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PubMed2004

Comparison of surgical site and patient's history with a simplified risk score for the prediction of postoperative nausea and vomiting.

Although site of surgery and previous occurrence of postoperative nausea and vomiting are often used to decide whether prophylactic anti-emetic drugs are indicated, the value of these predictors is unclear. We compared these two risk factors against a simplified four-factor risk score. We analysed data from 1566 adult inpatients who received balanced anaesthesia without prophylactic anti-emetics. Sensitivity, specificity, predictive value and area under the receiver operating characteristic curve were used to quantify predictive properties. Nausea and vomiting occurred in 600 (38.3%) patients within 24 h. Sensitivity and specificity were, respectively, 47% and 59% for surgical site; 47% and 70% for history of postoperative nausea and vomiting; and 58% and 70% for risk score with three or more factors. The area under the curve for surgical site was 0.53 (95% CI 0.50-0.56); that for patient's history was 0.58 (95% CI 0.56-0.61) while for risk score it was 0.68 (95% CI 0.66-0.71; P < 0.001). Prediction using surgical site or patient's history alone was poor while the simplified risk score provided clinically useful sensitivity and specificity.

Adult↗

PubMed2005

Assessing the applicability of scoring systems for predicting postoperative nausea and vomiting.

We have validated two scoring systems for predicting postoperative nausea and vomiting, derived by Apfel et al. and Koivuranta et al. from 1388 adult inpatients undergoing a wide range of surgical procedures. The predictive accuracy of the scoring systems was evaluated in terms of the ability to discriminate between patients with and without postoperative nausea and vomiting (discrimination) and agreement between observed and predicted outcomes (calibration). Discrimination and calibration were less than expected based on previous reports, with both scoring systems providing risk predictions that were too extreme. The area under the ROC curve was 0.63 for Apfel et al.'s scoring system and 0.66 for Koivuranta et al.'s scoring system. Neither of the scoring systems provided a risk threshold for administering anti-emetic prophylaxis that yielded satisfying results in terms of predictive values, sensitivity and specificity. Hence, in their original forms, the scoring systems do not guarantee accurate prediction of the risk of postoperative nausea and vomiting in other patient populations. Koivuranta et al.'s scoring system appears to be more robust across different populations.

Antiemetics↗

PubMed2005

Evaluation of capsaicin ointment at the Korean hand acupressure point K-D2 for prevention of postoperative nausea and vomiting.

The K-D2 point is the Korean hand acupressure point in Koryo Hand Therapy for prevention of postoperative nausea and vomiting. We evaluated the efficacy of capsaicin ointment at the K-D2 point in 186 patients undergoing laparoscopic cholecystectomy in a randomised, prospective, double-blind and placebo-controlled study. Patients were randomised to have either placebo ointment or capsaicin ointment applied to the K-D2 point of both hands 1 h before surgery under standardised anaesthesia. The ointment was removed 8 h later. Postoperative nausea and vomiting was evaluated 6 and 24 h following surgery. The incidence of postoperative nausea and vomiting was lower in the capsaicin group, with an absolute risk reduction (ARR) of 21%, a relative risk reduction (RRR) of 50% and a number-needed-to-treat (NNT) of 5 at 0-6 h (p = 0.001), and an ARR of 11%, a RRR of 85% and a NNT of 9 at 6-24 h (p = 0.003). The need for rescue anti-emetic treatment was also lower at 0-6 h (3 (3%) vs 11 (12%); p = 0.04) and at 6-24 h (5 (5%) vs 0; p = 0.02).

Acupuncture Points↗

PubMed2006

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy.

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.

Adenoidectomy↗

PubMed2006

Does the efficacy of supplemental oxygen for the prevention of postoperative nausea and vomiting depend on the measured outcome, observational period or site of surgery?

