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PubMed1994

Impact of postoperative nausea and vomiting in the surgical setting.

Postoperative nausea and vomiting is one of the most common complications of inpatient and day case surgical procedures. In a climate where total cost of an illness is becoming increasingly important, postoperative nausea and vomiting is a major contributor to direct and indirect costs for both the hospital and patient. In patient terms, the impact of increased recovery room stays and extra nursing time required by PONV patients has been estimated to range from 96-576 more surgical procedures which may be performed in an 'average' day case surgery centre. Postoperative nausea and vomiting is perceived by patients to account for equal or more debilitation than surgery itself and may cause them to lose wages due to absence from work. Reducing the incidence of nausea and vomiting and its associated problems may therefore provide opportunities to improve patient care, decrease the size of waiting lists and improve utilisation of scarce healthcare resources.

Activities of Daily Living↗

PubMed1996

Tropisetron and metoclopramide in the prevention of postoperative nausea and vomiting. A comparative, placebo controlled study in patients undergoing ophthalmic surgery.

One hundred and twenty patients undergoing elective ophthalmic surgery under general anaesthesia were investigated in a randomised, double-blind, parallel group study of postoperative nausea and vomiting. Patients received tropisetron 0.1 mg.kg-1, metoclopramide 0.25 mg.kg-1 or placebo given at the end of anaesthesia. In comparison with placebo, tropisetron significantly reduced the degree of nausea (p < 0.01), whereas metoclopramide reduced both nausea (p < 0.05) and vomiting (p < 0.05). There were no statistically significant differences between the two active agents in their efficacy to postoperative nausea and vomiting. The patients in the placebo group required rescue antiemesis more often in the postanaesthesia care unit. Our results suggest that tropisetron may not be suitable as a routine, primary therapy for the prevention of postoperative nausea and vomiting.

Adolescent↗

PubMed1997

A survey of postoperative nausea and vomiting.

A prospective interview-based survey on the incidence of postoperative nausea and vomiting in 1107 in-patients aged 4-86 years was conducted during a 3-month period. Nausea, emetic episodes and the need for anti-emetic medication were recorded for 24 h postoperatively. In the recovery room, the incidence of nausea and vomiting was 18% and 5%, respectively. Over the whole 24-h period, these figures were 52% and 25%, respectively; severe nausea was experienced by 8%. The highest incidence of emetic sequelae was observed in gynaecological patients; 52% of the 822 patients who received general anaesthesia and 38% of the 285 patients who received regional anaesthesia reported nausea. The most important predictive factors associated with an increased risk for nausea and vomiting were female gender, a previous history of postoperative sickness, a longer duration of surgery, nonsmoking and a history of motion sickness. Based on these five items, a simple score predicting the risk of nausea and vomiting was constructed with a moderately good discriminating power.

Adolescent↗

PubMed1995

Premedication with promethazine and transdermal scopolamine reduces the incidence of nausea and vomiting after intrathecal morphine.

Intrathecal morphine provides effective postoperative pain relief in major orthopaedic surgery. In use, however, is associated with unpleasant side effects like nausea and vomiting. The effect of different premedications on postoperative emetic sequelae induced by intrathecal morphine was studied in a prospective, double blind study. Sixty patients scheduled for arthroplasty surgery of the lower extremity were anaesthetized with spinal anaesthesia with a combination of isobaric bupivacaine 20 mg and morphine 0.3 mg. For premedication the patients were randomised to three groups of equal size. They received either oral diazepam (5-15 mg), oral promethazine (10 mg) or a combination of promethazine and transdermal scopolamine (1.5 mg). Sixty percent of the patients with both promethazine and transdermal scopolamine were totally free from postoperative nausea and vomiting (PONV) symptoms compared to those premedicated with diazepam (40%) or promethazine alone (30%). Promethazine together with transdermal scopolamine reduced significantly the number of patients with vomiting (to 25%) and also vomiting episodes. This combination was also more efficient in reducing the incidence of nausea (to 25%) and nausea episodes than promethazine along (P < 0.05). Combination also reduced the requests for additional pain relief (P < 0.05). PONV occurred in a majority of patients during the first 12 hours of the 24 hour study period and the need for additional analgesics thereafter. The incidence of itching (50-65%) and urinary catheterisation (55-70%) was similar in all groups. In conclusion, the combination of oral promethazine and transdermal scopolamine was most effective in reducing PONV symptoms and also reduced the need for postoperative pain treatment.

