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PubMed1998

The effect of duration of dose delivery with patient-controlled analgesia on the incidence of nausea and vomiting after hysterectomy.

AIMS: Postoperative nausea and vomiting (PONV) may be exacerbated by postoperative opioid analgesics and may limit patients' successful use of these medications when used with patient controlled analgesia (PCA). We tested the hypothesis that the rapid change in blood morphine concentration associated with PCA bolus delivery contributed to PONV, and that prolonging its delivery to a brief infusion would result in decreased PONV. METHODS: Patients, who were receiving morphine for pain relief via patient-controlled analgesia (PCA) after total abdominal hysterectomy, received 1 mg morphine sulphate incremental doses either over 40 s with a 5 min lockout interval or over 5 min delivery with a 1 min lockout interval. Episodes of nausea, retching and vomiting, along with the use of morphine and the pain relief obtained, were recorded. RESULTS: Data from 20 patients in each group were analysed. Contrary to expectations, most patients in both groups reported nausea postoperatively. Those patients receiving morphine over 5 min experienced more episodes of emesis (36) than those receiving the dose over 40 s (17). Most patients receiving the 40 s doses vomited in the first 12 h (median time 8 h), while those receiving the 5 min doses vomited between 12 and 24 h (median time 19 h) (P = 0.01). There were no differences between groups in the visual analogue pain scores or use of morphine between groups. CONCLUSIONS: Reasons for these unexpected findings remain speculative. The high incidence of PONV appears to be inherently high in gynaecological surgery patients and standard antiemetic medication regimens appear to be poorly efficacious. Reasons for the differences in the time-course of emetic episodes between the two groups may be related to differences in the time-course of central opioid receptor occupancy.

Adult↗
PubMed1997

Ondansetron is not superior to moderate dose metoclopramide in the prevention of post-operative nausea and vomiting after minor gynaecological surgery.

Peri-operative nausea and vomiting (PONV), remain a considerable problem. Ondansetron is being promoted currently as the drug of choice for the prevention and treatment of PONV. Experiments to investigate efficacy of ondansetron in PONV have been made with placebo or single doses of other drugs, e.g. metoclopramide, and often with different anaesthetic regimes with different emetic potential. This study investigated the relative benefits, in the prevention of PONV, of ondansetron compared with metoclopramide used at a dose higher than used in previous studies. Ninety-six patients undergoing minor gynaecological surgery were randomized to receive either ondansetron 4 mg or metoclopramide 0.4 mg kg-1. The patients were then assessed in the recovery room, in the day ward prior to discharge and the following day for the occurrence of PONV. Emetic symptoms occurred in similar proportions of patients who received ondansetron and metoclopramide. Nausea scores were similar between the groups in the recovery ward and 24-h follow-ups but there were higher post-operative nausea scores in the ondansetron group in the day ward (P = 0.001). There were no significant side effects due to either drug. We conclude that moderate dose metoclopramide is an effective alternative to ondansetron in the control of PONV.

Adult↗
PubMed1996

Comparison of ondansetron and metoclopramide for the prevention of post-operative nausea and vomiting after major gynaecological surgery.

The efficacy of ondansetron 4 mg was compared with metoclopramide 10 mg for the prevention of post-operative nausea and vomiting in patients after major gynaecological abdominal surgery. Anaesthesia was standardized using thiopentone, atracurium and methadone for induction followed by isoflurane in nitrous oxide-oxygen mixture. Fifty patients were randomized in a double-blind fashion to either receive intravenous (i.v.) ondansetron 4 mg or metoclopramide 10 mg during closure of the pelvic peritoneum. The incidence and frequency of vomiting, and the incidence of severe nausea was recorded for 24 h after surgery. One patient was excluded because of respiratory depression. In the first 4 h after surgery, five patients (20%) in the ondansetron group (n = 25) and eight patients (33%) in the metoclopramide group (n = 24) vomited, whereas at 4-12 h, this increased to 11 patients (44%) and nine patients (37.5%) respectively. The incidence was 52 and 37.5% respectively in the subsequent 12-24 h. The highest incidence of nausea was in the first 4 h after surgery, being 56 and 37.5% in the ondansetron and the metoclopramide groups respectively. This decreased to less than 25% in both groups in the 12-24 h period. Ondansetron 4 mg and metoclopramide 10 mg had similar but short lasting efficacy for the prevention of vomiting in patients who received continued opioid analgesia after major gynaecological surgery.

