Cost-effectiveness of three combinations of antiemetics in the prevention of postoperative nausea and vomiting

Background. This study compares the cost-effectiveness of threecombinations of antiemetics in the prevention of postoperativenausea and vomiting (PONV). Methods. We conducted a prospective, double-blind study. NinetyASA I–II females, 18–65 yr, undergoing general anaesthesiafor major gynaecological surgery, with standardized postoperativeanalgesia (intrathecal 0.2 mg plus i.v. PCA morphine), wererandomly assigned to receive: ondansetron 4 mg plus droperidol1.25 mg after induction and droperidol 1.25 mg 12 h later (Group1); dexamethasone 8 mg plus droperidol 1.25 mg after inductionand droperidol 1.25 mg 12 h later (Group 2); ondansetron 4 mgplus dexamethasone 8 mg after induction and placebo 12 h later(Group 3). A decision analysis tree was used to divide eachgroup into nine mutually exclusive subgroups, depending on theincidence of PONV, need for rescue therapy, side effects andtheir treatment. Direct cost and probabilities were calculatedfor each subgroup, then a cost-effectiveness analysis was conductedfrom the hospital point of view. Results. Groups 1 and 3 were more effective (80 and 70%) thanGroup 2 (40%, P=0.004) in preventing PONV but also more expensive.Compared with Group 2, the incremental cost per extra patientwithout PONV was €6.99 (95% CI, –1.26 to 36.57) forGroup 1 and €13.55 (95% CI, 0.89–132.90) for Group3. Conclusion. Ondansetron+droperidol is cheaper and at least aseffective as ondansetron+ dexamethasone, and it is more effectivethan dexamethasone+droperidol with a reasonable extra cost. Br J Anaesth 2003; 91: 589–92     

Dexamethasone is a cost-effective alternative to ondansetron in preventing PONV after paediatric strabismus repair

This study evaluated the antiemetic efficacy, cost-effectivenessand clinical utility of prophylactic ondansetron and dexamethasonecompared with placebo in the prevention of postoperative nauseaand vomiting (PONV) in 135 children (2–15 yr, ASA I–II)undergoing strabismus repair. After induction with halothaneand nitrous oxide in oxygen or i.v. thiopental, the childrenreceived i.v. dexamethasone 1 mg kg^–1 to a maximumof 25 mg, ondansetron 100 µg kg^–1to a maximum of 4 mg or placebo (n=45). Episodes of PONVwere recorded for the first 24 h after the operation. Trueoutcome measures (parental satisfaction score, duration of stayin the postanaesthesia care unit and fast tracking time), therapeuticoutcome measures (number needed to prevent (NNTP) PONV) andthe cost to benefit a child with each drug were analysed. Theincidence and severity of PONV in the first 24 h were significantlyless in the dexamethasone and ondansetron groups than in theplacebo group (P<0.05). The incidence (P=0.04) and severity(P=0.03) of PONV at the 6–24 h epoch were significantlyless in the dexamethasone group than in the ondansetron group.Recovery time (P=0.07), fast tracking time (P=0.6), parentalsatisfaction scores (P=0.08) and NNTP PONV were comparable (NNTP=2)in both the ondansetron and the dexamethasone group. The costto benefit a child with dexamethasone was approximately 22 timesless than that of ondansetron. Br J Anaesth 2001; 86: 84–9     

Supplemental oxygen for prevention of nausea and vomiting after breast surgery

Background. Administration of supplemental oxygen 80% has beenshown to halve the incidence of postoperative nausea and vomiting(PONV). We tested the efficacy of supplemental oxygen 50% indecreasing the incidence of PONV after breast surgery. Methods. One hundred patients receiving standardized sevofluraneanaesthesia were randomly assigned to two groups: oxygen 30%administration (Group 30); and oxygen 50% administration (Group50). Oxygen was administered during surgery and for 2 hfrom the end of surgery. Results. The incidence of PONV over 24 h after surgeryshowed no difference between the groups: 82% in Group 30 and89% in Group 50. However, during the postoperative oxygen administration,eight patients vomited in Group 30, compared with none in Group50 (P<0.05). After oxygen therapy ceased, there was no differencein the incidence of vomiting between the groups. Nausea andneed for rescue antiemetics did not differ between the groups. Conclusion. The incidence of vomiting decreased during the shortpostoperative administration of supplemental oxygen 50%. However,perioperative oxygen 50% administration did not prevent PONVover the 24-h follow-up period in patients undergoing breastsurgery performed under general anaesthesia. Br J Anaesth 2003; 91: 284–7     

