Menstrual stage influences postoperative nausea and vomiting following epidural buprenorphine

Background: Although buprenorphine sometimes causes severe emesis, its relation to the menstrual cycle has not been reported.
Methods: We conducted a prospective study on 68 reproductive-age women following lower extremity surgery under epidural anesthesia plus buprenorphine, to assess the effect of the day of the menstrual cycle on the incidence of postoperative nausea and vomiting. The patients were divided according to the phase of the menstrual cycle into four groups: day 1–7 group, day 8–14 group, day 15–24 group and day 25 to end of the cycle group.
Results: Nausea and vomiting were reported in 46 patients (67.6%), and the incidence was higher in the day 25 to end of the cycle group than in the day 8–14 or day 15–24 groups, and higher in the day 1–7 group than in the day 8–14 group.
Conclusion: We conclude that emesis after epidural buprenorphine is related to the menstrual cycle.     

盐酸帕洛诺司琼预防上腹部手术后硬膜外吗啡镇痛所致的恶心呕吐

目的 观察和评价帕洛诺司琼对上腹部手术后硬膜外吗啡镇痛引起的恶心呕吐的预防效果和安全性.方法 择期行上腹部手术并术后接受硬膜外吗啡镇痛患者60例,随机分为帕洛诺司琼组（P组）和托烷司琼组（T组）.手术结束前30 min,P组患者缓慢静注帕洛诺司琼0.25 mg,T组患者缓慢静注托烷司琼6 mg.观察记录两组患者术后24 h、48 h VAS及Ramsay评分、恶心呕吐的程度,计算恶心呕吐有效控制率.同时记录患者腹胀、头痛、椎体外系症状等不良反应.结果 两组患者术后24 h及48 h的VAS及Ramsay评分差异无统计学意义.P组患者术后24 h的恶心及呕吐有效控制率分别为80.0%和73.3%,T组分别为63.3%和60.0%;P组患者术后48 h的恶心及呕吐有效控制率分别为90.0%和93.3%,T组分别为66.6%和63.3%.两组患者术后24 h恶心、呕吐有效控制率差异无统计学意义.P组患者术后48 h恶心、呕吐有效控制率明显优于T组患者（P 〈 0.05）.帕洛诺司琼的不良反应主要为头痛.结论 腹部手术后24 h内,帕洛诺司琼预防吗啡硬膜外镇痛所致的恶心呕吐的效果与托烷司琼相当,但术后48 h预防恶心呕吐的效果优于托烷司琼,且不良反应发生率低,程度较轻,安全性好.     

术后恶心呕吐的风险评估及防治方法

术后恶心呕吐是最常见的术后并发症之一,防治其发生有重要的临床意义。现就近几年来关于术后恶心呕吐的风险因素、评估方法以及防治方面的研究进展作一综述。     

A prospective randomized blinded study of the effect of intravenous fluid therapy on postoperative nausea and vomiting in children undergoing strabismus surgery

BACKGROUND: Nausea and vomiting is a common postoperative complication that often necessitates the use of antiemetic agents. METHODS: In a prospective, randomized, double blind trial, the effect of perioperative fluid administration on postoperative adverse outcomes following anesthesia was studied. One hundred children undergoing strabismus repair were randomly assigned to receive 10 ml x kg(-1) x h(-1) (control group) or 30 ml x kg(-1) x h(-1) (superhydration group) of lactated Ringer's solution during the operation. During the first 24 h postoperatively, nausea and vomiting, thirst, pain, and fever were evaluated. RESULTS: Groups were similar with respect to demographic data, surgical procedures and baseline hemodynamic variables. In the first 24 h postoperatively, nausea and vomiting occurred in 27 patients (54%) of the control group and 11 (22%) of patients in the superhydration group (P = 0.001). Comparison of the superhydration group with the control group also showed a statistically significant benefit of superhydration on postoperative thirst (P = 0.0002) and fever (P = 0.02). The differences in nausea and vomiting, thirst, and fever remained significant after adjustment for age, gender, weight, and duration of surgery. There was no significant difference between the two groups in postoperative pain. CONCLUSIONS: Intravenous superhydration administration is an inexpensive and safe therapy for reducing postoperative nausea and vomiting and discomfort.     

Prevention and control of postoperative nausea and vomiting in post-craniotomy patients