Adolescent↗
PubMed1997

Comparison of metoclopramide and ondansetron for the prevention of nausea and vomiting after intrathecal morphine.

Nausea and vomiting remain unpleasant side effects of intrathecal (i.t.) morphine and of the numerous therapies tried, only prophylactic intravenous (i.v.) metoclopramide has been reported to be promising. Seventy-three patients, scheduled for orthopaedic prosthesis surgery of the hip or knee were studied. They received 4 mL of plain bupivacaine and 0.3 mg of preservative-free morphine i.t. for anaesthesia. The test drugs given in a double-blind and randomized fashion, were either metoclopramide 20 mg, three times, at 6 h intervals (23 patients), ondansetron, 8 mg, twice, at 12 h intervals (25 patients), or 0.9% saline three times, at 6 h intervals (25 patients). The occurrence of nausea, vomiting and pain was followed for 24 h. The incidences of nausea and vomiting were 60% (15/25) and 56% (14/25) in the saline group, 52% (12/23) and 48% (11/23) in the metoclopramide group, and 52% (13/25) and 40% (10/25) in the ondansetron group. Incidences of severe vomiting were 24, 35 and 12% respectively. Eight patients in the saline group, seven in the metoclopramide and 10 in the ondansetron group did not need additional opioids for post-operative pain relief. We conclude that, metoclopramide and ondansetron were not better than saline in the prevention of post-operative emesis induced by intrathecal morphine.

Aged↗
PubMed1999

Comparison of ondansetron and tropisetron combined with droperidol for the prevention of emesis in women with a history of post-operative nausea and vomiting.

The anti-emetic efficacy of prophylactic ondansetron and tropisetron in combination with a low dose of droperidol in patients with high probability for post-operative nausea and vomiting undergoing gynaecological laparoscopy was compared. Patients were randomly allocated in a double-blind manner to receive either ondansetron 8 mg (n = 45) or tropisetron 5 mg (n = 43) at the end of surgery. A standardized general anaesthetic technique was used, including droperidol 0.75 mg. The incidence of nausea was 36% and 49% (P = 0.28), and vomiting occurred in 13% and 14% of the patients in the ondansetron and tropisetron groups, respectively. The onset time for rescue medication was significantly sooner after tropisetron than ondansetron (3 h 18 min vs. 6 h 25 min; P = 0.007). There were no statistically significant differences in efficacy between prophylactic ondansetron and tropisetron combined with droperidol in a high-risk population. However, ondansetron appeared to be more effective in preventing post-operative nausea and vomiting in the early hours after surgery compared with tropisetron.

Adult↗
PubMed1999

Prevention of post-operative nausea and vomiting with combined granisetron and droperidol in women undergoing thyroidectomy.

We have compared the efficacy and safety of combined granisetron and droperidol with each anti-emetic alone for preventing post-operative nausea and vomiting after thyroidectomy. In a prospective, randomized, double-blind study, 180 women received granisetron 40 micrograms kg-1, droperidol 20 micrograms kg-1, or granisetron 40 micrograms kg-1 plus droperidol 20 micrograms kg-1 (n = 60 of each) intravenously immediately before induction of anaesthesia. A standard general anaesthetic technique and post-operative analgesia were used. A complete response, defined as no post-operative nausea and vomiting and no need for another rescue anti-emetic, during the first 24 h after anaesthesia occurred in 88%, 60% and 98% of patients who had received granisetron, droperidol and granisetron plus droperidol (P < 0.05; overall Fisher's exact probability test). No clinically important adverse events due to the drugs were observed in any of the groups. In summary, prophylactic use of combined granisetron and droperidol is more effective than each drug alone for the prevention of post-operative nausea and vomiting in female patients undergoing thyroidectomy.

Adult↗
PubMed1999

Assessment of ondansetron and droperidol for the prevention of post-operative nausea and vomiting after cholecystectomy and minor gynaecological surgery performed by laparoscopy.