Administration, Cutaneous↗

PubMed1997

Comparison of ondansetron and droperidol in the prevention of postoperative nausea and vomiting after laparoscopic surgery in women. A randomised, double-blind, placebo-controlled trial.

BACKGROUND: Women undergoing laparoscopic surgery are susceptible to postoperative nausea and vomiting (PONV). Ondansetron and droperidol are useful antiemetics. This study was designed to ascertain primarily the relative difference in efficacy of ondansetron and droperidol and secondarily between these drugs and placebo in the prevention of PONV after laparoscopic surgery. METHODS: The prophylactic antiemetic efficacy of ondansetron and droperidol was compared in a prospective, randomised, double-blind, placebo-controlled trial of 439 female inpatients scheduled for laparoscopic surgery. During induction of standardised general anaesthesia the patients received intravenously either ondansetron 8 mg (n=195), droperidol 1.25 mg (n=193) or placebo (n=51). The occurrence of nausea, vomiting, side-effects and the need for rescue antiemetic medication were recorded for 24 h postoperatively. RESULTS: The proportion of patients with nausea was 48%, 50% and 67% in the ondansetron, droperidol and placebo groups, respectively; with a significant difference when both ondansetron (P=0.02) and droperidol (P=0.04) were compared with placebo. Vomiting occurred in 18%, 26% and 37% of the patients in the three groups, respectively (P=0.05 between ondansetron and droperidol, P=0.004 between ondansetron and placebo, P=0.16 between droperidol and placebo). The proportion of patients given rescue medication was 34%, 28% and 49%, respectively (P=0.23 for ondansetron and droperidol, P=0.07 for ondansetron and placebo, P=0.007 for droperidol and placebo). During early recovery the patients treated with ondansetron were significantly more alert than after droperidol. Serious side-effects were not observed. Headache was significantly more common after ondansetron than after droperidol treatment. CONCLUSIONS: The efficacy of prophylactic ondansetron and droperidol in reducing postoperative nausea associated with laparoscopic surgery in female inpatients was similar, but ondansetron appeared to be slightly more efficient than droperidol in preventing vomiting. Ondansetron and droperidol were both significantly better than placebo in the prophylaxis of PONV.

Adolescent↗

PubMed1997

Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts. A prospective, randomized and blinded study.

BACKGROUND: Postoperative nausea and vomiting (PONV) after general anesthesia and surgery may have an incidence as high as 70% irrespective of antiemetic drug therapy. The use of preoperative hypnosis and mental preparation by means of an audio tape was investigated in the prophylaxis of nausea and vomiting before elective breast reduction surgery. Similar interventions have not been found in the literature. METHODS: Fifty women were randomized to a control group or a hypnosis group; the latter listened to an audio tape daily 4-6 days prior to surgery. A hypnotic induction was followed by suggestions as to how to relax and experience states incompatible with nausea and vomiting postoperatively (e.g. thirst and hunger). There was a training part on the tape where the patients were asked to rehearse their own model for stress reduction. Premedication and anesthetic procedures were standardized. RESULTS: Patients in the hypnosis group had significantly less vomiting, 39% compared to 68% in the control group, less nausea and less need of analgesics postoperatively. CONCLUSIONS: Preoperative relaxation and/or hypnotic techniques in breast surgery contribute to a reduction of both PONV and postoperative analgesic requirements.

Adult↗

PubMed1998

Oculocardiac reflex and postoperative vomiting in paediatric strabismus surgery. A randomised controlled trial comparing four anaesthetic techniques.

BACKGROUND: Oculocardiac reflex (OCR) and postoperative vomiting are major complications of paediatric strabismus surgery. METHODS: Children (3-16 yr) undergoing elective strabismus surgery as inpatients were randomly allocated to four anaesthetic techniques: (A) thiopentone induction and isoflurane maintenance; (B) as (A) plus ondansetron 5 mg x m(-2) i.v.; (C) propofol induction and maintenance; (D) as (C) plus lignocaine 2 mg x kg(-1) i.v. All children received prophylactic atropine 0.02 mg x kg(-1) and alfentanil. Nitrous oxide was omitted. RESULTS: Data on 157 children were analysed. The cumulative incidence of vomiting within 6 and 24 h after surgery with thiopentone-isoflurane was 26% and 46%, respectively. Adding ondansetron decreased the incidence to 8% and 33%, respectively. This improvement was significant within 6 h only; the number-needed-to-treat was 5.5 (95% CI 2.9-46). Propofol was not different from thiopentone-isoflurane. The addition of lignocaine to propofol was of no benefit. The risk of an OCR was significantly increased with propofol (incidence 40%) compared with isoflurane (14%); the number-needed-to-harm was 3.9 (95% CI 2.6-8). CONCLUSIONS: Thiopental-isoflurane-air/O2-alfentanil resulted in a moderate risk of vomiting. Adding ondansetron significantly decreased this risk, but 6 children have to be treated for one to benefit in the early postoperative period. Propofol and propofol-lignocaine showed no benefit on vomiting but significantly increased the risk of an OCR despite high-dose prophylactic atropine.