Inspired oxygen fraction of 0.8 compared with 0.4 does not further reduce postoperative nausea and vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy

Background. Postoperative nausea and vomiting (PONV) is oneof the most frequent complications after general anaesthesia.Single-dose antiemetic prophylaxis has limited efficacy in high-riskpatients. Adding a simple potential antiemetic approach, suchas increasing the inspired oxygen fraction, to the antiemeticportfolio would preserve pharmacological interventions for treatmentof symptoms in the postoperative period. However, the antiemeticeffect of a high inspired oxygen fraction is still discussedcontroversially. The aim of the study was to evaluate whetheran inspired oxygen fraction of 0.8 decreases PONV in patientsreceiving the 5-HT₃-antagonist dolasetron. Methods. In a randomized, placebo-controlled, double-blindedtrial we studied 377 patients (ASA I–III) undergoing electivelaparoscopic cholecystectomy. Induction of anaesthesia was standardized,including thiopental fentanyl and cis-atracurium. For all patientsthe individual risk for PONV was calculated using the Koivurantascore and all patients received 12.5 mg dolasetron i.v. beforesurgery. Patients were allocated randomly to one of three groups:Group A (n=125) received 80% oxygen in air, Group B (n=125)40% oxygen in air and Group C (n=127) 40% oxygen in nitrousoxide. Postoperative nausea, postoperative vomiting (PV), ornausea, vomiting, or both (PONV) was assessed in the early (0–4h) and overall postoperative period (0–24 h) by an anaesthesiologistunaware of patient allocation. Results. There was a significantly lower incidence of PONV andPV in Groups A (PONV: 11.2%; PV: 3.2%) and B (PONV: 10.4%; PV:3.2%) compared with Group C (PONV: 26.7%; PV: 13.3%), but therewere no significant differences between Groups A and B. Conclusions. An inspired oxygen fraction of 0.8 does not furtherdecrease PONV or vomiting in dolasetron-treated patients undergoinglaparoscopic cholecystectomy. The lower incidence of PONV inGroups A and B compared with Group C is most likely caused bythe omission of nitrous oxide.      

Nausea and vomiting after fast-track cardiac anaesthesia

Background. The aim of this study was to determine the prevalenceof postoperative nausea and vomiting (PONV) after fast-trackcardiac anaesthesia, risk factors for PONV and its influenceon the length of stay in the intensive care unit (ICU). Methods. A prospective study was performed in the cardiothoracicICU (CTICU) of a university hospital; 1221 consecutive patientsundergoing fast-track anaesthesia (FTCA) in cardiac surgerywere enrolled in the study. Severity of PONV was assessed immediatelyafter extubation and then every hour until discharge from theCTICU. Metoclopramide 10 mg i.v. was used as a first-line rescuemedication and ondansetron 4 mg i.v. as second-line rescue medicationfor PONV. Results. Nausea was reported in 240 (19.7%) patients, and vomitingin 53 (4.3%). A total of 269 (22%) patients were treated withmetoclopramide and 38 (3.1%) with metoclopramide and ondansetron.The latter was effective in all cases. Risk factors for PONVwere age less than 60 yr, female gender and previous historyof PONV. Discharge from the CTICU was delayed for a few hoursbecause of PONV in eight patients, all of whom were dischargedthe same day. Conclusions. The incidence of PONV is relatively low after FTCAand does not prolong ICU stay. Prophylactic administration ofanti-emetic drugs before FTCA is not necessary. Br J Anaesth 2003; 91: 214–17     

