Preoperative anxiety and postoperative nausea and vomiting in children: is there an association?

We performed a cross-sectional study to explore a potential association between preoperative anxiety and postoperative nausea and vomiting (PONV). The study enrolled 51 unpremedicated children 5-16 yr old undergoing outpatient surgery and standardized general anesthesia. Anxiety of children was assessed in the preoperative holding area and during the induction of anesthesia. The incidence of nausea and vomiting was documented in the postanesthesia care unit (PACU) and 24 h postoperatively (POD#1). In addition to univariate analysis, we used multivariate logistic regression models, wherein the dependent variable was the presence or absence of PONV and the independent variables included potential confounders such as age, sex, and perioperative opioid consumption. Univariate analysis showed that children who experienced nausea (32 +/- 5 vs 31 +/- 4, P = ns) or vomiting (32 +/- 4 vs 32 +/- 5, P = ns) in the PACU did not differ significantly in their anxiety before surgery. A multivariate model, in which the dependent variable was the presence or absence of vomiting at POD#1 and the independent variables included preoperative anxiety, age, sex, and opioid consumption, indicated that preoperative anxiety does not predict the occurrence of nausea and vomiting (P = ns). We conclude that children's anxiety in the preoperative holding area has no predictive value for the occurrence of PONV in the PACU or POD#1. IMPLICATIONS: This study was performed to explore a possible association between children's anxiety before surgery and postoperative nausea and vomiting. We found that controlling for confounding variables, anxiety in the preoperative holding area has no predictive value for the occurrence of postoperative nausea and vomiting.     

Postoperative Results after Desflurane or Sevoflurane Combined with Remifentanil in Morbidly Obese Patients

Background: This randomized prospective study with blinded postanesthesia care unit (PACU) observers compared the recovery profiles in morbidly obese patients who received sevoflurane or desflurane for maintenance of anesthesia in combination with a remifentanil target controlled infusion (TCI). Methods: 50 morbidly obese patients scheduled for laparoscopic gastric banding were included to receive BIS-guided sevoflurane or desflurane anesthesia with BIS-triggered inhalation boli in combination with remifentanil TCI. In the PACU, the following recovery scores were investigated: Modified Aldrete score, a modified Observers' Assessment of Alertness/Sedation Scale (OAA/S), pain numerical rating scale (NRS), oxygen saturation (SpO₂) and postoperative nausea and vomiting (PONV). Results: OAA/S and NRS pain scores showed a similar evolution in both groups from the moment of PACU admission up to 120 minutes after admission. In both groups, patients showed no serious hypoxemia during PACU stay. Incidence of PONV was shorter lasting in the sevoflurane group compared to the desflurane group. Conclusions: No clinically relevant difference was found in recovery in the PACU between morbidly obese patients anesthetized with desflurane or sevoflurane. Both agents resulted in satisfactory recovery in morbidly obese patients.     

P6 Acupoint Injections Are as Effective as Droperidol in Controlling Early Postoperative Nausea and Vomiting in Children

Background: P6 acupuncture in adults is reported to be an effective preventive treatment for postoperative nausea and vomiting (PONV). It is not clear, however, whether this technique is effective as a preventive treatment for PONV in children.

Methods: Children undergoing anesthesia and surgery were randomized to four groups: (a) intravenous saline + bilateral P6 acupoint injections (n = 50); (b) intravenous droperidol + bilateral P6 sham acupuncture (n = 49); (c) intravenous saline + bilateral sham point injections (n = 43); (d) intravenous saline +bilateral P6 sham acupuncture (n = 45). The perioperative anesthetic technique was standardized in all subjects. The incidence of postoperative nausea and vomiting (PONV) was evaluated in postanesthesia care unit (PACU) and 24 h after surgery.

