Tropisetron or droperidol in the prevention of postoperative nausea and vomiting

BACKGROUND: Women undergoing laparoscopic cholecystectomy are susceptible to postoperative nausea and vomiting (PONV). This study was undertaken to evaluate the efficacy of tropisetron or droperidol for preventing PONV after laparoscopic cholecystectomy. METHODS: In a prospective, randomised, double-blind trial, 120 female patients received either tropisetron 5 mg or droperidol 1.25 mg intravenously at the beginning of surgery. A standard general anaesthetic technique and postoperative analgesia were used. Nausea, emetic episodes and the need for rescue medication were recorded for 24 h postoperatively. RESULTS: Nausea was experienced by 55% of the patients in the tropisetron group and by 62% in the droperidol group (ns). The incidence of emetic episodes was 20% and 52% (P=0.001) in the two groups, respectively. Rescue antiemetic medication was needed in 42% and 50% (ns) of the patients, respectively. Patients in the droperidol group were more drowsy in comparison with patients in the tropisetron group, mean sedation score being 6.7 vs 5.7, respectively (P=0.023). No difference in other side-effects was observed. CONCLUSION: Tropisetron, when compared with droperidol, had no better efficacy on the prevention of postoperative nausea but resulted in a significantly lower incidence of vomiting after laparoscopic cholecystectomy.     

Tropisetron zur Prophylaxe von postoperativem Erbrechen bei Kindern

BACKGROUND: Postoperative nausea and vomiting (PONV) after tonsillectomy is a common problem in children. Tropisetron is a new 5HT3 receptor antagonist and is successfully used in paediatric patients receiving cancer therapy. The aim of the study was to assess efficacy and safety of a single intravenous dose of tropisetron for prevention of PONV in paediatric patients at risk for postoperative vomiting. METHODS: In a randomised, double-blind, placebo-controlled trial, we studied 98 children aged 2-12 years undergoing tonsillectomy or adenotonsillectomy. Patients received placebo or tropisetron 0.1 mg (= 0.1 ml)/kg body weight immediately after induction of anesthesia. A standard general anesthetic technique (Sevoflurane/N2O/O2 without neuromuscular blockers or opioids) was used. Perioperative vital signs, grade of sedation and episodes of postoperative nausea and vomiting were recorded. RESULTS: No vomiting episodes occurred in 65.3% of the tropisetron treated patients compared to 34.7% of the placebo group (p = 0.0024). Only 10.2% of the tropisetron treated patients vomited more than 3 times compared to 22.4% of the control patients (p = 0.0004). The need for antiemetic rescue medication was significantly lower in the study group (10.4%) compared to 28.6% (p = 0.025). No significant adverse effects of the study medication were shown. CONCLUSION: A single intravenous prophylactic dose of tropisetron effectively reduces the incidence of PONV during the first 24 postoperative hours after tonsillectomy and/or adenoidectomy. Because of the low incidence of adverse effects, the prophylactic use of tropisetron seems to be safe and justified in paediatric surgical patients at high risk for postoperative vomiting.     

Difference in Risk Factors for Postoperative Nausea and Vomiting

Background: It is commonly stated that risk factors for postoperative nausea are the same as for vomiting. The authors designed a prospective study to identify and differentiate the risk factors for postoperative nausea and vomiting in various surgical populations in a clinical audit setting.

Methods: The study included 671 consecutive surgical inpatients, aged 15 yr or more, undergoing various procedures. The study focused on postoperative nausea visual analog scale scores every 4 h and vomiting episodes within 72 h. Both vomiting and retching were considered as emetic events. Patient-, anesthesia-, and surgery-related variables that were considered to have a possible effect on the proportion of patients experiencing postoperative nausea and/or vomiting were examined. The bivariate Dale model for binary correlated outcomes was used to identify selectively the potential risk factors of postoperative nausea and vomiting.

Results: Among the 671 patients in the study, 126 (19%) reported one or more episodes of nausea, and 66 patients (10%) suffered one or more emetic episodes during the studied period. There was a highly significant association between the two outcomes. Some risk factors were predictive of both nausea and vomiting (female gender, nonsmoking status, and general anesthesia). History of migraine and type of surgery were mainly responsible for nausea but not for vomiting. The predictive effect of risk factors was controlled for postoperative pain and analgesic drugs.     

