Comparison of surgical site and patient's history with a simplified risk score for the prediction of postoperative nausea and vomiting

Although site of surgery and previous occurrence of postoperative nausea and vomiting are often used to decide whether prophylactic anti-emetic drugs are indicated, the value of these predictors is unclear. We compared these two risk factors against a simplified four-factor risk score. We analysed data from 1566 adult inpatients who received balanced anaesthesia without prophylactic anti-emetics. Sensitivity, specificity, predictive value and area under the receiver operating characteristic curve were used to quantify predictive properties. Nausea and vomiting occurred in 600 (38.3%) patients within 24 h. Sensitivity and specificity were, respectively, 47% and 59% for surgical site; 47% and 70% for history of postoperative nausea and vomiting; and 58% and 70% for risk score with three or more factors. The area under the curve for surgical site was 0.53 (95% CI 0.50-0.56); that for patient's history was 0.58 (95% CI 0.56-0.61) while for risk score it was 0.68 (95% CI 0.66-0.71; P < 0.001). Prediction using surgical site or patient's history alone was poor while the simplified risk score provided clinically useful sensitivity and specificity.     

全麻病人术后恶心呕吐的危险因素及预模型的构建

目的 筛选全麻病人术后恶心呕吐(PONV)的危险因素,并构建预测模型.方法 选择本院2008年8月至2008年9月全麻下行口腔、耳鼻喉、食管、肺部、骨科、普通外科、妇科手术的病人,年龄＞15岁、ASA Ⅰ～Ⅲ级,收集病人和手术等有关因素,记录术后24 h内恶心呕吐的发生情况.采用Logistic回归分析的方法筛选PONV的危险因素.根据Logistic回归分析得出的危险因素数量和危险因素及其相关系数(多元回归)分别构建两种PONV预测模型,绘制ROC曲线,计算曲线下面积(AUC)以评估预测模型的效能.结果 共纳入350例全麻病人,术后恶心和呕吐的发生率分别为36.6%和22.3%.Logistic回归分析结果显示,女性、PONV史、晕动史、偏头痛史和妇科或腹腔镜手术是PONV的独立危险因素.以危险因素数量建立的预测模型的AUC为0.749±0.027,多元回归预测模型的AUC为0.755±0.027.结论 女性、PONV史、晕动史、偏头痛史、妇科手术或腹腔镜手术是全麻病人PONV的危险因素,根据危险因素的数量可初步筛选PONV高危人群.     

Immediate postoperative refeeding in orthopedic surgery is safe

The purpose of this retrospective study was to investigate the morbidity of immediate postoperative refeeding after orthopedic surgery. We included all the 1077 patients who underwent orthopedic surgery between January and December 2003 at our military teaching hospital. General anesthesia was performed in 37% of the patients (n = 398), 24% (n = 259) had combined general and regional anesthesia, and 39% (n = 420) had isolated regional anesthesia (spinal anesthesia and/or peripheral regional anesthesia). After surgery, each patient was allowed free access to solid and liquid food immediately after discharge from the postanesthetic care unit. Although no systematic nausea and vomiting prophylaxis was performed, only 7% (n = 75) of the patients had postoperative nausea and vomiting during the first 48 h. Moreover, neither deglutition trouble nor aspiration syndrome was observed during that period. Our results suggest that immediate postoperative refeeding after orthopedic surgery is safe, does not increase postoperative nausea and vomiting, and probably increases the comfort of patients.     

Menstrual cycle irregularity and the incidence of nausea and vomiting after laparoscopy

Gender is an important risk factor for postoperative nausea and vomiting. Menstrual cycle phase has also been implicated as a further variable in female patients. It is not clear whether a history of an irregular menstrual cycle is a significant variable and studies to date have not examined this. The influence of an irregular menstrual cycle on nausea and vomiting after laparoscopy was evaluated in a blinded, prospective, observational study. One hundred and fifty-nine patients scheduled for laparoscopy and dye investigation were included. Anaesthetic technique and postoperative analgesia were standardised. In comparison with patients who had a regular cycle, an irregular menstrual cycle increased the incidence of nausea or vomiting from 20.5% to 40.5% (absolute difference 20%; 95% CI 0.03-0.37, p = 0.01). Other variables were similar between the groups. An irregular menstrual cycle appears to increase the risk of postoperative nausea and vomiting.     