Results: Incidence of nausea in the PACU was significantly lower in the acupoint group as compared with the sham point group (32%vs. 56%, P = 0.029) and P6 sham group (32%vs. 64%, P = 0.002) but not as compared with the droperidol group (32%vs. 46%, P = ns). Similarly, subjects in the acupoint group had a significantly lower incidence of vomiting in the PACU as compared with the sham point group (12%vs. 33%, P = 0.026) and P6 sham group (12%vs. 31%, P = 0.029) but not as compared with the droperidol group (12%vs. 18%, P = ns). The combined incidence of early PONV was also lower in the acupoint group as compared with the sham point group (P = 0.045) and P6 sham group (P = 0.004) but not as compared with the droperidol group (42%vs. 51%, P = ns). Finally, significantly fewer subjects in the acupoint group required intravenous ondansetron as an initial rescue therapy (P = 0.024). At 24 h after surgery, however, the incidence of late PONV was similar among the four study groups (P = ns).     

Intra-operative Fluid Volume Influences Postoperative Nausea and Vomiting after Laparoscopic Gastric Bypass Surgery

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a commonly performed operation for morbid obesity. A significant number of patients experience postoperative nausea and vomiting (PONV) following this procedure. The aim of this study was to determine the effect, if any, of intra-operative fluid replacement on PONV. Methods: Patients who underwent laparoscopic (RYGBP) for morbid obesity during a 12-month period were included in this retrospective analysis. Demographic data including age, gender, and body mass index (BMI) were collected. Perioperative data also included total volume of intra-operative fluids administered, rate of administration, urine output, length of surgery, and incidence of PONV as determined by nursing or anesthesia records in the postanesthesia care unit (PACU). Data were analyzed by t-test. Results: The table below depicts demographic and perioperative data, comparing patients who experienced PONV (n=125) in the PACU with those who did not (n=55). Values are mean ± standard deviation. Conclusions: PONV is a common complication after laparoscopic RYGB. Patient who did not experience PONV received a larger volume of intravenous fluid at a faster rate than similar patients who complained of PONV.     

P6 acupoint injections are as effective as droperidol in controlling early postoperative nausea and vomiting in children

BACKGROUND: P6 acupuncture in adults is reported to be an effective preventive treatment for postoperative nausea and vomiting (PONV). It is not clear, however, whether this technique is effective as a preventive treatment for PONV in children. METHODS: Children undergoing anesthesia and surgery were randomized to four groups: (a) intravenous saline + bilateral P6 acupoint injections (n = 50); (b) intravenous droperidol + bilateral P6 sham acupuncture (n = 49); (c) intravenous saline + bilateral sham point injections (n = 43); (d) intravenous saline +bilateral P6 sham acupuncture (n = 45). The perioperative anesthetic technique was standardized in all subjects. The incidence of postoperative nausea and vomiting (PONV) was evaluated in postanesthesia care unit (PACU) and 24 h after surgery. RESULTS: Incidence of nausea in the PACU was significantly lower in the acupoint group as compared with the sham point group (32% vs. 56%, P = 0.029) and P6 sham group (32% vs. 64%, P = 0.002) but not as compared with the droperidol group (32% vs. 46%, P = ns). Similarly, subjects in the acupoint group had a significantly lower incidence of vomiting in the PACU as compared with the sham point group (12% vs. 33%, P = 0.026) and P6 sham group (12% vs. 31%, P = 0.029) but not as compared with the droperidol group (12% vs. 18%, P = ns). The combined incidence of early PONV was also lower in the acupoint group as compared with the sham point group (P = 0.045) and P6 sham group (P = 0.004) but not as compared with the droperidol group (42% vs. 51%, P = ns). Finally, significantly fewer subjects in the acupoint group required intravenous ondansetron as an initial rescue therapy (P = 0.024). At 24 h after surgery, however, the incidence of late PONV was similar among the four study groups (P = ns). CONCLUSION: In children, P6 acupoint injections are as effective as droperidol in controlling early postoperative nausea and vomiting.     

Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children

BACKGROUND: Nausea, vomiting and pain are common complications after strabismus surgery in children. Diclofenac, a non-steroid anti-inflammatory drug, is widely used to treat acute and chronic pain but there are few reports of its use given rectally in children undergoing strabismus surgery. This open randomised study was designed to investigate the analgesic and anti-emetic properties of rectally administered diclofenac compared with opioid (morphine) given i.v. in connection with strabismus surgery in children. METHODS: After obtaining approval from the local ethics committee and written informed consent from the parents, 50 ASA class I-II children, 4-16 years of age, were randomised to receive either rectally administered diclofenac (Voltaren) 1 mg/kg or i.v. opioid (morphine) 0.05 mg/kg perioperatively. The children were consecutively operated upon from May 1999 to January 2001. Anaesthesia was induced with fentanyl and propofol and maintained with propofol. Nitrous oxide was omitted. The postoperative pain was assessed after arrival at the post anaesthesia care unit (PACU) by using the validated Wong and Baker scale (FACES) Pain Rating Scale. Postoperative nausea and vomiting (PONV) was assessed by measuring the frequency of vomiting and the degree of nausea. RESULTS: In the diclofenac group the incidence of PONV during the first 24 h was 12% (of which one child had severe vomiting). The incidence of PONV was much higher, 72% (P = 0.0000), in the morphine group, where 56% of the children also had severe vomiting. There were no difference in pain score between the two groups. Recovery time at the PACU was longer (P < 0.002) and the postoperative analgesic requirement higher in the morphine group (10 vs. 5 children). No children needed overnight admission to the hospital. CONCLUSION: Diclofenac given rectally is an effective analgesic for this kind of surgery and gives less postoperative nausea than i.v. morphine. No serious adverse events were observed.     

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     

Effects of high intraoperative inspired oxygen on postoperative nausea and vomiting in gynecologic laparoscopic surgery

Study ObjectiveTo assess the efficacy of intraoperative inspired oxygen fractions (FIO₂) of 0.8 and 0.5 when compared with standard FIO₂ of 0.3 in the prevention of postoperative nausea and vomiting (PONV).DesignProspective, randomized, double-blinded, controlled study.SettingGeneral hospital, postanesthesia care unit (PACU), and gynecology floor room.Patients120 ASA physical status I and II women, aged 21 to 76 years, undergoing elective gynecologic laparoscopic surgery.InterventionsPatients were randomized to receive a gas mixture of 30% oxygen in air (FIO₂ = 0.3, Group G30), 50% oxygen in air (FIO₂ = 0.5, Group G50), or 80% oxygen in air (FIO₂ = 0.8, Group G80); there were 36 patients in each group. A standardized sevoflurane general anesthesia, postoperative pain management, and antiemetic regimen were used.MeasurementsFrequency of nausea, vomiting, and both was assessed for early (0 to two hrs) and late PONV (two to 24 hrs), along with use of rescue antiemetic, degree of nausea, and severity of pain.Main ResultsThere was no overall difference in the frequency of PONV at the early and late assessment periods among the three groups. G80 patients had significantly less vomiting than Group G30 at two hours, 3% (1/36) vs. 22% (8/36), respectively, P = 0.028. Nausea scores, rescue antiemetic use, pain scores, and opioid consumption did not differ among the groups.ConclusionHigh intraoperative FIO₂ of 0.8 and FIO₂ of 0.5 do not prevent PONV in patients without antiemetic prophylaxis. An intraoperative FIO₂ of 0.8 has a beneficial effect on early vomiting only.     