The anti-emetic effects of ondansetron and droperidol were evaluated in 134 ASA Grade I and II female patients, scheduled for laparoscopic cholecystectomy and minor gynaecological laparoscopic surgery, who were randomly assigned to receive ondansetron 4 mg or droperidol 75 micrograms kg-1 intravenously immediately after induction of anaesthesia. The patients were assessed 1, 6, 12 and 24 h after surgery for intensity of nausea and number of vomiting episodes. In the case of the patients undergoing laparoscopy, vomiting episodes occurred in a similar proportion in patients treated with ondansetron or droperidol, with the probability of the Type I error of 0.05 and the Type error II of 0.1. Although there was no difference between the two groups in emetic episodes following all laparoscopic procedures and gynaecological laparoscopic surgery, there was a significant difference between these parameters after laparoscopic cholecystectomy. The patients treated with ondansetron experienced a lower intensity of nausea (P = 0.04) after laparoscopic cholecystectomy, less frequent severe nausea (P = 0.02) and episodes of vomiting (P = 0.04) when compared with those in the droperidol group. We conclude, that despite the result the droperidol prophylaxis appears to be an effective alternative to ondansetron in all patients undergoing laparoscopy, the ondansetron prophylaxis is superior to droperidol in patients undergoing laparoscopic cholecystectomy.

Adult↗
PubMed2000

Dolasetron for the prevention of postoperative nausea and vomiting following outpatient surgery with general anaesthesia: a randomized, placebo-controlled study. The Dolasetron PONV Prevention Study Group.

In a multicentre, randomized, double-blind, placebo-controlled dose-ranging study, 1030 patients undergoing outpatient surgery with general anaesthesia received i.v. dolasetron mesylate (12.5, 25, 50, or 100 mg) or placebo. The principal outcome measure was the proportion of patients who were free of emesis or rescue medication for the 24-h period after the study drug was given; the subsidiary outcome measure was survival time without rescue medication. Effects on nausea were quantified using a visual analogue scale. Compared with placebo, a complete response was significantly higher when all four dolasetron doses were combined (49% vs. 58%, P =0.025). In females, dolasetron, 12.5-mg, dolasetron provided maximum clinical benefit (effectiveness compared with adverse events), with no additional benefit in complete response rates or nausea visual analogue scale scores at higher doses. No significant differences were observed in complete response for any dolasetron dose in males compared with placebo. The majority of adverse events reported were mild or moderate. Dolasetron provided well-tolerated, safe, and effective prophylaxis for post-operative nausea and vomiting with maximum effectiveness observed at a dose of 12.5 mg.

Adult↗
PubMed2000

Efficacy of prophylactic droperidol, ondansetron or both in the prevention of postoperative nausea and vomiting in major gynaecological surgery. A prospective, randomized, double-blind clinical trial.

We conducted a prospective, randomized, double-blind clinical trial comparing droperidol 1.25 mg intravenously (i.v.) (group 1, n = 30), ondansetron 4 mg i.v. (group 2, n = 30), or both (group 3, n = 30) in the prevention of postoperative nausea and vomiting (PONV) in the first 24 h following major gynaecological procedures under combined general and epidural anaesthesia. PONV was analysed by a linear nausea/vomiting score, incidence of nausea and vomiting, and the need for antiemetic rescue. Our results showed a similar incidence of nausea and vomiting in all groups (G1 33%, G2 40%, G3 43%). However, when comparisons were made according to the time of assessment, combination therapy resulted in significantly lower PONV than droperidol in the first hour (0% vs. 13%, P < 0.05) and second hour (0% vs. 13%, P < 0.05), and than ondansetron on the first hour (0% vs. 13%, P < 0.05). A trend persisted up to the fourth hour but was not statistically significant in either group. In conclusion, droperidol and ondansetron are effective agents in the prevention of PONV, and their combination seems to provide slightly better results than either drug alone.

Adolescent↗
PubMed1999

Post-operative pain, nausea and vomiting: qualitative perspectives from telephone interviews.