Adolescent↗

PubMed2006

Does esomeprazole prevent post-operative nausea and vomiting?

BACKGROUND: Esomeprazole is a potent proton pump inhibitor (PPI), reducing acid production as well as gastric juice volume. This study evaluated the possible beneficial effect of esomeprazole on reducing post-operative nausea and vomiting (PONV). METHODS: Patients undergoing laparoscopic or open gynaecological surgery, or laparoscopic cholecystectomy were randomized to receive three peri-operative doses double blindly of either esomeprazole 40 mg or placebo, given intravenously or orally. All patients were given a standardized anaesthesia regimen including fentanyl and sevoflurane/nitrous oxide. RESULTS: The study population consisted of 284 patients. Demographic data and known PONV risk factors were similar for the two treatment groups. PONV was observed in 77% of patients on esomeprazole vs. 81% on placebo (NS) and rescue antiemetic medication was needed in 56% vs. 53%, respectively (NS). The proportion of patients that vomited during 0-24 h was lower on esomeprazole than placebo (38% vs. 49%; NS), and the mean amount of vomit was significantly lower (52 vs. 86 g; P < 0.05). The use of neostigmine, use of opioids and type of surgery were significant risk factors for PONV (P < 0.05). The 24-h incidence of PONV was 63% after laparoscopic gynaecology, 80% after laparoscopic cholecystectomy and 88% after open gynaecological laparotomy, whereas laparoscopic cholecystectomy had the lowest risk when corrected for other risk factors of PONV. CONCLUSION: Esomeprazole had no clinically relevant effect on the overall 24-h incidence of PONV. However, esomeprazole significantly reduced the total amount of vomit during 24-h post-operatively. This may be of value in patients with an increased risk of pulmonary aspiration.

Adult↗

PubMed1995

Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques.

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be as effective as opioid analgesia following tonsillectomy in children. Opioids are still frequently used but tonsillectomy is associated with a high incidence of vomiting. This study has attempted to assess postoperative analgesic consumption and nausea and vomiting after general anaesthesia for tonsillectomy using either paracetamol premedication, paracetamol plus a NSAID or intravenous morphine to provide postoperative analgesia. Some children required a rescue dose of morphine in the recovery room, including some who had received intravenous morphine at induction. Least supplementary morphine was required by those who had received paracetamol plus ketorolac. Postoperative nausea and vomiting was significantly less in the two groups which were not given intraoperative morphine. The number of vomiting incidents was also much less. We conclude that the preoperative administration of paracetamol alone provides satisfactory analgesia in many children but that supplementary analgesia is still required for some.

Acetaminophen↗

PubMed2006

Early vs late intraoperative administration of tropisetron for the prevention of nausea and vomiting in children undergoing tonsillectomy and/or adenoidectomy.

BACKGROUND: Tropisetron is a long-acting 5HT3 receptor antagonist and was shown to be effective in the prevention of postoperative nausea and vomiting (PONV) after tonsillectomy. The aim of the study was to compare the effects of early vs late intraoperative administration of tropisetron with regard to prevention of PONV during the first 48 h after extubation. METHODS: In a randomized double-blind study, we investigated 120 children aged 1-12 years undergoing general anesthesia for tonsillectomy or adenotonsillectomy. Patients received 0.1 mg x kg(-1) tropisetron (maximum 2 mg) immediately after inhalational induction (early) and establishment of intravenous access or after the end of surgery before extubation (late). PONV and the need for antiemetic rescue medications were recorded within the following 48 h. Patient data were analyzed using t-test, chi-squared test (significance level of alpha = 0.05) and Spearman rank correlation test. RESULTS: The overall incidence of vomiting was 55.3%, with 60% (36/60) in the early treatment and 51.6% (31/60) in the late treatment group (P = 0.46). The observed time course 48 h postoperatively showed no difference regarding the number of vomiting episodes between the two groups and the need for antiemetic rescue medication. The incidence of nausea was higher in the late application group in the first 6 h after extubation (P = 0.001) and higher in the early application group between 24 and 48 h after extubation (P = 0.02). Morphine and the age over 3 years had a strong influence on the incidence of vomiting. CONCLUSION: The intraoperative time point (early vs late) of intravenous administration of a single prophylactic dose of tropisetron has no impact on the incidence of PONV during the first 48 h after tonsillectomy and/or adenoidectomy in children.