Ketamine as an adjunct to fentanyl improves postoperative analgesia and hastens discharge in children following tonsillectomy - a prospective, double-blinded, randomized study

Objective: To evaluate the effect of ketamine, as an adjunct to fentanyl, on postoperative analgesia and duration of Postoperative Care Unit (PACU) stay, in children undergoing tonsillectomy. Background: Ketamine, as an N‐methyl‐d ‐aspartate antagonist, has been recognized to have an opioid sparing effect. In addition, it does not depress respiration or affect airway tone. Hence, addition of ketamine could be potentially beneficial in children undergoing tonsillectomy, due to the high incidence of sleep apnea in these patients. Methods: In a double blinded, randomized trial, 60 ASA status I and II children between 2 and 7 years of age, scheduled to undergo elective tonsillectomy were recruited. They were randomly assigned to one of four groups to receive fentanyl 1 mcg·kg^?1 (F1 group), fentanyl 2 mcg·kg^?1 (F2 group), ketamine 0.5 mg·kg^?1 (K group), or fentanyl 1 mcg·kg^?1 plus ketamine 0.5 mg·kg^?1 (FK group) pre‐incision. Postoperative pain was scored on arrival to the PACU and at 30, 60, and 90 min thereafter. Any incidence of nausea/vomiting and time to discharge from the PACU were also recorded. Results: Important predictors found for postoperative pain on arrival to the recovery room are the group (P = 0.02) and duration of surgery (P = 0.02). Least square means and standard errors of pain scores on PACU arrival were 4.87±0.69, 3.04±0.68, 2.10±0.68 and 2.03±0.69 for F1, F2, K and FK groups, respectively. On group‐wise comparison adjusted for surgical time, significant difference was detected between F1 and K (P = 0.02), and F1 and FK (P = 0.0048) groups. Marginal significance was detected in duration of PACU stay among groups (P = 0.08); F2 and FK group had a shorter PACU stay than F1 (P = 0.05 and 0.04 respectively). No significant difference was detected in the need for supplemental analgesia. Conclusion: We conclude that the administration of ketamine 0.5 mg·kg^?1 with 1 mcg·kg^?1 fentanyl in children undergoing tonsillectomy may improve postoperative pain control without delaying home discharge.     

Effect of Dexmedetomidine Compared to Remifentanil During Bariatric Surgery on Postoperative Nausea and Vomiting: a Retrospective Study

Purpose

Postoperative nausea and vomiting (PONV) occurs frequently after bariatric surgery and is a major cause of adverse outcomes. This retrospective study investigated whether opioid-restricted total intravenous anesthesia using dexmedetomidine as a substitute for remifentanil can reduce PONV in bariatric surgery.

Materials and Methods

The electronic medical records of adult patients who underwent laparoscopic bariatric surgery between January and December 2019 were reviewed. The patients were divided into two groups according to the agents used for anesthesia: Group D, propofol and dexmedetomidine; Group R, propofol and remifentanil.

Results

A total of 134 patients were included in the analyses. The frequency of postoperative nausea was significantly lower in Group D than that in Group R until 2 h after discharge from the postanesthesia care unit (PACU) (P?=?0.005 in the PACU, P?=?0.010 at 2 h after PACU discharge) but failed to significantly reduce the overall high incidence rates of 60.5% and 65.5%, respectively (P?=?0.592). Postoperative pain score was significantly lower in Group D until 6 h after PACU discharge. The rates of rescue antiemetic and analgesic agent administration in the PACU were significantly lower in Group D than those in Group R.

Conclusion

Opioid-restricted total intravenous anesthesia using dexmedetomidine reduces postoperative nausea, pain score, antiemetic, and analgesic requirements in the immediate postoperative period after bariatric surgery.