Previous studies on post-operative pain, nausea and vomiting tend to be quantitative in method and focus on in-patient or day case surgery. The objectives of this study carried out in one specialist eye hospital in England were to consider post-operative pain, nausea and vomiting from a qualitative perspective. Fifty-five patients undergoing general anaesthetic short-stay ophthalmic surgery (orbital hydroxyapatite implantation) consented to participate in telephone interviews 8 days post-surgery. The interviews lasted between 20 and 60 minutes. Data were analysed thematically and offer insight into varying experiences of pain, nausea and vomiting in hospital, on discharge and at home. Results indicate that not all patients were discharged home in optimum condition. The needs of post-operative short-stay patients should come before financial imperatives to vacate beds. Patient education and information giving is discussed in the light of the findings.

Adult↗
PubMed1997

Ondansetron reduces nausea and vomiting after paediatric adenotonsillectomy.

The efficacy, safety and resource implications of a single intravenous dose of ondansetron (0.1 mg.kg-1, maximum 4 mg) were assessed in a multinational, multicentre, randomized, double-blind, placebo-controlled trial of 427 children aged 1-12 years, undergoing tonsillectomy with/without adenoidectomy. Emesis (retching and/or vomiting) and nausea were analysed separately. Significantly more ondansetron-treated children had no episodes of emesis (127/212 (60%) vs 100/215 (47%); P = 0.004) and experienced no postoperative nausea (135/211 (64%) vs 108/213 (51%); P = 0.004) in the first 24 h. Ondansetron also reduced the number of emetic episodes (P < 0.001), the time to the first emetic episode (P < 0.001) and overall nausea severity (P = 0.003). Significantly fewer ondansetron-treated children were rescued or withdrawn from the study (5% vs 10%; P = 0.042). Fewer ondansetron-treated patients required nursing intervention (34% vs 45%; P = 0.007) and the average intervention time was significantly shorter (4.6 vs 8.1 minutes; P = 0.001). Resources used to manage PONV were significantly reduced by ondansetron (43% vs 57%; P = 0.014).

Adenoidectomy↗
PubMed1999

Incidence of nausea and vomiting in children after strabismus surgery following desflurane anaesthesia.

In a prospective, randomized parallel study, 60 ASA I-III children aged 1-17 years, scheduled for elective strabismus surgery, were anaesthetized with desflurane without prophylactic antiemetic medication. The objective of the study was to determine the incidence of postoperative nausea and vomiting after general anaesthesia with desflurane. To decide whether nitrous oxide further influences these symptoms, the patients were randomly assigned to two groups of 30 patients each. One group received desflurane in oxygen/air and a second group received desflurane in oxygen/nitrous oxide. In all children, after intravenous induction and tracheal intubation, anaesthesia was administered as minimal flow anaesthesia with oxygen and nitrous oxide or air according to the random plan. The patients were observed for 48 postoperative hours until their discharge from the ward. The overall incidence of nausea was found to be 37%, and vomiting was seen in 32% of all patients. No statistical correlation was found between the incidence of postoperative emesis and the administration of nitrous oxide or the duration of general anaesthesia. Instead, the incidence of vomiting was 2.5-fold higher when surgery was performed on both eyes compared with one eye. The relatively low incidence of postoperative nausea and vomiting, as well as the quick recovery from anaesthesia, permitting an early discharge from the postoperative care unit to the ward, show desflurane to be a suitable volatile anaesthetic in strabismus surgery in children.

Adolescent↗
PubMed2002

The addition of antiemetics to the morphine solution in patient controlled analgesia syringes used by children after an appendicectomy does not reduce the incidence of postoperative nausea and vomiting.

BACKGROUND: We studied the effect of intraoperative ondansetron 0.1 mg x kg(-1) or droperidol 0.01 mg.kg-1, followed by the same dose of the antiemetic agent added to the morphine solution during patient controlled analgesia (PCA) on the incidence of nausea and vomiting in children following an appendicectomy. METHODS: Sixty children, aged 5-13 years, were recruited and randomly allocated to receive no prophylactic antiemetic, the control group (group C), ondansetron (group O) or droperidol (group D). The PCA pump was programmed to deliver a bolus dose of 20 microg x kg(-1) of morphine.with a 5-min lockout period and a background infusion of 4 microg x kg(-1) x h(-1). RESULTS: Postoperatively, the three groups were compared for nausea, vomiting and sedation scores for 24 h. The incidence of postoperative nausea and vomiting was 33% for group C, 44% for group O and 41% for group D. There was no increase in sedation scores in the droperidol group. CONCLUSIONS: We were unable to show any significant benefit from the prophylactic administration of ondansetron or droperidol to children using morphine PCA devices following appendicectomy in the doses we employed.