Difference in risk factors for postoperative nausea and vomiting

BACKGROUND: It is commonly stated that risk factors for postoperative nausea are the same as for vomiting. The authors designed a prospective study to identify and differentiate the risk factors for postoperative nausea and vomiting in various surgical populations in a clinical audit setting. METHODS: The study included 671 consecutive surgical inpatients, aged 15 yr or more, undergoing various procedures. The study focused on postoperative nausea visual analog scale scores every 4 h and vomiting episodes within 72 h. Both vomiting and retching were considered as emetic events. Patient-, anesthesia-, and surgery-related variables that were considered to have a possible effect on the proportion of patients experiencing postoperative nausea and/or vomiting were examined. The bivariate Dale model for binary correlated outcomes was used to identify selectively the potential risk factors of postoperative nausea and vomiting. RESULTS: Among the 671 patients in the study, 126 (19%) reported one or more episodes of nausea, and 66 patients (10%) suffered one or more emetic episodes during the studied period. There was a highly significant association between the two outcomes. Some risk factors were predictive of both nausea and vomiting (female gender, nonsmoking status, and general anesthesia). History of migraine and type of surgery were mainly responsible for nausea but not for vomiting. The predictive effect of risk factors was controlled for postoperative pain and analgesic drugs. CONCLUSION: This study shows that differences exist in risk factors of postoperative nausea and vomiting. These could be explained by differences in the physiopathology of the two symptoms.     

Nausea and vomiting after laparoscopic gynecological surgery: a study of the incidence and the effects of tropisetron prophylaxis

The authors studied the incidence of postoperative nausea and vomiting (PONV) and the effect of prophylactic tropisetron, a 5-HT3 antagonist, during the first 24 h following elective gynecologic laparoscopic surgery. Thirty-two of 68 (47%) of the patients experienced nausea or vomiting some time during the observation period. Sixteen of the 32 PONV patients (50%) had their first emetic symptoms after discharge from the recovery room. We could see no difference in the frequency of PONV in the patients who were given prophylactic tropisetron 5 mg orally before anesthesia.     

Nausea and vomiting after laparoscopic gynecologic surgery: a study of the incidence and the effects of tropisetron prophylaxis

We have studied the incidence of postoperative nausea and vomiting (PONV) and the effect of prophylactic tropisetron, a 5-HT3 antagonist, during the first 24 hr after elective gynecologic laparoscopic surgery. Thirty-two of 68 patients (47%) experienced nausea or vomiting some time during the observation period. Sixteen of these patients (50%) had their first emetic symptoms after discharge from the recovery room. We could see no difference in the frequency of PONV in the patients who were given prophylactic tropisetron 5 mg orally before anesthesia.     

Small-dose dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy: a comparison of tropisetron with saline

Dexamethasone is an effective antiemetic drug, but the efficacy of small-dose dexamethasone 5 mg on the prophylaxis of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy has not been evaluated. We, therefore, evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on PONV in patients undergoing laparoscopic cholecystectomy. Tropisetron and saline served as controls. One-hundred-twenty patients scheduled for laparoscopic cholecystectomy were enrolled in a randomized, double-blinded, placebo-controlled study. At the induction of anesthesia, the Dexamethasone group received IV dexamethasone 5 mg, the Tropisetron group received IV tropisetron 2 mg, and the Placebo group received IV saline. We found that both dexamethasone and tropisetron significantly decreased the following variables: the total incidence of PONV (P < 0.01), more than four vomiting episodes (P < 0.05), and the proportions of patients requiring rescue antiemetics (P < 0.05). The differences between the Dexamethasone and Tropisetron groups were not significant. We conclude that prophylactic IV dexamethasone 5 mg significantly reduces the incidence of PONV in patients undergoing laparoscopic cholecystectomy. At this dose, dexamethasone is as effective as tropisetron 2 mg and is more effective than placebo. IMPLICATIONS: We evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy. Tropisetron (2 mg) and saline served as controls. We found that dexamethasone 5 mg (IV) significantly reduced the incidence of PONV in these patients, and, at this dose, dexamethasone was as effective as tropisetron and was more effective than placebo.     