Prevention of postoperative nausea and vomiting after spinal morphine for Caesarean section: comparison of cyclizine,dexamethasone and placebo

Background. Low-dose intrathecal (spinal) morphine (0.1–0.2mg) for Caesarean section delivers excellent postoperative analgesiabut is associated with significant nausea and vomiting. We comparedthe antiemetic efficacy of cyclizine, dexamethasone, and placeboin this clinical setting. Methods. Ninety-nine women undergoing elective Caesarean sectionunder spinal anaesthesia were allocated randomly, in a double-blindstudy design, to receive either cyclizine 50 mg, dexamethasone8 mg, or placebo as a single-dose infusion in saline 0.9%, 100ml on completion of surgery. Spinal anaesthesia consisted of:hyperbaric bupivacaine 0.5%, 2.0 ml; fentanyl 10 µg; andspinal morphine 0.2 mg. The primary outcome measure was theincidence of nausea. Results. The incidence of nausea was significantly less in patientsreceiving cyclizine compared with dexamethasone and placebo(33 vs 60 and 67%, respectively, P<0.05). Severity of nauseaand number of vomiting episodes were also less at 3–6h in cyclizine patients. Overall satisfaction with postoperativecare at 24 h, expressed on a 100 mm visual analogue scale, wasgreater in cyclizine [78 (28)] than either dexamethasone [58(31), P=0.03] or placebo [51 (28), P=0.008]. Conclusion. We conclude that following spinal morphine 0.2 mgand fentanyl 10 µg analgesia for Caesarean section, cyclizine50 mg i.v. reduces the incidence of nausea compared with dexamethasone8 mg i.v. or placebo. It also lessens the severity of nauseaand vomiting, and increases maternal satisfaction in the earlypostoperative period. Br J Anaesth 2003; 90: 665–70     

Emetic effects of morphine and piritramide

Background. Successful management of postoperative pain requiresthat adequate analgesia is achieved without excessive adverseeffects. Opioid-induced nausea and vomiting is known to impairpatients’ satisfaction, but there are no studies providingsufficient power to test the hypothesis that the incidence ofopioid-induced nausea and vomiting differs between µ-opioidreceptor agonists. Thus, we tested the hypothesis that the incidenceof vomiting and nausea differs between morphine and piritramide. Methods. In a prospective, randomized, double-blind fashion,we administered either morphine (n=250) or piritramide (n=250)by patient-controlled analgesia (PCA) for postoperative painrelief. We used a bolus dose of 1.5 mg with a lockout time of10 min. Incidence and intensity (numerical rating scale) ofpostoperative nausea, vomiting, pain, patient satisfaction (score0–10), side-effects (score 0–3) and drug consumptionwere measured. Results. Mean drug consumption did not differ between the piritramideand morphine groups (30.8 (SD 22.4) mg day^–1 vs 28.4 (21.8)mg day^–1) during the first postoperative day and therewere no significant differences in the overall incidence ofnausea (30% vs 27%) and vomiting (19% vs 15%). Intensity ofnausea correlated inversely (P=0.01) with morphine consumptionbut not with piritramide consumption. Pain scores both at rest(2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9(2.3)) were slightly but significantly less with morphine. Conclusions. Opioid-induced emesis was observed in about one-thirdof the patients using morphine and piritramide for PCA and theincidence of vomiting was one-half of that. Potential differencesin the incidence of vomiting during PCA therapy between theseµ-opioid receptor agonists can be excluded. Br J Anaesth 2003; 91: 218–23     

Antiemetic and analgesic-sparing effects of diphenhydramine added to morphine intravenous patient-controlled analgesia