阿扎司琼防治芬太尼镇痛病人恶心呕吐的应用时机探讨

目的探讨不同时间给予盐酸阿扎司琼对于腹腔镜下腹部外科手术术后芬太尼静脉镇痛病人的止呕作用。方法120例拟在静吸复合全麻下进行腹腔镜下腹部外科手术并行术后芬太尼镇痛的患者,根据使用静脉注射盐酸阿扎司琼的时间不同,患者被分为A、B、C三组,每组40例。A组是于麻醉前用药,B组是术毕即时用药,C组是术后首次出现恶心、呕吐时用药。观察术后0-8小时,8—16小时,16—24小时,24—48小时4时间段内恶心呕吐的发生情况。结果A、B两组间的恶心呕吐发生率差异没有显著性;C组恶心呕吐总发生率较A、B两组高但16—48小时恶心、呕吐的发生率及程度较C组低,且C组人均止呕药花费最少。结论盐酸阿扎司琼可有效预防和治疗术后恶心、呕吐,以术后首次出现恶心、呕吐时静注盐酸阿扎司琼效价比最高。     

The incidence of postoperative nausea and vomiting after caesarean section in patients with hyperemesis gravidarum: a retrospective cohort study

BackgroundPostoperative nausea and vomiting is one of the most common anaesthetic complications of caesarean section. This study examined the association between hyperemesis gravidarum during pregnancy and nausea and vomiting after caesarean section.MethodsA single-centre, retrospective cohort study, using electronic databases of patients with and without hyperemesis gravidarum, undergoing caesarean section from 2015 to 2019. The incidence and severity of postoperative nausea and vomiting were established by a review of the documentation of administration of postoperative anti-emetics within the 24-h period after surgery, and examined using univariable, multivariable binary and ordered logistic regression models.ResultsData were compared for 76 patients with hyperemesis gravidarum and 315 patients without the condition. The incidence of postoperative nausea and vomiting in the hyperemesis group versus the non-hyperemesis group was 43.4% vs 29.6%, respectively. The odds of experiencing postoperative nausea and vomiting was 1.95 times higher in women with hyperemesis gravidarum than in those without (aOR 1.95, 95% CI 1.13 to 3.36, P=0.016). The odds of having more severe postoperative nausea and vomiting were greater in the hyperemesis gravidarum group (aOR 1.91, 95% CI 1.14 to 3.20, P=0.014).ConclusionPatients with hyperemesis gravidarum are more likely to develop nausea and vomiting after caesarean section, and this is likely to be of greater severity than in those without the condition. This finding should assist the effective provision of intra-operative and postoperative anti-emetics for patients with hyperemesis gravidarum undergoing caesarean section.     

The use of droperidol decreases postoperative nausea and vomiting after gynecological laparoscopy

We evaluated whether or not routine prophylaxis with 2.5 mg of droperidol would efficiently prevent postoperative nausea and vomiting (PONV). Fifty-two patients scheduled for elective gynecological laparoscopic surgery were eligible for this study. Anesthesia was induced using propofol, fentanyl, and vecuronium, and maintained with sevoflurane in nitrous oxide, fentanyl, and vecuronium. Patients were randomized to one of two groups: group 1 patients (n = 23) received 2.5 mg droperidol intravenously when the surgery was started, while group 2 patients (n = 29) did not receive any droperidol. At the conclusion of the surgery, the patient was extubated on satisfactory emergence from general anesthesia. Any episodes of nausea and vomiting, rescue medications, and adverse effects were recorded until the next morning after the surgery. There were no differences in the duration of anesthesia on surgery between the groups, but the total fentanyl dose in group 1 was higher than that in group 2. Episodes of nausea and vomiting and the need for metoclopramide in group 1 were lower than in group 2, though the total fentanyl dose in group 1 was higher than in group 2. There were no differences in the need for analgesics between the groups. The use of 2.5 mg droperidol safely decreased PONV after gynecological laparoscopy.     