Oral ondansetron,tropisetron or metoclopramide to prevent postoperative nausea and vomiting: a comparison in high-risk patients undergoing thyroid or parathyroid surgery

BACKGROUND: Oral antiemetic prophylaxis may be a practical alternative to intravenous administration. Intravenous ondansetron and tropisetron prevent postoperative nausea and vomiting (PONV) at least as efficiently as traditional antiemetics, droperidol and metoclopramide. We tested the hypothesis that the incidence of PONV after oral ondansetron or tropisetron prophylaxis is lower compared with metoclopramide among high-risk patients. METHODS: In a prospective, double-blind study we studied 179 high-risk patients who received either ondansetron 16 mg, tropisetron 5 mg, or metoclopramide 10 mg orally 1 h before the operation. A standard general anesthetic technique and postoperative analgesia were used. The incidence of PONV and the need for rescue antiemetic medication was recorded for 24 h. RESULTS: In the postanesthesia care unit, the incidence of PONV was lower after premedication with tropisetron compared with ondansetron and metoclopramide (15%, 32% and 39%, respectively). The incidence of PONV during 0-24 h was the same in each group (68%, 58% and 75% in the ondansetron, tropisetron and metoclopramide group, respectively), but the incidence of vomiting was significantly lower after ondansetron (34%) and tropisetron (22%) prophylaxis compared with metoclopramide (53%). The need for additional antiemetics was significantly lower after tropisetron prophylaxis compared with metoclopramide. Patient satisfaction was significantly higher after tropisetron than after metoclopramide. CONCLUSIONS: In the initial period, the incidence of PONV was lower after premedication with oral tropisetron than after ondansetron or metoclopramide. Considering the entire 24-h postoperative period, the incidence of PONV was the same after all three premedications, but the incidence of vomiting was lower after oral ondansetron and tropisetron than after metoclopramide.     

The prophylactic effect of tropisetron on epidural morphine-related nausea and vomiting: a comparison of dexamethasone with saline

Tropisetron is a 5-hydroxytryptamine subtype 3 receptor antagonist that is primarily used in the prevention of chemotherapy-induced nausea and vomiting. We evaluated the prophylactic effect of tropisetron on postoperative nausea and vomiting associated with epidural morphine. Dexamethasone and saline served as controls. One-hundred twenty women (n = 40 in each of three groups) undergoing abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blinded, and placebo-controlled study. At the end of surgery, Group 1 received IV tropisetron 5 mg, whereas Groups 2 and 3 received dexamethasone 5 mg and saline, respectively. We found that tropisetron did not significantly reduce the occurrence of nausea and vomiting associated with epidural morphine. Dexamethasone, however, reduced the total incidence of nausea and vomiting from 59% to 21% (P < 0.01) and the percentage of patients requiring rescue antiemetic from 38% to 13% (P < 0.05). We conclude that IV tropisetron 5 mg did not prevent the occurrence of postoperative nausea and vomiting associated with epidural morphine. IV dexamethasone 5 mg was effective for this purpose. IMPLICATIONS: We compared the prophylactic IV administration of tropisetron 5 mg to prevent postoperative nausea and vomiting (PONV) associated with epidural morphine with dexamethasone 5 mg and saline in women undergoing hysterectomy. We found that tropisetron 5 mg did not significantly reduce the occurrence of PONV associated with epidural morphine. Dexamethasone 5 mg was effective for this purpose.     