Background. This study was designed to examine the analgesicand dose-related antiemetic efficacy of diphenhydramine–morphinemixture for intravenous patient-controlled analgesia (PCA). Methods. Healthy women, undergoing abdominal total hysterectomywere recruited to this double-blinded randomized placebo-controlledstudy. Patients were randomly allocated to one of three groups(n=40 each). In group 1, patients received saline at inductionand morphine 1 mg ml^–1 alone for postoperative PCA. Patientsin groups 2 and 3 received diphenhydramine 30 mg i.v. at inductionand were given a 1.2:1 or a 4.8:1 ratio, respectively, of diphenhydramine–morphinemixture for postoperative PCA. Results. A total of 112 patients completed the study. The incidenceof postoperative nausea (31.6% vs 67.6%, P<0.01) and vomiting(15.8% vs 40.5%, <0.05) was significantly lower in group3 than in group 1. Furthermore, the incidence of severe nauseawas significantly lower in group 3 than in group1 (2.6% vs 24.3%,P<0.05). The rescue antiemetic requirements were also significantlyless in group 3 than in group 1 (5.3% vs 24.3%, P<0.05).However, there was no significant difference between group 2and group 1 in any of the comparisons. Pain intensity, 24-hmorphine consumption and diphenhydramine-related side-effects,such as sedation or dry mouth, did not differ among the threegroups. Conclusion. An initial bolus of diphenhydramine 30 mg at anaestheticinduction followed by postoperative PCA with a 4.8:1, but not1.2:1, diphenhydramine–morphine mixture provides an effectiveantiemetic efficacy without morphine-sparing effects.     

Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidectomy

Background. Supplemental intra-operative oxygen 80% halves theincidence of nausea and vomiting after open and laparoscopicabdominal surgery, perhaps by ameliorating intestinal ischaemiaassociated with abdominal surgery. It is unlikely that thyroidsurgery compromises intestinal perfusion. We therefore testedthe hypothesis that supplemental perioperative oxygen does notreduce the risk of postoperative nausea and vomiting (PONV)after thyroidectomy. Methods. One hundred and fifty patients undergoing thyroidectomywere given sevoflurane anaesthesia. After induction, patientswere randomly assigned to the following treatments: (i) 30%oxygen, (ii) 80% oxygen, or (iii) 30% oxygen with droperidol0.625 mg. Results. The overall incidence of nausea during the first 24 hafter surgery was 48% in the patients given oxygen 30%, 46%in those given oxygen 80%, and 22% in those given droperidol(P=0.004). There were no significant differences between theoxygen 30% and 80% groups in incidence or severity of PONV,the need for rescue antiemetics, or patient satisfaction. Droperidolsignificantly shortened the time to first meal. Conclusions. Supplemental oxygen was ineffective in preventingnausea and vomiting after thyroidectomy, but droperidol reducedthe incidence. Br J Anaesth 2003; 91: 857–61     

A comparison of three antiemetic combinations for the prevention of postoperative nausea and vomiting

In this study we compared the efficacy and safety of three antiemetic combinations in the prevention of postoperative nausea and vomiting (PONV). Ninety ASA status I-II women, aged 18-65 yr, undergoing general anesthesia for major gynecological surgery, were included in a prospective, randomized, double-blinded study. A standardized anesthetic technique and postoperative analgesia (intrathecal morphine plus IV patient-controlled analgesia (PCA) with morphine) were used in all patients. Patients were randomly assigned to receive ondansetron 4 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 1, n = 30), dexamethasone 8 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 2, n = 30), or ondansetron 4 mg plus dexamethasone 8 mg after the induction of anesthesia and placebo 12 h later (Group 3, n = 30). A complete response, defined as no PONV in 48 h, occurred in 80% of patients in Group 1, 70% in Group 3, and 40% in Group 2 (P = 0.004 versus Groups 1 and 3). The incidences of side effects and other variables that could modify the incidence of PONV were similar among groups. In conclusion, ondansetron, in combination with droperidol or dexamethasone, is more effective than dexamethasone in combination with droperidol in women undergoing general anesthesia for major gynecological surgery with intrathecal morphine plus IV PCA with morphine for postoperative analgesia. IMPLICATIONS: The combination of ondansetron plus dexamethasone or droperidol was significantly better than the combination of dexamethasone plus droperidol in the prophylaxis of postoperative nausea and vomiting in women undergoing general anesthesia for major gynecological surgery, with intrathecal and IV morphine (patient-controlled analgesia) for management of postoperative pain.     