Graphical abstract

     

Dexamethasone versus ondansetron in combination with dexamethasone for the prophylaxis of postoperative vomiting in pediatric outpatients: a double‐blind,randomized, placebo‐controlled clinical trial

Objectives: To determine the frequency of postoperative vomiting (POV) in children submitted to outpatient surgery and to compare the efficacy of antiemetic drugs in preventing this complication. Background: Nausea and vomiting are common in the immediate postoperative period following anesthetic and surgical procedures. Compared to adults, pediatric patients are more likely to develop postoperative nausea and vomiting, the incidence of which ranges from 8.9% to 42%. Methods: This double‐blind, randomized, placebo‐controlled clinical trial included 129 children. The participants were randomized into three prophylactic treatment groups: dexamethasone (n = 43), ondansetron in combination with dexamethasone (n = 44), and placebo (n = 42). The variables studied were the frequency of POV and the incidence of vomiting after the patient had been discharged from hospital, the need for antiemetic rescue therapy in the postanesthesia care unit (PACU), need for hospitalization, and the time the patient remained in the PACU. A significance level of 5% was adopted. Results: Postoperative vomiting occurred in 12.4% of the children, with no statistically significant difference between the groups: 6.8% in the group receiving ondansetron combined with dexamethasone, 14.3% in the placebo group, and 14% in the group that received dexamethasone alone (P = 0.47). Furthermore, no significant difference was found between the groups with respect to the time the children remained in the PACU, and only five patients reported having vomited following discharge from hospital. Conclusions: The prophylactic use of antiemetic drugs failed to reduce the incidence of POV in pediatric outpatient surgery with a low emetic potential; therefore, routine prophylaxis may be unnecessary.     

Acupressure wristbands do not prevent postoperative nausea and vomiting after urological endoscopic surgery

PURPOSE: To evaluate the efficacy of acupressure wristbands in the prevention of postoperative nausea and vomiting (PONV). METHODS: Two hundred ASA I-II patients undergoing elective endoscopic urological procedures were included in a randomized, prospective, double blind, placebo-controlled study. Spherical beads of acupressure wristbands were placed at the P6 points in the anterior surface of both forearms in Group I patients (acupressure group, n = 100) whereas, in Group 2 (control group, n = 100) they were placed inappropriately on the posterior surface. The acupressure wristbands were applied 30 min before induction of anesthesia and were removed six hours postoperatively. Anesthesia was induced with thiopental and maintained with nitrous oxide and oxygen, fentanyl, isoflurane and vecuronium. The tracheas were extubated on the operation table after patients received neostigmine and atropine. Post operative nausea and vomiting were evaluated separately as none, mild, moderate or severe at the time of patient's arrival in PACU, then at six hours and twenty-four hours after surgery by a blinded observer. RESULTS: In the acupressure group, 25 patients had PONV compared with 29 patients in the control group (P = NS). CONCLUSION: Application of acupressure wristbands at the P6 of both forearms 30 min before induction of anesthesia did not decrease the incidence of PONV in patients undergoing endoscopic urological procedures.     

The effect of supplemental 70% oxygen on postoperative nausea and vomiting in patients undergoing inguinal hernia surgery

Background Postoperative nausea and vomiting (PONV) are among the leading side-effects after surgery performed under general anaesthesia. The role of oxygen as an important method for treatment of PONV was studied. The aim of this study was to compare intraoperative 30% oxygen with 70% oxygen for improvement of PONV in patients undergoing inguinal hernia surgery. Methods In a clinical double-blind study, patients (n = 100) undergoing inguinal hernia surgery were given a standardized halothane anesthetic. After induction, they were randomly assigned to the following two groups: routine oxygen administration with 30% oxygen, balance nitrogen (“30% oxygen group,” n = 50) and supplemental oxygen administration with 70% oxygen, balance nitrogen (“70% oxygen group,” n = 50). The overall incidence of nausea and vomiting during the initial postoperative 24 h and correlation between arterial oxygen saturation and incidence of PONV was evaluated. Results There was significant difference in PONV incidence between the two studied groups (14.3% in group treated with 70% oxygen versus 40.0% in group treated with 30% oxygen, P < 0.0001). There was a positive correlation between increase in arterial oxygen saturation and decrease in PONV incidence (P < 0.0001). Conclusion Supplemental oxygen effectively prevents postoperative nausea and vomiting after inguinal hernia surgery: the higher the arterial oxygen saturation, the less frequent PONV.     