Analgesia, Patient-Controlled↗
PubMed2001

The development of a protocol for the use of 5-HT3 antagonists in chemotherapy-induced nausea and vomiting.

The purpose of this study was to evaluate the effectiveness of three 5-HT3 antagonists in routine clinical practice. The ultimate aim was to develop an antiemetic protocol, selecting a single 5-HT3 antagonist. Each of the drugs was studied for a 4-month period and data was collected from patients on nausea, vomiting (both acute and delayed) and side-effects by means of a diary card. A total of 274 patients were enrolled into the study. Success rates for acute emesis seen over the study period were in excess of 90%. There were no statistically significant differences between any of the three drugs investigated with respect to both acute and delayed nausea and vomiting. Similarly, there was no difference between the three groups for the incidence of constipation, diarrhoea and headache. Granisetron demonstrated a lesser deviation from the protocol in respect of the number of intravenous doses given to patients. The study allowed an effective 5-HT3 antagonist protocol to be developed for use in the management of nausea and vomiting in cancer patients.

Adolescent↗
PubMed2002

Small dose of propofol for preventing nausea and vomiting after third molar extraction.

PURPOSE: The study goal was to evaluate the efficacy and safety of a small dose of propofol for the prevention of nausea and vomiting following third molar extraction. PATIENTS AND METHODS: In a prospective, randomized, double-blinded, placebo-controlled trial, 90 women received placebo or propofol at 2 different doses (0.25 mg/kg, 0.5 mg/kg) (n = 30 of each) intravenously at the end of surgery. A standard general anesthetic technique, including sevoflurane and nitrous oxide in oxygen, was employed throughout the surgical procedure. Emetic episodes and safety assessments were performed during 0 to 3 hours and 3 to 24 hours after after anesthesia. RESULTS: The rate of patients experiencing emesis-free (no nausea, retching, or vomiting) during 0 to 3 hours after anesthesia was 60% with placebo, 66% with propofol 0.25 mg/kg (P =.395), and 90% with propofol 0.5 mg/kg (P =.001); the corresponding rate during 3 to 24 hours after anesthesia was 60%, 63% (P = 0.5), and 87% (P =.02) (P values compared with placebo). No clinically serious adverse effects due to the study drug were observed in any group. CONCLUSIONS: Prophylactic therapy with a small dose (0.5 mg/kg) of propofol is effective for preventing postoperative nausea and vomiting in female patients undergoing general anesthesia for third molar extractions.

Adolescent↗
PubMed2001

Hypothetical framework for a relationship between maternal thyroid function, nausea and vomiting of pregnancy, and congenital heart disease.

Our objective was to investigate whether a relationship exists among maternal thyroid function, nausea and vomiting of pregnancy, and congenital heart disease. A Medline search from 1966 to the present was conducted to look for reports on the existence of this relationship. The results were supplemented by abstract searches and personal communication with relevant authors. Our search found independent evidence that maternal hyperthyroidism is related to increased rates of nausea and vomiting of pregnancy, which in turn is significantly related to a decrease in the incidence of congenital heart disease. Early evidence indicates that the converse may be true: maternal hypothyroidism and thyroid replacement therapy are associated with an increase in congenital heart disease in children. The potential relationship between maternal thyroid function, nausea and vomiting of pregnancy, and thyroid replacement therapy needs further study. We propose a case-control study of children presenting for echocardiography to elicit specific information regarding the pregnancy.

Female↗
PubMed1999

[Dimenhydrinate and metoclopramide for prevention of nausea and vomiting following septorhinoplasties in women].