Comparison of the effectiveness of metoclopramide, ondansetron, and granisetron on the prevention of nausea and vomiting after laparoscopic cholecystectomy

BACKGROUND AND GOALS: A relatively high incidence of postoperative nausea and vomiting (PONV) occurs in patients undergoing a laparoscopic cholecystectomy. Prophylaxis of PONV is usually achieved with a single-dose antiemetic drug administered during the surgical procedure. The aim of the current study was to compare the antiemetic activity of different 5-hydroxytryptamine-3 receptor antagonists with that of metoclopramide. MATERIALS AND METHODS: In a randomised, double-blind study, 75 patients received the following: Group M, 10 mg metoclopramide; Group K, 40 mcg . kg(-1) granisetron; and Group Z, 15 mcg . kg(-1) ondansetron intravenously (IV) diluted in 20 cc 0.9% NaCl (n = 25 of each) i.v. immediately before the induction of anesthesia. The standard general anesthetic technique, which consisted of sevoflurane in air-oxygen and a fentanyl perfusion, was used. Nausea, vomiting, and safety assessments were performed continuously during the first 24 hours after anesthesia. RESULTS: There were no statistically significant differences for demographic data, American Society of Anesthesiology (ASA), operation duration, or anesthesia time among the three groups (P > 0.05). Evaluated nausea and vomiting scores in the first 3-hour period revealed that each of the drugs had a similar antiemetic effect (P > 0.05). Nausea and vomiting scores, evaluated between the 4-24 hours, also revealed that the group M scores were obviously higher than groups K and Z (P < 0.001). A comparison of incidences of dose administrations were statistically not significant among the groups (P > 0.05). CONCLUSIONS: Granisetron, when given prophylactically, resulted in a significantly lower incidence of PONV than metoclopramide and ondansetron, whereas metoclopramide was ineffective. Garnisetron may be an effective treatment in the proflaxy of PONV.     

Randomized,double-blinded comparison of tropisetron and placebo for prevention of postoperative nausea and vomiting after supratentorial craniotomy

This prospective, randomized, placebo-controlled, double-blinded study was designed to evaluate the efficacy of tropisetron in preventing postoperative nausea and vomiting after elective supratentorial craniotomy in adult patients. We studied 65 ASA physical status I-III patients aged 18 to 76 years who were undergoing elective craniotomy for resection of various supratentorial tumors. Patients were divided into two groups and received either 2 mg of tropisetron (group T) or saline placebo (group P) intravenously at the time of dural closure. A standard general anesthetic technique was used. Episodes of nausea and vomiting and the need for rescue antiemetic medication were recorded during 24 hours postoperatively. Demographic data, duration of surgery and anesthesia, and sedation scores were comparable in both groups. Nausea occurred in 30% of group T patients and in 46.7% of group P patients (P >.05). The incidence of emetic episodes was 26.7% and 56.7% in the two groups (P <.05). Rescue antiemetic medication was needed in 26.7% and 60% of the patients (P <.05). Administration of a single dose of tropisetron (2 mg intravenously) given at the time of dural closure was effective in reducing postoperative nausea and vomiting after elective craniotomy for supratentorial tumor resection in adult patients.     

Postoperative nausea and vomiting with special reference to risk factors and prevention in laparoscopic surgery

The current incidence, risk factors and prevention of postoperative nausea and vomiting (PONV) were prospectively evaluated in 1703 inpatients. The objectives of the study were: 1) to create a predictive model based on patient characteristics in order to enable the estimation of the risk for PONV, 2) to ascertain the antiemetic efficacy of prophylactic intravenous ondansetron in comparison with droperidol and placebo against PONV following laparoscopic surgery, and 3) to evaluate the antiemetic effectiveness of combining ondansetron with a low dose of droperidol in high-risk inpatients. The incidence of nausea and vomiting after common surgical procedures was high. In the recovery room, the overall incidence of nausea and vomiting was 18% and 5%, respectively, and over the whole 24-h observation period the respective figures were 52% and 25%. The most significant predictive factors associated with an increased risk for the symptoms were female sex, a previous history of postoperative nausea and vomiting, a history of motion sickness, a longer duration of surgery and non-smoking. Based on these five items, a risk score predicting nausea and vomiting was constructed with a moderately good discriminating power, as judged from the area under the receiver operating characteristic curve. Intravenous ondansetron 4 mg was ineffective in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy. A higher dose of prophylactic ondansetron 8 mg effectively reduced the incidence and alleviated the intensity of PONV in women scheduled to have laparoscopy for gynaecological and general surgical procedures, as compared with placebo. The antiemetic efficacy of prophylactic ondansetron 8 mg and droperidol 1.25 mg was similar as for overall nausea during the 24-h observation period, but ondansetron seemed to be slightly more efficacious in preventing vomiting. Both ondansetron and droperidol were well-tolerated with only minor side-effects. In a high-risk, female, inpatient laparoscopic population, with a mean estimated risk of 65% for PONV, prophylactically administered ondansetron 8 mg in combination with either a 0.75 mg or 1.25 mg dose of droperidol reduced the incidence of post-operative nausea to 35% and that of vomiting to 15% during the first 24 h after surgery. Of these drug combinations, the smaller dose of droperidol resulted in less postoperative sedation than the higher dose; both combinations being otherwise equally well-tolerated without serious adverse events. These results indicate that postoperative nausea and vomiting can, to some extent, be predicted by a few patient characteristics, and in laparoscopic surgery - which is associated with an increased risk for PONV - the incidence can be reduced with either a single dose of ondansetron or droperidol or a combination of these drugs.     