What can be expected from risk scores for predicting postoperative nausea and vomiting?

Several risk scores have been developed to calculate the probabilityof postoperative nausea and vomiting (PONV). However, the powerto discriminate which individual will suffer from PONV is stilllimited. Thus, we wondered how the number of predictors in ascore affects the discriminating power and how the characteristicsof a population—which is needed to measure the power ofa score—may affect the results. For ethical reasons andto be independent from centre specific populations, we developeda computer model to simulate virtual populations. Four populationswere created according to number, frequency, and odds ratioof predictors. Population I: parameters were derived from apreviously published paper to verify whether calculated andreported values are in accordance. Population II: a gynaecologicalpopulation was created to investigate the impact of the studysetting. Populations III and IV: to meet ideal assumptions amodel with up to seven predictors with an odds ratio of 2 and3 was tested, respectively. The discriminating power of a riskscore was measured by the area under a receiver operating characteristiccurve (AUC) and an increase of more than 0.025 per predictorwas considered to be clinically relevant. The AUC of populationI was similar to those reported in clinical investigations (0.72).The study setting had a considerable impact on the discriminatingpower since the AUC decreased to 0.65 in a gynaecological setting.The AUC with the ‘idealized’ populations III andIV was at best in the range of 0.7–0.8. The inclusionof more than five predictors did not lead to a clinically relevantimprovement. The currently available simplified risk scores(with four or five predictors) are useful both as a method toestimate individual risk of PONV and as a method for comparinggroups of patients for antiemetic trials. They are also superiorto single predictor models which are just using the patients’history of PONV or female gender alone. However, our analysissuggests that the power to discriminate which individual willsuffer from PONV will remain imperfect, even when more predictorsare considered. Br J Anaesth 2001; 86: 822–7     

Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 ml kg(-1)

Background. I.V. fluid administration has been shown to reducepostoperative nausea and vomiting (PONV). The optimum dose isunknown. We tested the hypothesis that administration of i.v.crystalloid of 30 ml kg^–1 would reduce the incidence ofPONV compared with 10 ml kg^–1 of the same fluid. Methods. A total of 141 ASA I female patients undergoing electivegynaecological laparoscopy were randomized, in double-blindfashion, to receive either 10 ml kg^–1 (n=71; CSL-10 group)or 30 ml kg^–1 (n=70; CSL-30 group) of i.v. compound sodiumlactate (CSL). Results. In the first 48 h after anaesthesia, the incidenceof vomiting was lower in the CSL-30 group than in the CSL-10group (8.6% vs 25.7%, P=0.01). Anti-emetic use was less in theCSL-30 group at 0.5 h (2.9% vs 14.3%, P=0.04). The incidenceof severe nausea was significantly reduced in the treatmentgroup at awakening (2.9% vs 15.7%, P=0.02), 2 h (0.0% vs 8.6%,P=0.04) and cumulatively (5.7% vs 27.1%, P=0.001). The numbersneeded to treat to prevent vomiting, severe nausea and antiemeticuse in the first 48 h were 6, 5 and 6, respectively. Conclusion. I.V. administration of CSL 30 ml kg^–1 to healthywomen undergoing day-case gynaecological laparoscopy reducedthe incidence of vomiting, nausea and anti-emetic use when comparedwith CSL 10 ml kg^–1.     