Adenoidectomy↗

PubMed1991

Reversible quantitative EEG changes in a case of cyclic vomiting: evidence for migraine equivalent.

Medical experts have disputed whether childhood cyclic vomiting is a manifestation of epilepsy or a migraine equivalent. Quantitative EEG provides an objective measure of changes in brain activity during and between episodes. This paper reports reversible changes involving two episodes in a patient whose history included cyclic vomiting and emotional/behavioural problems. Abnormal delta activity seen during both episodes resolved at follow-up, when the patient asymptomatic. The brain wave changes counter the hypothesis that vomiting in these patients is psychosomatic, and support the interpretation of cyclic vomiting as a migraine equivalent.

Adolescent↗

PubMed1992

Nausea and vomiting during pregnancy: effects on the quality of women's lives.

More than 70 percent of all pregnant women experience nausea and vomiting during pregnancy, and 28 percent report that symptoms cause them to change their usual activities. We investigated the magnitude of problems that nausea and vomiting impose on the lifestyle of pregnant women and their families. Twenty-seven women who were experiencing different degrees of nausea and vomiting were selected from 147 pregnant women and asked to participate in semistructured telephone interviews. All participants reported changes in family, social, or occupational functioning as a result of these symptoms. Nausea and vomiting can impose substantial lifestyle limitations on pregnant women that can have short- and long-term consequences for them and their families. Both the duration and severity of symptoms were greater for many participants than is generally believed. All participants reported that recumbent rest or dietary alterations provided relief. Caregivers should recognize and validate the need for pregnant women to make changes in lifestyle that will enable them to achieve comfort.

Adult↗

PubMed1989

Vomiting as the main presenting symptom of acute asthma.

Vomiting as a dominant symptom in a patient with acute asthma is reported. The traditionally recognized triad of cough, tachypnea and wheezing were absent or trivial whenever this patient presented with persistent vomiting. A careful history, laboratory evaluation and a course of bronchodilators eventually ascertained that the episodes of vomiting were due to attacks of acute asthma. It is suggested that acute asthma be included in the differential diagnosis of recurrent and/or severe vomiting in children.

Acute Disease↗

PubMed1987

Effects of feeding and social factors on diarrhoea and vomiting in infants.

In a prospective study of infants and their feeding in south east Queensland, Australia, the incidences of reported diarrhoea and/or vomiting in breast, bottle, and mixed (breast and bottle) fed infants were compared from birth to 1 year. Up to 6 months infants who were given breast feeds, with or without other milks, had less diarrhoea and/or vomiting than those given bottle feeds only. Breast feeding seemed to protect the infant against possible introduced infections even when other milks were given along with the breast milk. After 6 months breast feeding did not reduce the incidence of gastrointestinal infection. In both upper and lower social class families infants given solids before 3 months had less diarrhoea and/or vomiting than those given solids later. Bottle fed infants aged 3-6 months in upper social class families had fewer gastrointestinal problems than those of lower social class families. This study suggests that up to the age of 6 months, in this population, breast feeding protects the infant against diarrhoea and/or vomiting, but other milks and solids can safely be given to supplement the breast milk. Breast feeding conferred no significant protection after 6 months.

Age Factors↗

PubMed1999

Extraoccipital benign childhood partial seizures with ictal vomiting and excellent prognosis.

In a previous report of 900 patients with epileptic seizures, 24 children had ictal vomiting. Twelve had a previously unrecognised syndrome of early onset benign childhood occipital seizures (EBOS) and three had symptomatic epilepsy. The other nine children with extraoccipital EEG foci or normal EEG are described in this paper based on a prospective follow up for a median of 9 years after their first seizure. All had normal neurology, mental state, and development. All seizures of all but one patient occurred in sleep. Seizures manifested with ictal vomiting (nine), deviation of the eyes (four), speech arrest (three), hemiconvulsions (five), oropharyngolaryngeal symptoms, and hypersalivation (one) with or without impairment of consciousness. Median age at onset was 5 years, seizures were infrequent and remitted at a median age of 6. Four children had a single fit, four had two to three, and only one child had many seizures before the initiation of treatment. This study certifies that idiopathic childhood partial seizures with ictal vomiting may occur with EEG spike foci in other than the occipital regions or EEG may be normal. Despite some clinico-EEG differences from the EBOS, childhood seizures with ictal vomiting, and extraoccipital EEG foci are of equally excellent prognosis. Their existence on the border between rolandic and occipital seizures is consistent with a unified concept of a benign childhood partial seizure susceptibility syndrome.