Postoperative nausea and vomiting (PONV) are the most frequent side-effects in the postoperative period, impairing subjective well-being and having economic impact due to delayed discharge. However, emetic symptoms can also cause major medical complications, and post-craniotomy patients may be at an increased risk. A review and critical appraisal of the existing literature on PONV in post-craniotomy patients, and a comparison of these findings with the current knowledge on PONV in the general surgical population, leads to the following conclusions: (1) Despite the lack of a documented case of harm caused by retching or vomiting in a post-craniotomy patient, the potential risk caused by arterial hypertension and high intra-abdominal/intra-thoracic pressure leading to high intracranial pressure, forces to avoid PONV in these patients. (2) There is unclarity about a specifically increased (or decreased) risk for PONV in post-craniotomy patients compared with other surgical procedures. (3) The decision whether or not to administer an antiemetic should not be based primarily on risk scores for PONV but on the likelihood for potential catastrophic consequences of PONV. If such a risk cannot be ruled out, a multimodal antiemetic approach should be considered regardless of the individual risk. (4) Randomized controlled trials with antiemetics in post-craniotomy patients are limited with respect to sample size and methodological quality. This also impacts upon the meaning of meta-analyses performed with trials that showed marked heterogeneity and inconclusive results. (5) No studies on the treatment of established PONV are available. This highlights the need to transfer knowledge about PONV treatment from other surgical procedures. (6) Despite the possibility that PONV in post-craniotomy patients can be triggered by specific conditions (e.g. surgery near the area postrema at the floor of the fourth ventricle with the vomiting centre located nearby), recommendations based on trials in post-craniotomy patients may be flawed. Thus, general knowledge on prevention and treatment of PONV must adopted for craniotomy settings.     

妇科腹腔镜手术术后恶心呕吐的临床研究

目的 分析妇科腹腔镜手术术后恶心呕吐(PONV)的发生情况及其影响因素.方法 按前瞻性临床队列研究设计,应用单因素和多因素logistic回归分析围术期变量与术后PONV发生之间的关系.术后6 h及24 h内发生的恶心或呕吐为本研究的结局变量.结果 研究期间共有260例患者行妇科腹腔镜手术,最终有237例有效病例.其中术后6 h内有80例出现PONV,术后24 h内有94例发生PONV.多因素logistic回归分析提示妇科腹腔镜手术术后6 h及24 h PONV的危险因素为既往FONV史及术毕疼痛,而氟哌利多有助于减轻术后6 h内PONV.结论 妇科腹腔镜手术PONV,高发,尤以6 h内明显;既往PONV史及术毕疼痛可增加本次手术PONV发生的风险.     

Intravenous fluid and postoperative nausea and vomiting after day-case termination of pregnancy

Background : Deprivation of oral fluid before minor surgery has been alleged to cause postoperative nausea. We examined the effect of intraoperative fluid load on postoperative nausea and vomiting over 3 d after day-case termination of pregnancy.
Methods : In a randomized study, 100 patients were allocated into one of two groups; receiving 1000 ml of compound sodium lactate solution during surgery or no intraoperative fluid. Propofol and alfentanil was used to induce and maintain anaesthesia with nitrous oxide (67%) and oxygen (33%). Visual analogue scores for nausea and pain, the time and frequency of emetic episodes, analgesic and antiemetic consumption were recorded for 3 d postoperatively.
Results : The scores of nausea were significantly lower in the fluid group ( P <0.05) compared with the control group at 1, 2, 4 h and during 24–48 h following surgery. The incidence of emesis was lower ( P <0.01) after discharge, and the time to first oral fluid was shorter ( P <0.05) in the fluid group. There was no difference in pain score or analgesic consumption between the groups. Five patients (10%) in the control group requested antiemetic medication compared with none in the fluid group.
Conclusion : Intraoperative fluid administration may offer some benefit in decreasing the incidence of postoperative nausea and vomiting following day-case surgery.     

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.     

A survey of postoperative nausea and vomiting

A prospective interview-based survey on the incidence of postoperative nausea and vomiting in 1107 in-patients aged 4–86 years was conducted during a 3-month period. Nausea, emetic episodes and the need for anti-emetic medication were recorded for 24 h postoperatively. In the recovery room, the incidence of nausea and vomiting was 18% and 5%, respectively. Over the whole 24-h period, these figures were 52% and 25%, respectively; severe nausea was experienced by 8%. The highest incidence of emetic sequelae was observed in gynaecological patients; 52% of the 822 patients who received general anaesthesia and 38% of the 285 patients who received regional anaesthesia reported nausea. The most important predictive factors associated with an increased risk for nausea and vomiting were female gender, a previous history of postoperative sickness, a longer duration of surgery, nonsmoking and a history of motion sickness. Based on these five items, a simple score predicting the risk of nausea and vomiting was constructed with a moderately good discriminating power.     

Simplified algorithm for the prevention of postoperative nausea and vomiting: a before-and-after study

Background

Poor adherence to guidelines aimed at reducing the incidence of postoperative nausea and vomiting (PONV) is well known. In a before-and-after study, we tested the effectiveness of a simplified algorithm for PONV prophylaxis on the incidence of PONV.

Association of oculocardiac reflex and postoperative nausea and vomiting in strabismus surgery in children anesthetized with halothane and nitrous oxide