Prospective randomized, double-blind comparative study of dexamethasone, ondansetron, and ondansetron plus dexamethasone as prophylactic antiemetic therapy in patients undergoing day-case gynaecological surgery

Dexamethasone alone and in combination with selective 5-hydroxytryptaminereceptor antagonists is of benefit in the prophylaxis of post-operativenausea and vomiting. In this study, the effectiveness of sucha combination in comparison to either drug alone is investigatedin day case gynaecological surgery. A total of 177 patientswere randomized to three treatment groups: dexamethasone 8 mg,ondansetron 4 mg, and dexamethasone 8 mg plus ondansetron 4mg. The only significant difference between groups was seenin the first 3 h when failure of prophylaxis was more frequentin patients who had received dexamethasone alone (P=0.0085;Fisher’s exact probability test). Confidence intervalanalysis indicates a modest treatment effect for the combinationand the decision whether to perform a larger study depends uponwhether such an effect is clinically relevant. Br J Anaesth 2001; 87: 588–92     

Dextromethorphan and intrathecal morphine for analgesia after Caesarean section under spinal anaesthesia

Background. Dextromethorphan is an N-methyl-D-aspartic acidantagonist which can attenuate acute pain with few side-effects.In this prospective, randomized, double-blind study of dextromethorphanand intrathecal morphine, we investigated postoperative pain,pruritus, nausea and vomiting in women undergoing Caesareansection under spinal anaesthesia. Methods. Women were allocated randomly to one of six groups,to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plusoral dextromethorphan 60 mg or placebo. Results. The addition of dextromethorphan did not reduce postoperativepain scores (P=0.83). Compared with women receiving intrathecalmorphine 0.05 mg, women receiving higher doses had a significantlyhigher incidence of nausea and vomiting [odds ratio for intrathecalmorphine 0.1 mg, 4.0 (95% confidence interval 1.2–14.1);for intrathecal morphine 0.2 mg, 7.9 (2.3–27.1)].Compared with women receiving intrathecal morphine 0.05 mg,women receiving higher doses also had a significantly higherincidence of pruritus [odds ratio for intrathecal morphine 0.1 mg,3.2 (95% confidence interval 1.3–8.2); for intrathecalmorphine 0.2 mg, 3.7 (1.4–9.5)]. Women receivingdextromethorphan had a lower incidence of nausea and vomiting[odds ratio 2.6 (1.1–6.3)]. Conclusions. Postoperative pain after Caesarean section underspinal anaesthesia was not reduced by the addition of oral dextromethorphanto a multimodal approach including intrathecal morphine. Br J Anaesth 2003; 90: 653–8     

Dexamethasone is as effective as ondansetron for the prevention of postoperative nausea and vomiting following breast surgery

INTRODUCTION: Postoperative nausea and vomiting remain a common problem following breast surgery. This study assesses whether dexamethasone is as effective as ondansetron in the control of postoperative nausea and vomiting (PONV). METHODS: Eighty ASA I-III patients undergoing breast surgery for carcinoma of the breast were included in the study. Following premedication with diazepam 5-10 mg, patients were induced with fentanyl 50 micro g and propofol 2-2.5 mg kg-1. A larynx mask was inserted and anesthesia maintained with sevoflurane in oxygen and nitrous oxide. Patients were then randomly divided into two groups: Group D (dexamethasone) was given 4 mg dexamethasone i.v. after induction and Group O (ondansetron) was given 4 mg ondansetron at the same time point. Postoperatively, nausea, vomiting and pain were recorded at 1-h intervals during 4 h, and thereafter every 4 h during 24 h. RESULTS: The incidence of PONV during 24 h was 37% and 33% in Group D and Group O, respectively (NS). No differences were found between the groups in the incidence of postoperative nausea, vomiting or pain at the different time intervals. No differences were found in the incidence of PONV in smokers vs. non-smokers. No side-effects of these drugs were observed. CONCLUSIONS: Ondansetron 4 mg or dexamethasone 4 mg are equally effective in the prevention of postoperative nausea and vomiting following breast surgery. Other factors being similar, the difference in cost between these drugs would favor the use of dexamethasone instead of ondansetron when monotherapy against PONV is used.     