地塞米松联合恩丹西酮对手术后病人自控镇痛相关恶心呕吐的影响

目的　观察地塞米松联合恩丹西酮对手术后病人自控镇痛 (PCA)所致恶心呕吐的防治效果。方法　随机将 2 0 0例在连续硬膜外麻醉下行下肢手术的患者分为四组 :对照 (C)组于手术切皮前 (T1)和手术结束时 (T2 )分别静脉注射生理盐水 2ml;地塞米松 (D)组于T1、T2 时分别注射地塞米松 10mg和生理盐水 2ml;恩丹西酮 (O)组于T1、T2 时分别注射生理盐水 2ml和恩丹西酮4mg ;地塞米松 +恩丹西酮 (D +O)组于T1、T2 时分别注射地塞米松 10mg和恩丹西酮 4mg。术毕均行病人自控静脉芬太尼镇痛 (PCIFA)。观察术后 2 4h内病人镇痛效果、镇静评分和恶心呕吐发生情况。结果　 5例患者因故退出此观察。组间镇痛效果、镇静评分无明显差异。C组恶心呕吐发生率为 5 2 1% ,明显高于D组 (33 3% )和O组 (32 7% ) ,P <0 0 5 ;D +O组恶心呕吐发生率为16 0 % ,与C组比较 ,P <0 0 1,与D组和O组比较 ,P <0 0 5 ;各处理组恶心程度均小于对照组 ,P <0 0 5 ;D +O组呕吐程度低于C组 ,P <0 0 5。结论　地塞米松与恩丹西酮单独应用均能有效地减少手术后PCIFA相关的恶心呕吐 ,减轻恶心程度 ;两药联合应用进一步降低患者的恶心呕吐发生率和呕吐的程度     

枢复宁预防全麻腹部手术后恶心和呕吐的临床研究

全麻患者术后常易发生恶心、呕吐，枢复宁有抗呕吐作用。随机选择１００例腹部外科手术患者，分为枢复宁组（４ｍｇ，ｎ＝５０）和安慰剂组（生理盐水，ｎ＝５０），诱导前静注枢复宁或安慰剂，注速１分钟，双盲法观察术后２４小时抗恶心、呕吐效果及副作用。结果表明，用药组恶心、呕吐发生率（１８％，０）明显低于安慰剂组（５０％，４０％）（Ｐ＜０．０１），两组患者的平均动脉压、经皮血氧饱和度，呼吸频率和心率，血液成分，肝、肾功能无明显改变。因此，枢复宁适用于腹部外科患者术后恶心、呕吐的防治。     

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.     

How to study postoperative nausea and vomiting

Anesthesiological journals are flooded by innumerable studies of postoperative nausea and vomiting (PONV). Nevertheless, PONV remains a continuing problem with an average incidence of 20-30%. This paper should provide essential information for the design, conduct, and presentation of these studies. It should also increase comparability among future studies and help clinicians in assessing and reading the literature on PONV. First, future studies should address new and relevant questions instead of repeatedly investigating prophylactically given antiemetics whose main results are predictable (e.g. already proven by meta-analysis). Second, group comparability should be based on well-proven risk factors and a simplified risk score for predicting PONV. Endless listings of doubtful risk factors should be avoided. Third, a realistic sample size estimation should be performed, i.e. in most cases at least 100 patients per group are necessary. Fourth, nausea, vomiting and rescue medication should be recorded and reported separately with the corresponding incidences (and number of patients with these separate symptoms), and the main end-point should be PONV. The entire observation period should cover 24 h. Additional reporting of the early (0-2 h) and delayed (2-24 h) postoperative period is desirable and should consider single and cumulative incidences. Lastly, interpretation of results should take into account the study hypothesis, sources of potential bias or imprecision, and the difficulties associated with multiplicity of analysis and outcomes.     

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.     

The value of risks scores for predicting postoperative nausea and vomiting when used to compare patient group in a randomised controlled trial

Whilst conducting a randomised controlled trial into the effects of combination anti-emetics, we endeavoured to confirm that our patient groups were matched using the predictive scoring systems for postoperative nausea and vomiting (PONV) and postoperative vomiting (POV) reported in the literature. One hundred and seventy-seven female patients attending for day case gynaecological surgery were studied and their individual risks of PONV and POV were calculated using four predictive models for PONV and two predictive models for POV. The scoring systems were then evaluated to see if agreement existed between them using the method described by Bland and Altman. Bias and 95% limits of agreement were calculated for each combination. Agreement between scoring systems was poor. As the scoring systems gave widely divergent predictions, we concluded that the predictive risk for PONV or POV would be dependent upon the scoring system chosen, thus limiting their usefulness in this role.     