High intra-operative oxygen concentration reportedly reduces postoperative nausea and vomiting (PONV), but recent data are conflicting. Therefore, we tested whether the effectiveness of supplemental oxygen depends on the endpoint (nausea vs. vomiting), observation interval (early vs. late) or surgical field (abdominal vs. non-abdominal). We randomly assigned 560 adult patients undergoing various elective procedures with a PONV risk of at least 40% to intra-operative 80% (supplemental) or 30% oxygen (control). Potential confounding factors were similar between groups. Incidences of nausea were similar in the groups during early (12% (supplemental) vs. 10% (control), p = 0.43) and late intervals, 26%vs. 20%, p = 0.09, as were the incidences of vomiting (early: 2%vs. 3%, p = 0.40; late: 8%vs. 9%, p = 0.75). Supplemental oxygen was no more effective at reducing PONV in abdominal (40%vs. 31%, p = 0.37) than in non-abdominal surgery (25%vs. 21%, p = 0.368). Thus, supplemental oxygen was unable to reduce PONV independent of the endpoint, observational period or site of surgery.

Abdomen↗

PubMed2006

A comparison of cyclizine and granisetron alone and in combination for the prevention of postoperative nausea and vomiting.

We conducted a randomised double-blinded study of 960 women undergoing day-case surgery to determine whether combination anti-emetic therapy of granisetron and cyclizine was more effective at decreasing the incidence of postoperative nausea and vomiting than these agents used alone. The women were randomly allocated to three groups to receive intravenous granisetron 1 mg, cyclizine 50 mg or both before induction of general anaesthesia. The incidence of postoperative nausea and vomiting was 77/322 (24%) in the granisetron group, 73/316 (23%) in the cyclizine group and 53/322 (17%) in those women given both drugs (p = 0.04). There was no difference in the requirement for rescue anti-emetic drugs. There were no differences in the anaesthetic techniques used in the three groups. We conclude that the risk of postoperative nausea and vomiting is less with cyclizine and granisetron given together than with either given alone.

Adult↗

PubMed2004

Chemotherapy-related nausea and vomiting - past reflections, present practice and future management.

Although much progress has occurred in the last decade regarding the management of chemotherapy-induced nausea and vomiting, these remain among the most intolerable side-effects of treatment and patients continue to report the negative impact such symptoms have on their ability to enjoy life. Inadequate control of nausea and vomiting reduces patients' quality of life and functional status and jeopardizes the delivery of optimal treatment, so making its management a priority for oncology health care workers. This article will reflect on past and present evidence regarding the management of chemotherapy-induced nausea and vomiting while highlighting some of the most recent scientific advances before drawing conclusions about the future management of this troublesome symptom for patients receiving chemotherapy.

Aged↗

PubMed2005

Clinical usefulness of oral granisetron hydrochloride for alleviation of delayed nausea and vomiting induced by CPT-11.

This open label pilot study evaluated the safety and efficacy of the oral 5-HT3 receptor antagonist granisetron for prophylaxis of delayed chemotherapy-induced nausea and vomiting (CINV) in 30 patients with advanced or recurrent colorectal cancer. Patients were studied during two cycles of a 5-week regimen with irinotecan (CPT-11) and UFT. Patients received prophylactic anti-emetic therapy that included intravenous granisetron. If Grade 1 or higher severity gastrointestinal symptoms occurred during 6 days after CPT-11 administration in Cycle 1, then oral granisetron was administered daily for the following 5 days of CPT-11 in Cycle 2. Sixteen patients (53.3%) experienced delayed CINV in Cycle 1. The incidence of Grade 2 or higher vomiting was 32.1% and 27.7% in Cycles 1 and 2 in males (P = 0.554) respectively, and 54.6% and 32.4% in females (P = 0.001) respectively. Granisetron is effective against delayed Grade 2 or higher vomiting induced by CPT-11/UFT in female patients, although granisetron alone may not sufficiently control nausea induced by this regimen.

Administration, Oral↗

PubMed1991

Theories of self-care: their relevance to chemotherapy-induced nausea and vomiting.

Nausea and vomiting are reputed to be two of the most disruptive side-effects associated with chemotherapy. Pharmacological and behavioural interventions are well described in the literature, but sparse attention appears to have been focused upon the role of self-care. This paper outlines the problem of chemotherapy-induced nausea and vomiting. The concept of self-care is described, including possible motivations to perform self-care, and potential relationships between symptom perception and self-care are noted. It concludes with suggestions for theoretical work and future research studies concerning self-care behaviour for nausea and vomiting induced by chemotherapy.