Comparative effects of intravenous ketorolac and pethidine on perioperative analgesia and postoperative nausea and vomiting (PONV) for paediatric strabismus surgery

BACKGROUND: Corrective strabismus surgery is associated with moderate pain and a very high incidence of postoperative nausea and vomiting (PONV). Ketorolac tromethamine, a nonsteroidal anti-inflammatory drug, is a popular analgesic in adults. There are only limited published data on the use of intravenous ketorolac for paediatric analgesia perioperatively. This study evaluated and compared the emetic and analgesic effect of ketorolac with pethidine and its suitability for this kind of surgery. METHODS: Following institutional ethics committee approval and parental consent, 52 ASA class I children of age 2.5 to 15 yr were randomised to receive either ketorolac 0.9 mg kg-1 or pethidine 0.5 mg kg-1 given intravenously (i.v.). A blinded observer assessed recovery by Steward's method immediately after arrival at the post anaesthesia care unit (PACU), pain by validated Objective Pain Score (OPS) at 0 h, 1/2 h and 1 h after arrival at the PACU and PONV by Numeric Rank Score at specified time intervals. RESULTS: There were no differences in demographic data, anaesthesia time or surgery duration. Recovery scores, OPS and postoperative analgesic requirement were similar in both groups. PONV at various time intervals for the first 24 h, occurred more frequently in the pethidine group as compared to the ketorolac group (P < 0.001) There were no side effects observed with either drug. CONCLUSION: Ketorolac in a dose of 0.9 mg kg-1 i.v. at the induction of anaesthesia is as effective as pethidine 0.5 mg kg-1 i.v. as an analgesic and is associated with significantly less PONV.     

Opioid‐free anesthesia for patients undergoing mastectomy: A matched comparison

Opioid‐free anesthesia (OFA) is being implemented in breast surgery due to increased awareness of adverse effects and the national opioid crisis. The objective of this study was to examine the effect of OFA on postoperative pain and postoperative nausea and vomiting (PONV) in mastectomy patients. A single‐institution matched‐cohort study was conducted from 2014 to 2017 on 48 women undergoing mastectomy, with the majority also undergoing immediate prosthetic‐based reconstruction. Patients received either conventional anesthesia (CA) or a novel OFA regimen. Primary outcomes included postoperative pain scores, opioid use, and need for antiemetics that were evaluated both in the PACU and on the hospital floors. No significant differences were found in PACU opioid or antiemetic use between OFA and CA. Pain scores in PACU and on POD0 were not significantly different. There was a significant but modest decrease on POD1 in OFA patients (3.9 vs. 5.1, P = .046). Additionally, patients with higher intraoperative opioid regimens experienced significantly increased PONV (P = .023). This study demonstrated the efficacy of OFA in controlling postoperative pain and nausea compared to a traditional opioid‐based regimen. Regardless of intraoperative opioids, patients experienced similar postoperative opioid requirements and PONV with decreased pain scores. Thus, OFA is feasible in mastectomy patients and should be further evaluated in select patients.     

A comparison of ondansetron and prochlorperazine for the prevention of nàusea and vomiting after tympanoplasty

Purpose

To evaluate the effects on PONV and headache after tympanoplasty of prochlorperazine 0.2 mg·kg^?1 im, ondansetron 0.06 mg·kg^?1 iv or placebo (isotonic saline) 0.02 ml·kg^?1 iv given immediately after induction of anaesthesia prior to tracheal intubation.

Methods

The study was randomised, double blind and prospective. One hundred and forty-eight patients, aged 9–61 yr, received a standardised balanced inhalational anaesthetic with controlled ventilation and induced hypotension. Postoperatively, the frequencies of retching and vomiting in the PACU and of nausea, retching, vomiting, headache, analgesic and antiemetic requirements in the surgical ward for 24 hr were recorded.