Management of post-strabismus nausea and vomiting in children using ondansetron: a value-based comparison of outcomes

Background. This study evaluated the clinical efficacy and cost-effectivenessof prophylactic ondansetron versus early ondansetron treatmentin the management of postoperative nausea and vomiting (PONV)in children undergoing strabismus repair using clinically meaningfuloutcomes and value-based principles. Methods. One hundred and fifty children were randomly assignedto either prophylactic (P) or early symptomatic treatment only(T) group (n=75). Children in group P received ondansetron 100 µg kg^–1i.v. and those in group T received placebo at the end of theprocedure. After surgery, at the earliest sign of nausea orvomiting, children in both groups received ondansetron 100 µg kg^–1i.v. Besides the incidence of PONV, non-surrogate (fast trackingtime, duration of stay in the postanaesthesia care unit (PACU)and parental satisfaction scores), therapeutic (numbers neededto prevent and treat) and pharmacoeconomic (cost to benefita child and cost per PONV-free child) outcome measures wereevaluated. Results. The incidences of PONV in the immediate, early, lateand first 24-h periods were significantly less in group P (20,12, 19 and 35% respectively) than in group T (37, 29, 47 and72%, P<0.05). Time to achieve fast-track eligibility andduration of PACU stay were significantly shorter in group P(P<0.001). Children in group P had superior mean (SD) parentalsatisfaction scores (8.2 (1.8)) compared with those in groupT (6.8 (1.7), P<0.001). The number needed to prevent PONVwas 2 and the number needed to treat PONV was 9. The cost tobenefit a child was more than fourfold less and the cost perPONV-free child was 35% less in group P. Conclusions. Compared with early symptomatic treatment withondansetron, prophylactic ondansetron shortened fast-trackingtime and duration of PACU stay and improved parental satisfactionand therapeutic outcomes at a lower direct cost. Br J Anaesth 2002; 89: 473–8     

Randomized prospective study of the analgesic effect of nefopam after orthopaedic surgery

Background. Balanced postoperative analgesia combines non-narcoticdrugs and opioids. We organized a large study to evaluate nefopamanalgesia and tolerance in combination with morphine for patient-controlledanalgesia (PCA) after orthopaedic surgery. Methods. Two hundred and one patients scheduled to undergo hiparthroplasty were included in this multicentre (n=24), double-blind,randomized study comparing nefopam (20 mg every 4 h for 24 h)with placebo, the first dose being infused peroperatively. Theprimary outcome measure was the cumulative morphine dose receivedpostoperatively by PCA over 24 h. Secondary outcome measureswere the amount of morphine received as a loading dose in thepostanaesthesia care unit (PACU) and during the 24-h observationperiod, and pain assessments using a visual analogue scale (VAS)and a verbal pain scale (VPS), patient’s satisfactionwith analgesia and treatment tolerance. Results. The two groups were comparable with respect to theircharacteristics and preoperative pain assessment. PCA-administeredmorphine over 24 h was significantly less for the nefopam groupthan the control group (21.2 (15.3) and 27.3 (19.2) mg respectively;P=0.02). This morphine-sparing effect was greater (35.1%) forpatients with severe preoperative pain (VAS>30/100). Forthe entire study period (loading dose and PCA), morphine usewas less for the nefopam group (34.5 (19.6) vs 42.7 (23.6) mg;P=0.01). Pain VAS at PACU arrival and during the whole PACUperiod was significantly lower for the nefopam than for theplacebo group (P=0.002 and 0.04 respectively). Patient satisfactionwas similar for the nefopam and placebo groups. Conclusion. In combination with PCA morphine, nefopam givessignificant morphine-sparing with lower immediate postoperativepain scores without major side-effects. This analgesic effectseems to be particularly notable for patients with intense preoperativepain. Br J Anaesth 2003; 91: 836–41     