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.     

Prevention of nausea and vomiting following breast surgery

BACKGROUND: The purpose of this study was to determine the rate of nausea and vomiting in women following breast surgery (PONV) under general anesthesia (GA), before and after the introduction of a standardized prophylactic anti-emetic (AE) regimen. METHODS: We performed a retrospective review of eligible patients, between July 2001 and March 2003. Patients operated on before September 2002 had standard preoperative care (old cohort [OC]); patients operated on after September 2002 were treated prophylactically with oral dronabinol 5 mg and rectal prochlorperazine 25 mg (new cohort [NC]). Data were collected from hospital records regarding age, diagnosis, comorbid conditions, previous anesthesia history, anesthesia and operative details, episodes PONV, and use of AE. The rate and severity of PONV was calculated for both cohorts. RESULTS: Two hundred forty-two patients were studied: 127 patients in the OC and 115 patients in the NC. The median age was 56 years (range 32 to 65). The rate of nausea and vomiting were significantly better in the patients treated prophylactically with dronabinol and prochlorperazine (59% vs. 15%, P < .0001 and 29% vs. 3%, P < .0001). Twenty patients in the OC were given some prophylactic AE treatment and 12 (60%) of them required further treatment; only 12 of 109 patients (11%) in the NC required further AE treatment (P < .0001). CONCLUSION: PONV is a significant problem in breast surgical patients. Preoperative treatment with dronabinol and prochlorperazine significantly reduced the number and severity of episodes of PONV.     

Ondansetron prevents postoperative emesis in male outpatients

Study Objectives: To determine (1) the efficacy and safety of ondansetron in the prevention of postoperative nausea and vomiting (PONV) in male outpatients; (2) prognostic factors for PONV in male outpatients; and (3) patients' perceptions of the debilitating effects of PONV in the ambulatory surgery setting.Design: Prospective, randomized, stratified, double-blind study.Setting: Multicenter—24 medical centers.Patients: 468 ASA physical status I and II males at least 12 years of age scheduled for general anesthesia.Interventions: All patients received intravenous ondansetron 4 mg or placebo prior to undergoing general balanced (opioid) anesthesia.Measurements and Main Results: In the postanesthesia care unit (PACU), the number of emetic episodes, vital signs, adverse events, and nausea assessments were recorded by a blinded observer. After discharge, and until the end of the 24-hour study period, patients completed a diary that collected emetic episodes, adverse events, nausea, and pharmacoeconomic data. There were no differences in patient demographics or safety profiles between groups. The number of patients with no emesis and no nausea during the 24-hour study period was significantly greater (p < 0.05) with ondansetron 4 mg compared with placebo. Prognostic factors for an increased likelihood of developing PONV in males included a history of motion sickness or previous PONV, patients undergoing nonorthopedic procedures, and surgeries lasting longer than one hour. Finally, 38 % of patients experiencing PONV perceived PONV to be as, or more debilitating than, the aftereffects of surgery itself.Conclusions: Ondansetron 4 mg was more effective than placebo in preventing PONV in male outpatients. Males at potential risk for developing PONV include: (1) those with a history of motion sickness and/or PONV; (2) patients undergoing nonorthopedic procedures; and (3) procedures lasting longer than one hour. Such patients may benefit from receipt of a prophylactic antiemetic. Postoperative nausea and vomiting has a debilitating effect that can be differentiated by patients from the effects of surgery itself.     