Results

The four test groups (n = 37 each) were comparable. The incidences of vomiting in the PACU were similar. During the first 24 hr after surgery the antiemetics produced no reductions in the incidence of nausea alone or of vomiting alone. However, the combination of nausea and vomiting was reduced from 53% (placebo) to 16% (P < 0.0005), 19% (P < 0.0005) and 30% (P < 0.05) by im. prochlorperazine, iv ondansetron and iv prochlorperazine, respectively. The frequency of those experiencing no PONV was increased from 27% (placebo) by prochlorperazine im to 57% (P < 0.01), by ondansetron iv to 62% (P < 0.005) and by prochlorperazine iv to 43% (P = NS). The. onset of PONV was delayed in those given prochlorperazine im, and vomiting was less severe in those given ondansetron iv. Headache occurred with similar frequency in each group.

Conclusion

Prophylactic prochlorperazine 0.2 mg·kg^?1 im and ondansetron 0.06 mg·kg^?1 iv are similarly efficacious in reducing nausea with vomiting after tympanoplasty, while prochlorperazine 0.1 mg·kg^?1 iv is less efficacious. Neither drug given as described appeared to reduce the frequency of postoperative nausea alone or vomiting alone.     

The effect of premedication with OTFC, with or without ondansetron, on postoperative agitation, and nausea and vomiting in pediatric ambulatory patients

BACKGROUND: The purpose of this study was to evaluate, in the pediatric ambulatory surgical population, the efficacy of: (i) oral transmucosal fentanyl citrate (OTFC), when given preoperatively, to reduce postoperative excitement associated with sevoflurane, and (ii) intravenous ondansetron to reduce postoperative nausea and vomiting (PONV) associated with OTFC. METHODS: This randomized, double-blinded, placebo controlled study evaluated the efficacy of OTFC [normal dose (ND) = 10-15 microg x kg(-1) or low dose = 100 microg] compared with placebo in the prevention of postoperative agitation; and the efficacy of ondansetron (0.1 mg x kg(-1) to 4 mg) compared with placebo to reduce PONV associated with OTFC. RESULTS: There were 125 patients evaluated (2-10 years old, ASA class I or II and weight 10-40 kg). Preoperatively OTFC was associated with an increased likelihood of cooperation at baseline (P = 0.018). Postoperatively there was a higher incidence of vomiting in children that received OTFC. The anxiety/agitation of patients entering the PACU was significantly less in children who received OTFC ND (P < 0.001). This effect decreased over time. Patients with respiratory adverse events related to the study drug were significantly higher in groups who received OTFC, however, they were not of clinical significance. OTFC was associated with delays in time for eligibility to PACU discharge (P = 0.003). CONCLUSIONS: Even though OTFC reduced early postoperative agitation the increase in side effects, namely PONV and prolonged recovery times, limits its clinical usefulness. The study demonstrates the tradeoffs between anxiety and agitation vs vomiting, respiratory events and prolonged recovery times. Ambulatory pediatric patients undergoing procedures in which opioids would be routinely used might benefit the most from OTFC combined with ondansetron as part of the anesthetic technique.     

Impact of a prophylactic strategy on the incidence of nausea and vomiting after general surgery

Background

This study aimed to evaluate the implementation of a strategy to prevent postoperative nausea and vomiting (PONV) in patients undergoing general surgery.

Study design

Prospective observational study.

Methods

A first period was observational. During a second period, a strategy to prevent PONV was based on five risk factors (RF) identified after the first phase. From two RF, antiemetic treatment was given according to the number of RF. The incidence of PONV was recorded in postoperative anaesthesic care unit (PACU) and at the 24th postoperative hour (24 h).