Antineoplastic Agents↗

PubMed2004

Evaluation of the Rhodes Index of Nausea and Vomiting for ambulatory surgery patients.

BACKGROUND: The Index of Nausea and Vomiting (INV), developed by Rhodes and others in 1984, measures three dimensions of upper gastrointestinal distress: nausea, vomiting and retching (NVR). While the revised version has been tested with a variety of high-risk populations, there are no data suggesting that it can be used to assess upper gastrointestinal distress among the growing numbers of ambulatory or day surgery patients. AIM: The aim of this study was to evaluate a modified version of the INV for use with ambulatory surgery patients. METHODS: A secondary analysis was conducted using data obtained from a descriptive study designed to identify risk factors for postdischarge nausea and vomiting (PDNV) among adult ambulatory surgery patients. Patients who reported PDNV (n = 190) participated via phone interview 24 hours after discharge by completing a modified Rhodes INV. FINDINGS: Reliability analysis (alpha = 0.897) indicated that the modified Rhodes INV measured upper gastrointestinal distress as a single concept in the postdischarge ambulatory surgical sample. One item of the 8-item scale was dropped. Principal component analysis extracted one factor that accounted for 67% of the variance with all items loading. CONCLUSIONS: Upper gastrointestinal distress following ambulatory surgery discharge comprises a different symptom mix than during other high-risk events such as pregnancy or chemotherapy. Further research on the differences in assessing NVR among different populations is indicated.

Adolescent↗

PubMed1993

Comparison of P6 acupoint injection with 50% glucose in water and intravenous droperidol for prevention of vomiting after gynecological laparoscopy.

Postoperative vomiting causes patients distress and delays discharge after outpatient surgery. Although P6 electroacupuncture is recognized as having an antiemetic effect, its inconvenient instrumentation may limit its clinical applicability. The purpose of this study was to explore a simple and effective alternative method for control of postoperative vomiting in outpatient surgery. We prospectively compared the effect of P6 acupoint injection with 0.2 ml 50% glucose in water (G/W) and intravenous injection of 20 micrograms/kg droperidol for prevention of vomiting in 120 consecutive outpatients undergoing gynecological laparoscopy with general anesthesia. Patients were randomly allocated to receive P6 acupoint injection, i.v. droperidol, or nothing as control group. Both P6 acupoint injection and i.v. droperidol 20 micrograms/kg were found to have a significant antiemetic effect when compared with the control group. We conclude that P6 acupoint injection with 50% G/W is a simple and effective method for reducing the incidence of postoperative emesis in outpatient surgery.

Acupuncture Points↗

PubMed1996

Effect of P-6 acupressure on prevention of nausea and vomiting after epidural morphine for post-cesarean section pain relief.

BACKGROUND: Nausea and vomiting are important side effects following administration of epidural morphine for post-Cesarean section pain relief. Stimulation of the P-6 (Neiguan) acupoint is a traditional Chinese acupuncture modality used for antiemetic purpose; it has been found to be effective. The aim of this study was to evaluate the antiemetic effect of P-6 acupressure in parturients given epidural morphine for post-Cesarean section pain relief. METHOD: In a randomized, double-blind and controlled trial, sixty parturients receiving epidural morphine for post-Cesarean section pain relief were investigated. Parturients were allocated to receive the acupressure bands or placebo bands on the P-6 acupoint bilaterally before the administration of spinal anesthesia and were observed over a 48-hour study period. RESULTS: The incidence of nausea and vomiting was significantly decreased from 43% and 27% in the control group, to 3% and 0% in the acupressure group, respectively (P < 0.05). CONCLUSION: The results demonstrate that prophylactic use of acupressure bands bilaterally on the P-6 acupoint can significantly reduce incidence of nausea and vomiting after epidural morphine for post-Cesarean section pain relief.

Acupressure↗

PubMed1998

Comparison of subhypnotic doses of thiopentone vs propofol on the incidence of postoperative nausea and vomiting following middle ear surgery.