How much are patients willing to pay to avoid postoperative nausea and vomiting?

Postoperative nausea and vomiting (PONV) are unpleasant experiences. However, there is no drug that is completely effective in preventing PONV. Whereas cost effectiveness analyses rely on specific health outcomes (e.g., years of life saved), cost-benefit analyses assess the cost and benefit of medical therapy in terms of dollars. We hypothesized that patients were willing to pay for a hypothetical new drug that would eliminate PONV. Eighty elective day surgical patients using general anesthesia participated in the study. After their recovery in the postanesthetic care unit, they were asked to complete an interactive computer questionnaire on demographics, the value of avoiding PONV, and their willingness to pay for an antiemetic. Patients were willing to pay US$56 (US$26--US$97; median, 25%--75%) for an antiemetic that would completely prevent PONV. Patients who developed nausea (n = 21; 26%) and vomiting (n = 9; 11%) were willing to pay US$73 (US$44--US$110) and $100 (US$61--US$200; median, 25%--75%), respectively (P < 0.05). Seventy-six percent of patients considered avoiding postoperative nausea and 78% of patients considered avoiding vomiting as important (> or = 50 mm on a 0--100-mm visual analog scale). Nausea or vomiting in the postanesthetic care unit, greater patient income, previous history of PONV, more importance placed on avoiding nausea and vomiting, increasing age, and being married are independent covariates that increase the willingness to pay estimates. Patients associated a value with the avoidance of PONV and were willing to pay between US$56 and US$100 for a completely effective antiemetic.     

A prospective study of incidence of postoperative nausea and vomiting in a tertiary care hospital in Oman

INTRODUCTION: This is a pilot study conducted in a tertiary referral center in Oman, to assess the incidence of postoperative nausea and vomiting (PONV) so that an institutional policy towards its alleviation could be evolved. METHODS AND MATERIALS: This is a prospective study of 491 patients undergoing obstetric and gynecological, general surgical, pediatric and urological surgical procedures that received general anesthesia, regional anesthesia or a combination of both. Data regarding the incidence of PONV was collected and was documented in a standardized questionnaire based on the patient history, anesthetic protocol, a postoperative interview of the patient and a review of the nursing records. RESULT: The over all incidence of PONV in our institution was 19.6%. The occurrence of vomiting compared to nausea or retching was high (p < 0.01). PONV was less in urological cases (p < 0.05) compared to general surgical cases. The incidence of PONV was similar (p > 0.05) in both groups, whether the patients received anti emetics along with pre-medication or not. PONV occurrence was significant in the first 6 hrs postoperatively (p < 0.01). In those patients who received propofol the prevalence of PONV was significantly less (p < 0.01). CONCLUSIONS: There should be a reassessment of the existing anti emetics in the institution. Propofol was found to be a good anti emetic.     

Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) are frequent and unpleasant symptoms. This prospective study aimed to assess the efficacy of a multimodal approach to prevent PONV, and patient satisfaction using the willingness-to-pay method. Two validated risk scores were applied to forecast the individual risk for PONV in 900 consecutive patients of whom 108 were identified as high-risk patients (predicted risk: 79-87%). High-risk patients received multimodal anti-emetic prophylaxis: total intravenous anaesthesia with propofol, high fractional inspired oxygen (80%), omission of nitrous oxide, dexamethasone 8 mg, haloperidol 10 microg.kg(-1), and tropisetron 2 mg. Of the remaining patients with low or moderate risk for PONV, a random sample of 71 females received balanced propofol-desflurane anaesthesia without prophylactic anti-emetics. All patients were interviewed 2 and 24 h after surgery for occurrence of nausea and vomiting. Patient satisfaction was measured using the willingness-to-pay method. The incidence of PONV (95%-confidence interval) in the control-group was 41% (29-51%), slightly lower than predicted by the risk scores (53-57%). The multimodal anti-emetic approach reduced the predicted risk (79-87%) in the high risk-group to 7% (3-14%). This was associated with a high willingness-to-pay median (25th/75th percentile) of 84 UK pounds (33-184 UK pounds) in the multimodal anti-emetic group compared to 14 UK pounds (4-30 UK pounds) in the control group. A multimodal anti-emetic approach can considerably reduce the incidence of PONV in high-risk patients and is associated with a high patient satisfaction as measured by the willingness-to-pay method.     