帕洛诺司琼在加速康复外科中的作用

目的探讨帕洛诺司琼在加速康复外科中的作用,为临床患者的围手术期康复提供更优质的服务。 方法采用前瞻性、随机的研究方法,选择2015年9月至2016年2月拟行结直肠腹腔镜手术者120例,随机分为3组,各40例,各组术后行同配方的静脉镇痛。A组手术结束前1 h静推托烷司琼6 mg;B组手术结束前1 h静推帕洛诺司琼0.25 mg;C组手术结束前1 h静推帕洛诺司琼0.25 mg,静脉镇痛泵中静脉泵注帕洛诺司琼0.25 mg/72 h。记录并比较各组患者术后恶心、呕吐（PONV）等并发症发生率以及下床天数、出院时间。 结果B组和A组术后恶心、呕吐发生率差异无统计学意义,C组较之A组、B组在术后24 h后PONV发生率差异有统计学意义（χ²=5.165、5.165,P=0.023、0.023）;C组、B组较之A组术后镇痛24 h内除PONV外其余并发症发生率差异无统计学意义,24 h后除PONV外其余并发症发生率差异有统计学意义（χ²=4.500、6.275,P=0.033、0.012）;C组较之A组、B组术后下床天数（t=3.718、2.975,P<0.001、0.004）、出院时间（t=6.650、5.440,均P<0.001）差异有统计学意义。 结论帕洛诺司琼持续用药效果更稳定,可降低术后恶心、呕吐发生率,加速患者术后康复。     

Efficacy of prophylactic intravenous granisetron in postoperative emesis in adults

Purpose This randomized, double-blind, placebo-controlled trial evaluated the efficacy, safety, and optimal dose of granisetron in the prophylactic control of postoperative nausea and vomiting in patients undergoing gynecologic surgery or cholecystectomy.Methods Three-hundred and fifteen patients (age, 20–65 years) received intravenous granisetron (1mg or 3mg) or placebo immediately before the end of anesthesia. After treatment, patients were observed for 24h, and the occurrence of nausea and vomiting was recorded and safety was assessed. The no-vomiting rate, time-to-first vomiting episode, and severity of nausea were recorded.Results The no-vomiting rates in patients receiving granisetron 1mg and 3mg were significantly higher than that in the placebo group (83.7%, 78.8%, and 57.9%, respectively; P = 0.0004 for 1mg vs placebo, P = 0.001 for 3mg). Time-to-first vomiting episode was longer in the granisetron 1-mg and 3-mg groups than in the placebo group (time-to-event analysis, Kaplan-Meier, log-rank test; 83.2%, 80.1%, and 59.1%, respectively; P = 0.0002 and P = 0.0010). The severity of nausea was also less in granisetron-treated patients (25.2%, 11.5%, and 15.4% severe nausea incidence for placebo, granisetron 1mg, and granisetron 3mg, respectively; P = 0.00003 and P = 0.002). Fewer rescue medications were required in the two granisetron-treated groups compared with those receiving placebo. Adverse events were similar in all groups. No differences in efficacy or safety were observed between granisetron doses.Conclusion Granisetron is well-tolerated and more effective than placebo in the prophylactic control of nausea and vomiting after surgery. This study suggests that the optimum dose of granisetron is 1mg.*See Appendix.     

盐酸帕洛诺司琼预防硬膜外自控镇痛所致恶心呕吐的分析

【摘要】　目的 观察盐酸帕洛诺司琼预防术后硬膜外腔自控镇痛引起恶心呕吐副作用的效果。方法 选取择期硬膜外麻醉下开腹胆囊切除术后施行硬膜外腔自控镇痛(PCEA)的患者60例,PCEA采用吗啡6 mg+0.125%布比卡因混合液(100 mL)。将患者分为盐酸帕洛诺司琼组,氟哌啶组和对照组(每20例),在术前静脉给予盐酸帕洛诺司琼0.25 mg,氟哌啶2.5 mg和生理盐水100 mL。术后记录使用PCEA镇痛期间的恶心例数及其严重程度;呕吐例数及次数;出现呕吐后给予胃复安,非那根,地塞米松等药物止吐的控制率。结果 对照组13例出现Ⅰ~Ⅲ级恶心呕吐的不良反应,盐酸帕洛诺司琼组患者1例1级恶心呕吐的发生,与其他两组相比P<0.001;氟哌啶组出现5例Ⅰ~Ⅱ级恶心呕吐的,与对照组相比P=0.022。结论 术前预防性给予盐酸帕洛诺司琼可显著降低胆囊切除术后PCEA引起恶心呕吐副作用的发生。     

Comparação entre palonosetrona‐dexametasona e ondansetrona‐dexametasona na prevenção de náuseas e vômitos no pós‐operatório de cirurgia do ouvido médio: estudo clínico randomizado