Patient preferences for immediate postoperative recovery

Background. Several attempts have been made to evaluate patients’concerns with respect to postoperative recovery. To identifyaspects of postoperative recovery relevant to patients, severalmethodological and statistical approaches have been used. Oneof the first to provide useful information was Fredrick Orkinwho used conjoint analysis. This methodology is usually performedby market researchers to learn about the relative importanceof product attributes. We used conjoint analysis in the presentstudy. Methods. A total of 220 patients undergoing preoperative anaestheticexamination before impending surgery under general anaesthesiawere asked to rate nine scenarios during immediate postoperativerecovery based on four factors (alertness, pain, postoperativenausea and vomiting (PONV), and extra costs) each with threelevels. Using conjoint analysis the relative impact of eachfactor on ranking the scenarios was assessed. Results. The relative importance of the four factors (as a percentageof the preference decision) was PONV (49%), pain (27%), alertness(13%), and additional costs (11%). Conclusion. Avoidance of PONV is a major concern for patientsbefore surgery. Br J Anaesth 2002; 89: 760–1     

Dolasetron prophylaxis reduces nausea and postanaesthesia recovery time after remifentanil infusion during monitored anaesthesia care for extracorporeal shock wave lithotripsy

Background. Remifentanil is used as an analgesic for differentprocedures performed during monitored anaesthesia care. Opioid-inducednausea and vomiting can be troublesome. Methods. This prospective, randomized, double-blind study wasperformed to evaluate the efficacy of prophylaxis with dolasetronin reducing the frequency of postoperative nausea and durationof discharge time. Forty urological patients, undergoing electiveambulatory extracorporeal shock wave lithotripsy (ESWL) receivedrandomly either dolasetron 12.5 mg i.v. (Group 1) or placebo(Group 2) 10 min before a patient-adapted continuous infusionof remifentanil 0.15–0.4 µg kg^–1 min^–1was administered. Frequency and intensity (VAS 0–100 mm)of nausea, retching, and vomiting were assessed by patientsand blinded investigators during and after the procedure. Results. Patient characteristics, baseline values, durationof ESWL, and total dose of remifentanil did not differ betweengroups. The frequency (Group 1/Group 2; 20/55%; P<0.05) andmean (SD) maximal intensity [15 (9)/45 (14) mm; P<0.05] ofnausea during 24 h was significantly reduced after dolasetronand discharge times in Group 1 were less than Group 2[22 (14)/45 (28) min; P<0.05]. Br J Anaesth 2003; 90: 194–8     

Patient well-being after general anaesthesia: a prospective, randomized, controlled multi-centre trial comparing intravenous and inhalation anaesthesia

Background. The aim of this study was to assess postoperativepatient well-being after total i.v. anaesthesia compared withinhalation anaesthesia by means of validated psychometric tests. Methods. With ethics committee approval, 305 patients undergoingminor elective gynaecologic or orthopaedic interventions wereassigned randomly to total i.v. anaesthesia using propofol orinhalation anaesthesia using sevoflurane. The primary outcomemeasurement was the actual mental state 90 min and 24 h afteranaesthesia assessed by a blinded observer using the AdjectiveMood Scale (AMS) and the State-Trait-Anxiety Inventory (STAI).Incidence of postoperative nausea and vomiting (PONV) and postoperativepain level were determined by Visual Analogue Scale (VAS) 90min and 24 h after anaesthesia (secondary outcome measurements).Patient satisfaction was evaluated using a VAS 24 h after anaesthesia. Results. The AMS and STAI scores were significantly better 90min after total i.v. anaesthesia compared with inhalation anaesthesia(P=0.02, P=0.05, respectively), but equal 24 h after both anaesthetictechniques (P=0.90, P=0.78, respectively); patient satisfactionwas comparable (P=0.26). Postoperative pain was comparable inboth groups 90 min and 24 h after anaesthesia (P=0.11, P=0.12,respectively). The incidence of postoperative nausea was reducedafter total i.v. compared with inhalation anaesthesia at 90min (7 vs 35%, P<0.001), and 24 h (33 vs 52%, P=0.001). Conclusion. Total i.v. anaesthesia improves early postoperativepatient well-being and reduces the incidence of PONV. Br J Anaesth 2003; 91: 631–7