The timing of haloperidol administration does not affect its prophylactic antiemetic efficacy

PURPOSE: Postoperative nausea and vomiting (PONV) occurs frequently after general anesthesia. We evaluated the timing of 2 mg iv doses of haloperidol on the efficacy of this drug as a prophylactic antiemetic for PONV. METHODS: Ninety-four non-smoking female patients with a history of motion sickness and/or PONV (Apfel's simplified risk score=3; predicted incidence of PONV=60%) were eligible to participate in this randomized, double-blind study. Patients were divided into two groups. Group 1 patients received haloperidol 2 mg iv during induction of anesthesia. Group 2 patients received haloperidol 2 mg iv approximately 30 min before the end of surgery. The occurrence of nausea and vomiting, nausea scores, pain scores, sedation levels, and adverse effects (cardiac arrhythmias, and extrapyramidal effects) were recorded by a trained, blinded investigator. RESULTS: The percentages of patients who experienced PONV in the first 24 hr were similar for the two groups (Group 1=30%; Group 2=26%, P=0.645). The incidence of PONV was significantly smaller in both groups than that predicted (60%) according to the patients' underlying risks (Group 1, P=0.004; Group 2, P=0.001). Nausea scores, pain scores, sedation scores, emergence times, and time to first rescue treatment were similar in the two groups. No adverse effects attributable to the study medication were observed. CONCLUSION: The timing of administration of haloperidol 2 mg iv does not influence its antiemetic efficacy. The recovery profiles were also similar whether haloperidol was administered at the start, or at the end of surgery.     

Frequency of postoperative nausea and vomiting in patients undergoing laparoscopic foregut surgery

Background: Wrap disruption or intrathoracic herniation of a fundoplication is a dreaded complication of laparoscopic foregut surgery. This problem may often be related to postoperative nausea and vomiting (PONV). This study aimed to investigate the occurrence of PONV and its management in patients undergoing laparoscopic foregut procedures. Methods: Between January 31 and May 23, 2000, 104 patients undergoing laparoscopic foregut procedures (fundoplication, myotomy, or paraesophageal hernia repair) were followed prospectively. Their postoperative course was documented along with the occurrence and management of PONV. All laparoscopic foregut surgery patients are managed postoperatively with a uniform clinical pathway, and their care is focused on a nursing unit with skill and experience in postoperative management. Results: Nausea was documented in the postanesthesia care unit (PACU) for 30.1% of the patients, and for 59.6% of the patients during their nursing unit stay. Antiemetics were given to all the patients with documented nausea. Emesis was noted in 1.9% of the patients in the PACU, as compared with 3.8% of the patients on the floor. In one of the patients with nursing unit emesis, an acute wrap herniation into the chest occurred, necessitating a return to the operating room for correction. The patients with a history of postoperative nausea did not have a higher rate of PONV than in those with no history of postoperative nausea. The use of preoperative or intraoperative antiemetics did not appear to alter the occurrence of PONV. Postoperative nausea occurred in 60% of the patients administered preoperative antiemetic, as compared with 64% of the patients who received no preoperative antiemetic. The average length of hospital stay was longer in those with PONV than in those with no PONV (2.6 vs 1.8 days). Conclusion: Nausea after laparoscopic foregut procedures is common, occurring twice as often on the nursing unit as in the PACU. The occurrence of PONV leads to a longer hospital stay, and can result in significant sequelae requiring reoperation. The use of preoperative or intraoperative antiemetics does not alter the frequency of postoperative nausea, suggesting the need to develop effective preemptive regimens for patients undergoing laparoscopic foregut procedures. The high rate of PONV and its potential risk of damage to a fundoplication and hiatal hernia repair should lead surgeons to consider whether laparoscopic foregut procedures should ever be performed on an outpatient basis.