Use of Apfel Simplified Risk Score to Guide Postoperative Nausea and Vomiting Prophylaxis in Adult Patients Undergoing Same-day Surgery

PurposeThe quality improvement (QI) project implemented a postoperative nausea and vomiting (PONV) risk screening tool and introduced a risk-tailored prophylactic guideline to identify patients at risk for PONV and aimed to minimize PONV adverse events.DesignThis project represents the initial PDSA (Plan-Do-Study-Act) cycle for quality improvement with use of a pre-post design with two independent groups designed to compare PONV rates before and after implementation of an Apfel Simplified Risk Score screening and prophylactic guideline intervention.MethodsThe project implemented the screening of patient PONV risk using the Apfel Simplified Risk Score and a combination antiemetic drug class prophylactic guideline for adult patients undergoing elective same-day surgery procedures. An online education module was provided to anesthesia professionals and was reviewed in-person with the relevant anesthesia professional team prior to surgery. Pre-implementation (N=107) PONV outcomes were collected. Data collected from a retrospective chart review was used to compare pre- and post-implementation PONV rates (N=96) and determine post-implementation anesthesia professional adherence to guideline recommendations.FindingsForty percent of screened patients were identified as having an increased PONV risk with an Apfel Simplified Risk Score of 3 or 4. The PONV rates for the pre-group (19.6%) and post-group (22.9%) did not significantly differ (P=.5567). Anesthesia professional adherence to administration of the recommended number of antiemetic drug classes was 89.6%. A Spearman point-biserial correlation analysis indicated a significant positive relationship between Apfel Simplified Risk Score and PONV onset in the post-group (r_s=0.21, P=.0428).ConclusionsThe Apfel Simplified Risk Score and prophylactic guideline increased identification of patients at risk for PONV but did not affect PONV rate despite a high anesthesia professional adherence to the guideline recommendations.     

Preventing Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blind Study

Background

Postoperative nausea and vomiting (PONV) are potential complications in patients after laparoscopic cholecystectomy (LC). Combination antiemetic therapy often is effective for preventing PONV in patients undergoing LC, and combinations of antiemetics targeting different sites of activity may be more effective than monotherapy.

Objective

The aim of this study was to compare the administration of a subhypnotic dose of propofol combined with dexamethasone with one of propofol combined with metoclopramide to prevent PONV after LC.

Methods

Sixty adult patients scheduled for LC were randomly assigned to 1 of 2 treatment groups. The patients in group 1 received 0.5 mg/kg propofol plus 8 mg dexamethasone, and those in group 2 received 0.5 mg/kg propofol plus 0.2 mg/kg metoclopramide. The number of patients experiencing nausea and vomiting at 0 to 4, 4 to 12, and 12 to 24 hours postoperatively and as well as additional use of rescue antiemetics were recorded.

Results

The total PONV rates up to 24 hours postanesthesia were 23.3% and 50% for group 1 and group 2, respectively. Comparisons of the data revealed that at 0 to 4 hours, the number of patients experiencing vomiting was 6 (20%) in group 1 and14 (46.7%) in group 2 (P = 0.028). The frequency of vomiting in group 1 was significantly lower than that for group 2 (P = 0.028), and the rate of rescue antiemetic use in group 2 was higher than that in group 1 (20% vs 46.7%; P = 0.028). In the evaluation of PONV based on the nausea and vomiting scale scores, the mean PONV score was 0.4 (0.2) in group 1 compared with 1.0 (0.2) in group 2 (P = 0.017). There were no significant differences between the values at 4 to 12 hours and at 12 to 24 hours. The frequency of adverse reactions (respiratory depression: 1.3%, 1.3%; laryngospasm: 1.3%, 0%; cough: 1.3%, 0%; hiccup: 1.3%, 0%;) was not significantly different in the 2 groups.

Conclusions

Administration of a subhypnotic dose of 0.5 mg/kg propofol plus 8 mg dexamethasone at the end of surgery was more effective than administration of 0.5 mg/kg propofol plus metoclopramide in preventing PONV in the early postoperative period in adult patients undergoing LC.     