BACKGROUND: Middle ear surgery is associated with a high incidence of emetic sequelae and propofol has been reported to have antiemetic activity in subhypnotic doses. METHODS: In a double-blind, randomized study, the patients received either thiopentone 1.0 mg.kg-1 (n = 26) or 0.5 mg.kg-1 propofol (n = 26) at the end of middle ear surgery under isoflurane-N2O-fentanyl-vecuronium anaesthesia. Trained nurses, unaware of the group assignment, assessed postoperative nausea, retching and vomiting up to 24 h after the end of anaesthesia. Droperidol 10 micrograms.kg-1 was used as a "rescue" antiemetic. RESULTS: The main result was that the patient in the propofol group did not suffer from retching and vomiting (R&V) during the first 6 h, whereas these symptoms occurred in 46% (P < 0.001) of the patients in the thiopentone group. The patients in the propofol group needed significantly less droperidol during the first 24 h (mean number of doses 0.39 +/- 0.57 (SD)) than the patients in the thiopentone group (1.35 +/- 1.47, P < 0.005). Treatment with propofol was a predictor for lowered incidence of R&V, as well as male gender and negative history of motion sickness. CONCLUSION: Propofol at a subhypnotic dose of 0.5 mg.kg-1 provides prophylaxis against retching and vomiting for the first 6 h postoperatively after middle ear surgery. The incidence of nausea was not reduced by propofol.

Adult↗

PubMed1998

The discriminating power of a risk score for postoperative vomiting in adults undergoing various types of surgery.

BACKGROUND: Recently, we have demonstrated that the probability of postoperative vomiting (PV) following ENT surgery with inhalational anaesthetics can be predicted using a risk score. This score is based on gender, age, smoking status, history of motion sickness or postoperative nausea and vomiting and the duration of anaesthesia. Therefore, it is of interest whether this score is also accurate in predicting PV in patients undergoing different types of surgery. METHODS: Inpatients scheduled for bone, vascular, general or eye surgery were included in a prospective survey for PV over 24 h. Data of 1091 patients were analyzed, of which 542 were used for the validation of the previously constructed risk score (Score I). The data of the remaining 549 patients were used to evaluate the risk factors that contribute to PV in this setting and to develop a new score (Score II). The discriminating power of both scores to predict PV was tested in the validation set (n=542) and compared by calculating the area under the receiver operating characteristic (ROC) curves. RESULTS: The area under the ROC curve of Score I was 0.77 (SD 0.024). Risk factors for PV in the evaluation set were female gender, young age, history of motion sickness or postoperative nausea and vomiting and the type of surgery. The area under the curve of Score II was 0.75 (SD 0.026) and was not significantly different from Score I (P=0.57). CONCLUSION: Score I was accurate in predicting PV in patients after most types of surgery with volatile anaesthetics, which suggests that this score might be useful for other centres as well.

Adult↗

PubMed2005

Less postoperative nausea and vomiting after propofol + remifentanil versus propofol + fentanyl anaesthesia during plastic surgery.

BACKGROUND: The effect of different opioids on postoperative nausea and vomiting (PONV) has not been conclusively determined yet, thus the aim of this study was to compare the incidence of PONV in propofol-anaesthetized patients receiving either fentanyl or remifentanil as opioid supplement. METHODS: Sixty ASA physical status I and II patients scheduled for plastic surgery gave their written informed consent for this prospective, randomized, double-blind study. Anaesthesia was induced with propofol, rocuronium and fentanyl (n = 30; 2 microg kg(-1)) or remifentanil (n = 30; 1 microg kg(-1)). After tracheal intubation, anaesthesia was maintained with propofol, oxygen in air and an infusion of the opioid studied, which was modified according to clinical criteria. Baseline postoperative analgesia was achieved with intravenous propacetamol + metamizol. Intravenous morphine was given if visual analogic scale (VAS) for pain was > or = 4 (scale 0-10) and metoclopramide was administered if a patient presented > or = 2 PONV episodes (nausea or vomiting) in less than 30 min. Postoperatively (2, 12 and 24 h), we registered VAS, rescue morphine consumption, number of patients with episodes of PONV and number of patients requiring metoclopramide. P < 0.05 was considered significant. RESULTS: There were no significant differences between groups in the demographic parameters, ASA physical status, propofol dose, VAS, and rescue morphine requirements. Fourteen patients in the fentanyl group and four in the remifentanil group presented PONV episodes 2-12 h postoperative hours' interval; (P < 0.05). Ten patients in the fentanyl group and four in the remifentanil group presented vomiting episodes in the same period (P < 0.05); and eight patients in the fentanyl group and one in the remifentanil group required metoclopramide; (P < 0.05). The number of postoperative PONV episodes were low, both in the 0-2-h period (n = 2 vs. n = 1, fentanyl and remifentanil, respectively) and in the 12-24-h period (n = 3 vs. n = 1). CONCLUSION: Propofol + fentanyl anaesthesia resulted in a higher incidence of PONV and requirements of antiemetic drugs in the period between 2 and 12 postoperative hours compared with propofol + remifentanil, in patients undergoing plastic surgery.