Results

We prospectively enrolled 823 patients. Implementation of a prophylactic PONV strategy was associated with a decrease of nausea in PACU from 29.9 to 9.8% (P < 0.001) and at 24 h from 19 to 10.3% (P < 0.001). Vomiting decreased from 12.4 to 2.3% (P < 0.001) in PACU and from 5.6 to 3.7% at 24 h (non-significant).

Conclusion

Prophylaxis of PONV by the administration of antiemetic treatment according to a strategy based on a local risk score was efficient and associated with a significant decrease of PONV.     

Patient-controlled antiemesis: a randomized, double-blind comparison of two doses of propofol versus placebo.

BACKGROUND: The role of propofol for the management of postoperative nausea and vomiting (PONV) is not well established. This study determines the efficacy of small doses of propofol administered by patient-controlled device for the treatment of PONV. METHODS: Patients presenting for ambulatory surgery received a standardized general anesthetic. Those who experienced significant nausea or emesis within 1 h of arrival in the recovery room were randomized to receive repeated doses of propofol 20 mg (P-20), propofol 40 mg (P-40), or intralipid (placebo) on demand. Study medications (in equal volumes) were administered with a patient-controlled delivery device for 2 h. A lockout interval of 5 min between doses was used. The following parameters were assessed: nausea, vomiting, rescue antiemetic use, recovery profile, study drug administration history, and satisfaction with treatment. RESULTS: Sixty-nine patients participated in the study. Patient demographics were similar. The average nausea score for a patient in the P-20 and P-40 groups was 25% and 29% less, respectively, compared with placebo during the study period (P < 0.05). This difference was apparent 15 min after initiation of therapy. More placebo patients vomited (P-20, 12%; P-40, 23%; placebo, 56%; P = 0.003) and needed rescue antiemetics (P-20, 17%; P-40, 23%; placebo, 70%; P = 0.001) compared with treatment groups. Sedation scores were similar between groups. Propofol-treated patients had shorter stays in the post-anesthesia care unit (PACU; P-20, 131+/-35 min [mean +/- SD]; P-40, 141+/-34 min; placebo, 191+/-92 min; P = 0.005) and higher satisfaction with their control of PONV than placebo (P < 0.01). CONCLUSIONS: Propofol is effective in managing PONV with shorter PACU stay and great degree of patient satisfaction. There were two episodes of oversedation in the P-40 group. Hence, propofol at a demand dose of 20 mg seems more appropriate.     

Randomized comparison of two anti-emetic strategies in high-risk patients undergoing day-case gynaecological surgery

Background: Postoperative nausea and vomiting (PONV) is a significant causeof morbidity among patients undergoing general anaesthesia.The optimal strategy for prevention of PONV, however, remainsunclear. This study compared two commonly used prophylacticstrategies in high-risk, day-case, gynaecological surgery patients. Methods: We conducted a randomized trial comparing sevoflurane combinedwith dolasetron (SD), with propofol-based total intravenousanaesthesia (TIVA) in 126 high-risk patients undergoing day-casegynaecological surgery. The primary endpoints included the incidenceand severity of nausea or vomiting before discharge and theincidence of nausea or vomiting between discharge and 24 h.To identify the factors most predictive of a complete response(no PONV at any time within the 24 h period), multiplelogistic regression models were fitted. Results: Before discharge, there was no significant difference betweenthe two treatment groups with respect to nausea and vomitingoutcomes (P = 0.3). Post-discharge nausea and vomiting (PDNV),however, were significantly more common for patients in theTIVA group (nausea, P = 0.004 and vomiting, P = 0.03). Typeof anaesthetic, adjusted for weight and anaesthesia durationwas significantly associated with complete response (odds ratio= 2.7, 95% confidence interval = 1.15 to 6.4). Conclusions: Although both TIVA and dolasetron prophylaxis reduce the predictedrate of PONV in the early postoperative period, the anti-emeticeffects of propofol are short-lived. A longer-acting drug suchas dolasetron may therefore be necessary to prevent PDNV.