BackgroundPostoperative nausea and vomiting is the second most common complaint in the postoperative period after pain. The incidence of postoperative nausea and vomiting was 60−80% in middle ear surgeries in the absence of antiemetic prophylaxis. Because of this high incidence of postoperative nausea and vomiting, we aimed to assess the effect of palonosetron‐dexamethasone and ondansetron‐dexamethasone combination for the prevention of postoperative nausea and vomiting in patients of middle ear surgery.MethodsSixty‐four patients, scheduled for middle ear surgery, were randomized into two groups to receive the palonosetron‐dexamethasone and ondansetron‐dexamethasone combination intravenously before induction of anesthesia. Anesthesia technique was standardized in all patients. Postoperatively, the incidences and severity of nausea and vomiting, the requirement of rescue antiemetic, side effects and patient satisfaction score were recorded.ResultsDemographics were similar in the study groups. The incidence difference of nausea was statistically significant between groups O and P at a time interval of 2−6 hours only (p = 0.026). The incidence and severity of vomiting were not statistically significant between groups O and P during the whole study period. The overall incidence of postoperative nausea and vomiting (0−24 hours postoperatively) was 37.5% in group O and 9.4% in group P (p = 0.016). Absolute risk reduction with palonosetron‐dexamethasone was 28%, the relative risk reduction was 75%, and the number‐needed‐to‐treat was 4. The patient's satisfaction score was higher in group P than group O (p = 0.016). The frequency of rescue medication was more common in group O than in group P patients (p = 0.026).ConclusionThe combination of palonosetron‐dexamethasone is superior to ondansetron‐dexamethasone for the prevention of postoperative nausea and vomiting after middle ear surgeries.     

芬太尼静脉镇痛对血浆胃动素的影响

目的　研究芬太尼静脉镇痛对血浆胃动素水平的影响。方法　接受矫形外科手术的ASAI～II级患者 5 0例 ,随机分为哌替啶镇痛组 (P组即对照组 ,n =2 0 )和芬太尼静脉镇痛组(F组 ,n =30 )。镇痛方式 :F组采用病人自控静脉镇痛 (PCIA) ,配方 :芬太尼 1 2mg、氟哌利多 5mg,加生理盐水至 10 0ml。背景流量 2ml/h ,自控剂量 0 5ml,锁定时间 15min。P组采用肌注哌替啶镇痛。分别于手术当天、术后第 1、2和 3天晨抽取空腹静脉血 2ml,放免法测定胃动素含量。观察指标 :镇痛评分、恶心呕吐评分和镇痛药用量。结果　F组镇痛效果显著优于P组 (P <0 0 1)。术后第 1天两组血浆胃动素水平均显著下降 (P <0 0 1) ,但两组间比较无显著差异 (P >0 0 5 )。F组第 2天胃动素水平显著上升 (与基础值相比 ,P <0 0 1;与P组相比 ,P <0 0 1) ,第 3天逐渐下降。有 11例患者发生恶心呕吐。P组第 2、3天胃动素水平逐渐上升 ,接近术前水平 ,3例患者出现恶心呕吐。结论　芬太尼静脉镇痛升高血浆胃动素水平 ,可能是芬太尼静脉镇痛增加术后恶心呕吐的机制     

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.     

Transdermal scopolamine patch in addition to ondansetron for postoperative nausea and vomiting prophylaxis in patients undergoing ambulatory cosmetic surgery

Study ObjectiveTo determine the efficacy of transdermal scopolamine in addition to ondansetron in decreasing the incidence of postoperative nausea and vomiting (PONV).DesignRandomized controlled trial.SettingAcademic hospital.Patients126 ASA physical status I and II patients undergoing outpatient plastic surgery with three or more risk factors for PONV.InterventionsPatients were randomly assigned to one of two groups to receive (Group 1) a transdermal scopolamine (TDS) patch or (Group 2), a placebo patch two hours before surgery.MeasurementsOccurrence of vomiting, severity of nausea using a visual analog scale (VAS), rescue medication, pain intensity and pain medications, and side effects were recorded every hour until discharge from hospital, then every 4 hours thereafter for a total of 24 hours.Main ResultsA statistically significant reduction in postoperative nausea between 8 and 24 hours in patients receiving TDS was noted.ConclusionsTransdermal scopolamine in addition to ondansetron benefits patients at high risk for PONV undergoing outpatient plastic surgery for up to 20 hours after surgery.