Adolescent↗

PubMed2006

Supplemental 80% oxygen does not attenuate post-operative nausea and vomiting after breast surgery.

BACKGROUND: Although supplemental oxygen has been shown to be as effective as ondansetron in the prevention of post-operative nausea and vomiting (PONV) in one study in abdominal surgery patients, the antiemetic efficacy of supplemental oxygen is controversial on the basis of studies with other patients. We compared the efficacy of 80% and 30% oxygen in decreasing PONV in breast surgery. Ondansetron was used as an active control. METHODS: Ninety patients were given a standardized sevoflurane anesthetic. They were randomly assigned to three groups: 30% oxygen in nitrogen and saline 2 ml intravenously (i.v.) at the end of surgery (group 30); 80% oxygen in nitrogen and saline 2 ml (group 80); and 30% oxygen in nitrogen and ondansetron 4 mg (group O). Oxygen was administered during surgery and up to 2 h after surgery. RESULTS: The incidence of total response (no retching or vomiting, no nausea) during the first 24 post-operative hours was not different between group 80 (17%) and group 30 (11%) but was higher in group O (43%) than in group 30 (P<0.05). Compared with group O, patients in group 80 experienced more vomiting during the study period 0-24 h (66% vs. 32%; P<0.05) and more nausea during the period 6-24 h (72% vs. 39%; P<0.05). There was no difference between the groups in their risk for PONV, pain scores, opioid consumption, or patient satisfaction. CONCLUSIONS: In this study, supplemental 80% oxygen administration failed to decrease PONV in breast surgery.

Adolescent↗

PubMed1995

Cyclical vomiting syndrome.

Cyclical vomiting syndrome is an uncommon, disabling symptom complex of unknown cause, with features in common with migraine. It affects principally children and adolescents. Differential diagnosis and theories of pathogenesis are discussed. Therapy should be aimed at prophylaxis of vomiting bouts, 'switching off' episodes once they commence and preventing complications of established vomiting episodes. Families need rapid access to care to minimize morbidity and disruption to functioning.

Adolescent↗

PubMed1996

Posttonsillectomy vomiting. Ondansetron or metoclopramide during paediatric tonsillectomy: are two doses better than one?

This randomized, double blinded, placebo controlled, prospective study compared the anti-emetic efficacy of one preoperative dose of metoclopramide 0.25 mg.kg-1 intravenously or ondansetron 0.15 mg.kg-1 intravenously with two doses of the same drugs (second dose administered one h postoperatively) in 200 preadolescent children undergoing tonsillectomy with either isoflurane or propofol anaesthesia. The incidence of posttonsillectomy vomiting was significantly reduced (P < 0.005) by two doses of either metoclopramide or ondansetron (18% and 8%, respectively) compared with placebo (50%). No difference in posttonsillectomy vomiting exists between the children who received isoflurane and those who received a propofol infusion. Our results suggest that two doses of metoclopramide 0.25 mg.kg-1 intravenously, like two doses of ondansetron 0.15 mg.kg-1, are effective in reducing vomiting after tonsillectomy in children who have received either isoflurane or propofol anaesthesia.

Analysis of Variance↗