Anticonvulsants↗

PubMed2005

Crisis management during anaesthesia: regurgitation, vomiting, and aspiration.

BACKGROUND: Regurgitation, vomiting and aspiration may occur unexpectedly in association with anaesthesia. "Aspiration/regurgitation" was ranked fifth in a large collection of previously reported incidents that arose during general anaesthesia. These problems are encountered by all practising anaesthetists and require instant recognition and a rapid, appropriate response. However, the diagnosis may not be immediately apparent as the initial presentation may vary from laryngospasm, desaturation, bronchospasm or hypoventilation to cardiac arrest. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for regurgitation, vomiting and aspiration, in the management of these complications occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 183 relevant incidents of regurgitation, vomiting and aspiration among the first 4000 reports to the AIMS. Aspiration was documented in 96, was excluded in 69, and in 18 it could not be determined whether or not aspiration had occurred. It was considered that the correct use of an explicit algorithm would have led to earlier recognition and/or better management of the problem in 10% of all cases of regurgitation and vomiting and in 19% of those in which aspiration occurred. CONCLUSION: Regurgitation and/or aspiration should always be considered immediately in any spontaneously breathing patient who suffers desaturation, laryngospasm, airway obstruction, bronchospasm, bradycardia, or cardiac arrest. Any patient in whom aspiration is suspected must be closely monitored in an appropriate perioperative facility, the acuity of which will depend on local staffing and workload. If clinical instability is likely to persist or if there are concerns by attending staff, the patient should be admitted to a high dependency unit or intensive care unit.

Algorithms↗

PubMed1990

Mechanics of vomiting: a minireview.

In a cineradiographic analysis of the vomiting reflex in response to i.v. administration of an emetic drug (lanatoside C, 12 mg/kg) in cats, it was shown that the vomiting act is preceded by cyclic periods of abnormal peristaltic activity of the small bowel and inhibition of gastric peristalsis. It was further observed that massive antiperistalsis of the upper small bowel with reflux into the stomach is a common occurrence in the period immediately preceding vomiting. The emetic act itself is composed of phases of esophageal dilation, gastric emptying, gastric reflux, and esophageal collapse in cyclic repetition. The response of the esophagus and the stomach during emesis is passive, with external pressures and forces apparently providing the expulsive forces, the gastric bolus being contained by contraction of the pylorus and probably an upper esophageal or pharyngeal barrier. Earlier studies were conducted in cats in which observations were made on changes in thoracic venous pressure, abdominal venous pressure, and arterial blood pressure associated with vomiting induced by Veratrum alkaloids. Retching was characterized by a growing series of brief negative intrathoracic pressure pulses mirrored by positive pressure pulses in the abdomen. Expulsion then occurred and was followed with a sudden reversal of intrathoracic pressure from negative to positive. Expulsion involved a more sustained abdominal contraction, but both retching and expulsion were brought about by the same set of muscles, according to their EMG profiles. From results observed following phrenicotomy and spinal cord section at T5, it was concluded that the diaphragm, acting together with the inspiratory muscles against a closed glotis is responsible for the negative intrathoracic pressure that occurs in retching.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed2004

Effects of antioxidant herbs on chemotherapy-induced nausea and vomiting in a rat-pica model.

Nausea and vomiting are significant adverse effects of chemotherapeutic agents like cisplatin, and cause significant patient morbidity. Cisplatin treatment results in oxidant gut injury, which is postulated to be the primary cause of nausea and vomiting. We evaluated the effects of two antioxidant herbs, Scutellaria baicalensis and American ginseng berry, on cisplatin-induced nausea and vomiting using a rat model. Rats react to emetic or nausea-producing stimuli, such as cisplatin, with altered feeding habits, manifested by increased kaolin consumption (pica). We measured pica in rats to quantify cisplatin-induced nausea. We observed that pretreatment of rats with S. baicalensis or ginseng berry extracts resulted in a significant reduction in cisplatin-induced pica. The in vitro free radical scavenging ability of the herbal extract observed in the study, further confirmed the antioxidant action of the herb. We conclude that herbal antioxidants may have a role in attenuating cisplatin-induced nausea and vomiting.

Animals↗