P6刺激对术后恶心呕吐有效性的Meta分析

目的采用Meta分析比较P6（内关穴：NeiGuan）刺激与假刺激/安慰剂/药物预防术后恶心呕吐（POVN）的有效性。方法计算机检索PubMed（1990～2010）、OVID全文数据库（1990～2010）、EBSCO（1990～2010）、Cochrane图书馆（1996～2010）、中国学术期刊网全文数据库（CNKI,1999～2010）,美国科学院院刊（PNAS1990～2010）和High Wire Pres数据库（1990～2010）,手工检索《中华麻醉学杂志》（1990/2010）、Anastasia等5种中外文期刊。按照纳入与排除标准进行文献筛选和质量评价后,采用随机效应模型进行Meta分析。结果最终纳入21篇文献,其中2篇为多中心随机双盲对照研究,4篇为随机单盲对照研究,其余15篇均为单中心随机双盲对照研究（Ⅱa级）。Meta分析结果显示：①与假刺激相比,P6刺激可有效预防术后恶心（开始～研究终止）（P〈0.000 01）、术后早期恶心（〈术后6 h）（P=0.000 6）和术后后期恶心（〉术后6 h）（P=0.001）。②与假刺激相比,P6刺激也可有效预防术后呕吐（开始～研究终止）（P〈0.000 1）、术后早期呕吐（〈术后6 h）（P=0.002）,但对术后后期呕吐（〉术后6 h）无预防作用（P=0.08）。③与药物干预相比,P6刺激预防术后恶心（P=0.29）、呕吐（P=0.15）的有效性较弱。结论 P6刺激相对于假刺激可有效预防术后早期恶心呕吐（术后0～6 h）、后期恶心,但对术后后期呕吐（术后6～12 h）并无预防作用。相对于药物而言,尚需高质量临床试验来证明P6刺激可以取代药物预防术后恶心呕吐发生。     

Prevention and Management of Postoperative Nausea and Vomiting: A Look at Complementary Techniques

Complementary modalities, used alone or in combination with pharmacologic therapies, play an important role in the prevention and management of postoperative nausea and vomiting (PONV) and post discharge nausea and vomiting (PDNV). This article will review the evidence for the effective use of complementary modalities: acupuncture and related techniques, aromatherapy, and music therapy that may be integrated in the perianesthesia nurse's plan of care to prevent or manage PONV.     

Prevention and Management of Postoperative Nausea and Vomiting in Adults

In early 2007, patients at our small community hospital's outpatient surgery center experienced postoperative nausea and postoperative nausea and vomiting (PONV) at a rate of 27% to 35%. Many record reviews and a written survey of nurses in the postanesthesia care unit and same day surgery center revealed that little or no risk assessment and no consistent prophylaxis or treatment were in use by nurses, physicians, or anesthesia care providers.After a review of the literature and discussions with anesthesia care providers, we developed and put into practice a risk assessment tool and perioperative care path. A formal evaluation to assess the effectiveness of the plan was performed one year after implementation. We found that the rates of PONV had decreased to 16%. AORN J 90 (September 2009) 391-413. © AORN, Inc, 2009.     

Effectiveness of Music Intervention on Postoperative Nausea and Vomiting: A Systematic Review and Meta-analysis

PurposeTo evaluate the evidence for the effectiveness of music intervention on postoperative nausea and vomiting in the first 24 hours after surgery.DesignA systematic review and meta-analysis of randomized controlled trials.MethodsThe study was conducted according to recommendations from Cochrane Handbook. The studies were selected based on PICOS inclusion and exclusion criteria. The revised Cochrane risk-of-bias tool for randomized trials was used for bias assessment and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for reporting the study. Data was analyzed using the Comprehensive Meta-analysis version 3 software. A meta-analysis of randomized controlled trials was conducted using both fixed and random-effect models.FindingsThere were 576 patients in the seven studies who met the inclusion criteria. The number of participants ranged from 58 to 163. Music was implemented in postoperative, intraoperative, and perioperative periods. Meta-analyses revealed that music interventions significantly reduced postoperative vomiting (95% CI: 0.01 to 0.63, Z = 2.07, P < 0.05, Hedge's g = 0.32), and had no statistical significant effect on postoperative nausea (95% CI: ?0.13 to 0.70, Z = 1.34, P > 0.05, Hedge's g = 0.28).ConclusionMusic intervention is effective in decreasing postoperative vomiting. Music intervention can be applied by healthcare professionals and the patients. However, more studies are still necessary to estimate the effects of postoperative nausea and vomiting and to increase the amount of available evidence.Study registration numberCRD42020209691     

The Effect of Ginger on Postoperative Nausea and Vomiting Among Patients Undergoing Upper and Lower Limb Surgery: A Randomized Controlled Trial

PurposePostoperative nausea and vomiting is one of the most common side effects associated with anesthesia. The aim of this study is to determine the effect of ginger on severity and incidence of nausea and vomiting after lower and upper limb surgery.DesignThis was a triple-blinded clinical trial.MethodsSixty eligible patients were randomly assigned to the intervention and control groups. The intervention group received four 250 mg ginger capsules and the control group received four placebo capsules 2 hours before surgery. Incidence and severity of nausea and vomiting immediately after the surgery and 2, 4, 6, and 8 hours after the surgery were evaluated.FindingsThe results of this study showed that the use of ginger capsules significantly reduces the incidence and severity of postoperative nausea and vomiting at different hours after surgery compared to placebo, P < .05, irrespective of the gender and the age of the patients.ConclusionsUse of ginger is effective in decreasing postoperative nausea and vomiting. However, further studies in comorbid patients are required to verify these outcomes.