6) remifentanil or fentanyl. The primary aim parameter was nausea and vomiting within 24 h after surgery, which was evaluated blindly.

RESULTS

Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26%, propofol reduced the risk by 19%, and nitrogen by 12%. The risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics alone. All the interventions acted independently of each other and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. However, absolute risk reduction was a critical function of patients' baseline risk.

CONCLUSIONS

Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

[Postoperative nausea and vomiting]

Numerous pathophysiological mechanisms are known to cause nausea or vomiting but their role for postoperative nausea and vomiting (PONV) is not quite clear. Volatile anesthetics, nitrous oxide and opioids appear to be the most important causes for PONV. Female gender, non-smoking and a history of motion sickness and PONV are the most important patient specific risk factors. With these risk factors an objective risks assessment is achievable as a good rational basis for a risk dependent antiemetic approach: When the risk is low, moderate, or high, the use of none, a single or a combination of prophylactic antiemetic interventions seems to be justified. Performing a total intravenous anesthesia (Ti.v.A) with propofol is a reasonable prophylactic approach, but does not solve the problem satisfactorily alone if the risk is very high, reducing the risk of PONV only by 30%. This is comparable to the reduction rate of antiemetics, such as serotonin antagonist, dexamethasone and droperidol. It must be stressed that metoclopramide is ineffective. Data from IMPACT indicate that prophylaxis is not very effective if the patients risk is low. At a moderate risk the use of Ti.v.A or an antiemetic is reasonable and only a (very) high risk justifies the combination of several prophylactic antiemetic interventions. For the treatment of PONV an antiemetic should be chosen which has not been used prophylactically. The necessary doses are usually a quarter of those needed for prophylaxis.

A factorial trial of six interventions for the prevention of postoperative nausea and vomiting

BACKGROUND

Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown.

METHODS

We enrolled 5199 patients at high risk for postoperative nausea and vomiting in a randomized, controlled trial of factorial design that was powered to evaluate interactions among as many as three antiemetic interventions. Of these patients, 4123 were randomly assigned to 1 of 64 possible combinations of six prophylactic interventions: 4 mg of ondansetron or no ondansetron; 4 mg of dexamethasone or no dexamethasone; 1.25 mg of droperidol or no droperidol; propofol or a volatile anesthetic; nitrogen or nitrous oxide; and remifentanil or fentanyl. The remaining patients were randomly assigned with respect to the first four interventions. The primary outcome was nausea and vomiting within 24 hours after surgery, which was evaluated blindly.

RESULTS

Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk.

CONCLUSIONS

Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

Aromatherapy with peppermint, isopropyl alcohol, or placebo is equally effective in relieving postoperative nausea

To determine whether aromatherapy can reduce postoperative nausea, the investigators studied 33 ambulatory surgery patients who complained of nausea in the PACU. After indicating the severity of nausea on a 100-mm visual analogue scale (VAS), subjects received randomized aromatherapy with isopropyl alcohol, oil of peppermint, or saline (placebo). The vapors were inhaled deeply through the nose from scented gauze pads held directly beneath the patients' nostrils and exhaled slowly through the mouth. Two and 5 minutes later, the subjects rated their nausea on the VAS. Overall nausea scores decreased from 60.6 +/- 4.3 mm (mean +/- SE) before aromatherapy to 43.1 +/- 4.9 mm 2 minutes after aromatherapy (P <.005), and to 28.0 +/- 4.6 mm 5 minutes after aromatherapy (P < 10(-6)). Nausea scores did not differ between the treatments at any time. Only 52% of the patients required conventional intravenous (IV) antiemetic therapy during their PACU stay. Overall satisfaction with postoperative nausea management was 86.9 +/- 4.1 mm and was independent of the treatment group. Aromatherapy effectively reduced the perceived severity of postoperative nausea. The fact that a saline "placebo" was as effective as alcohol or peppermint suggests that the beneficial effect may be related more to controlled breathing patterns than to the actual aroma inhaled.