BACKGROUND: Postoperative nausea and vomiting (PONV) occurs frequently after strabismus surgery. The controversy still exists regarding the association of PONV and the oculocardiac reflex (OCR). A recent study has proven that rocuronium attenuates OCR. If these two occurrences are dependent, it is expected that with the diminution of OCR, occurrence of PONV will also be reduced. The goal of this randomized, controlled study was to prove an association between OCR and PONV by attenuating OCR with 0.4 mg x kg(-1) of rocuronium and subsequently diminishing PONV if these occurrences are associated. METHODS: A total of 119 ASA 1 children, aged between 3 and 10, undergoing surgery of the medial rectus muscle, were randomly assigned to two groups. In group R (n = 59), 0.4 mg x kg(-1) of rocuronium was administered i.v. before intubation. Group C (controls, n = 60) received no muscle relaxant. The anesthesia was induced and maintained with halothane and N(2)O/O(2) (50/50%). Chi-squared test, Fisher's exact test, t-test, and anova were used for statistical analysis; P-value <0.05 was considered statistically significant. RESULTS: There were no differences between groups regarding patients' characteristics as well as endtidal halothane and duration of surgery and anesthesia. The occurrence of OCR was different between groups (R: 16/59, 27.1%, C: 28/60, 46.7%; P = 0.027), but not the occurrence of PONV (R: 27/59, 45.8%, C: 28/60, 46.7%; P = 0.921). There was an equal number of patients with PONV and bradycardias in both groups (R: 4/27 vs C: 4/28; P = 0.858), whereas there was different, but statistically insignificant distribution of patients (R: 3/27 vs C: 10/28; P = 0.086) with PONV and arrhythmias other than bradycardia. However, simultaneous occurrence of total OCR and PONV in the 24-h period was not different between the two groups (P = 0.964). CONCLUSIONS: Rocuronium (0.4 mg x kg(-1)) attenuates the occurrence of OCR, but with the reduced occurrence of OCR we were not able to attenuate the occurrence of PONV, therefore the association of OCR and PONV in strabismus surgery in children anesthetized with halothane and nitrous oxide remains unclear, and if there is a link between the two, it could be related to arrhythmias and not bradycardia.     

Double–blind comparison of transdermal scopolamine, droperidol and placebo against postoperative nausea and vomiting

Since transdermal scopolamine (TS) seems effective against seasickness, we compared its antiemetic effect with intravenous droperidol (DHBP), our routine antidote for postoperative emesis. Ninety-six female patients (ASA I-II) scheduled for short-stay surgery were randomly allocated to three study groups after giving their informed consent. The three groups were as follows: TS adhesive, delivering 140 micrograms initially and 5 micrograms/h thereafter + placebo 0.5 ml i.v. 5 min before the end of surgery; transdermal placebo adhesive preoperatively + DHBP 0.5 ml (1.25 mg) i.v. 5 min before the end of surgery; transdermal placebo + 0.5 ml placebo i.v. as indicated above. Oxycodone i.m. and glycopyrrolate i.v. were given for premedication together with the test adhesive. Anaesthesia was induced with thiopental and maintained with nitrous oxide and oxygen, enflurane, vecuronium and fentanyl. Neostigmine and glycopyrrolate were administered for reversal. In the recovery room no differences in nausea or vomiting were observed between the groups. Sedation was significantly more marked (P less than 0.15-0.0001) after DHBP than after either TS or the given DHBP and 6% of those given the placebo (P less than 0.05). During the following 24 h nausea was reported more by the placebo patients (25) than by those on TS (20) or DHBP (15) (P less than 0.05). However, actual vomiting on the ward did not differ between the groups. Visual disturbances were more frequent after TS (P less than 0.01). We conclude that prophylactic transdermal scopolamine does not diminish postoperative emetic sequelae.     

穴位按压腕带缓解术后恶心呕吐随机对照试验的Meta分析

目的评价穴位按压腕带作用于内关穴缓解成人术后恶心呕吐的效果。方法检索MEDLINE、CNKI等数据库,纳入所有相关的随机对照试验(RCT),采用RevMan5.0分析数据。结果共纳入9个RCT。相对于安慰剂对照组,试验组即穴位按压腕带作用于内关穴可以有效减少术后呕吐的发生率(RR=0.50,95%CI:0.37~0.66,P<0.01)。而对于术后恶心的发生率,试验组和安慰剂对照组的差异无统计学意义(RR=0.85,95%CI:0.72~1.00,P>0.05)。结论术后护理中应用穴位按压腕带作用于内关穴可以有效缓解术后呕吐,而缓解术后恶心作用不显著,需要今后的研究者进行更加可靠的RCT试验进一步研究和探讨。护理人员可以引进穴位按压腕带进行有效性和适用性的研究。     

The effect of smoking on postoperative nausea and vomiting

In an attempt to quantify the postoperative effects of smoking, 327 consecutive patients undergoing arthroscopic day case knee surgery were given a standard anaesthetic consisting of an intravenous induction with propofol and fentanyl followed by inhalational maintenance using isoflurane in an oxygen and nitrous oxide mixture. Pre-operatively, patients were asked inter alia to give details of social smoking habits. Postoperatively, patients were given standard analgesic and anti-emetic drugs. Prior to discharge patients were asked to give details of postoperative nausea and vomiting together with details of the severity of postoperative pain. There were 85 smokers and 242 nonsmokers. Of the 327 patients, a total of 42 (13%) complained of postoperative nausea and vomiting. Of the smokers, only 6% complained of postoperative nausea and vomiting in contrast to 15% of the nonsmokers (p < 0.05). It is postulated that enzyme induction is the most likely reason for this anti-emetic effect. Possible ways in which this clinically beneficial mechanism can be utilised to improve outcome after anaesthesia are discussed.