OBJECTIVES: Dimenhydrinate and metoclopramide are inexpensive antiemetic drugs. Metoclopramide, especially, has been studied extensively in the past, but there are no studies that used the combination of both drugs for prevention of postoperative nausea and vomiting (PONV). METHODS: 120 female inpatients undergoing endonasal surgery were randomised to receive one of four antiemetic regimes: placebo, dimenhydrinate (1 mg x kg-1), metoclopramide (0.3 mg x kg-1), or the combination of both drugs (1 mg x kg-1 + 0.3 mg x kg-1) were administered intravenously after induction of anaesthesia and repeated 6 hours after the first administration. For general anaesthesia a standardised technique including benzodiazepine premedication, propofol, desflurane in N2O/O2 vecuronium and a continuous infusion of remifentanil was used. Postoperative analgesia (diclofenac or metamizole supplemented with piritramide) and antiemetic rescue medication (dolasetron and droperidol) were standardised. Episodes of vomiting, retching, nausea, and the need for additional antiemetics were recorded in the recovery room and 2, 5, 8, and 24 hours after surgery. The main goal of the study was to increase the number of females staying completely free from PONV (Chi 2-test). Furthermore, the severity of PONV was analysed, using a standardised scoring algorithm. RESULTS: There were no differences between the two groups with regard to biometric data and distribution of risk factors for developing PONV. In all four groups nearly the similar number of patients stayed completely free from PONV: Placebo: 60.7%, metoclopramide: 66.7%, dimenhydrinate: 64.3%, combination: 64.4% (differences not significant). There was also no difference in the severity of nausea and emetic sequel. DISCUSSION: In females undergoing endonasal surgery under propofol-desflurane-remifentanil anaesthesia the incidence of PONV is about 40%. In this setting, both metoclopramide and dimenhydrinate were ineffective to reduce the incidence and the severity of PONV. The combination of both drugs revealed no additional synergistic effect.

Adult↗
PubMed2002

[Prophylaxis of Postoperative Nausea and Vomiting FollowingGynaecological Laparoscopy].

OBJECTIVE: Compared to other procedures, gynaecological laparoscopies are followed rather frequently by postoperative nausea and vomiting (PONV). Therefore, we investigated the prophylactic antiemetic efficacy of metoclopramide and droperidol under general anaesthesia with isoflurane (part 1). Given the rather unsatisfying results of this monoprophylaxis we examined the effects of a quintuple prophylaxis in this setting (part 2). METHODS: Part 1: Following ethical committee approval and written informed consent 120 patients scheduled for elective gynaecological laparoscopy were allocated prospectively, randomly and observer-blinded to the following groups: group P (placebo): 2 ml NaCl 0.9 %, group D: 2.5 mg droperidol, group M: 10 mg metoclopramide. Part 2: Subsequently 50 patients scheduled for elective gynaecological laparoscopy and bearing a minimum risk of 25 % to experience postoperative vomiting were allocated prospectively and blinded to the observers to a quintuple prophylaxis group: group X: 10 mg metoclopramide, 2.5 mg droperidol, 12.5 mg dolasetron, 62.5 mg dimenhydrinate, 8mg dexamethasone. Part 1 and 2: Anaesthesia was induced with fentanyl, etomidate and succinycholine and maintained with isoflurane/N2O, fentanyl and cisatracurium. The antiemetics were applied intravenously 20 min prior to end of surgery. RESULTS: Within the first 24 h postoperatively vomiting occurred more frequently in group P (44 %) compared to group D (21 %, p = 0.046) and group M (33 %, n. s.). Nausea also occurred more frequently in group P (61 %) compared to group D (24 %, p = 0.003) and group M (48 %, n. s.). Intensity of nausea was reduced both in group D and group M compared to group P (p = 0.03). Likewise the requirements for antiemetics as a rescue medication were reduced in group D (p = 0.02) and group M (p = 0.047) compared to group P. In group X no patient suffered from postoperative vomiting, no patient required a rescue antiemetic. CONCLUSIONS: Whereas droperidol provides a reliable antiemetic effect, the prophylactic effect of metoclopramide is rather uncertain. Therefore, further studies regarding a dose response-relationship for metoclopramide are deemed necessary. Since a monoprophylaxis with droperidol or metoclopramide failed to attain a satisfying PONV-prophylaxis in patients at high risk for PONV, the quintuple antiemetic combination might be an effective and safe solution.

Adolescent↗