Increased incidence of retching and vomiting during periovulatory phase after middle ear surgery

Purpose  

To assess the effect of the menstrual cycle on post-operative retching and vomiting (R& V) after middle ear surgery, and the efficacy of prophylaxis against R& V in female patients with transdermal scopolamine during either general or local anaesthesia and with intravenous ondansetron during general anaesthesia.     

Comparison of subhypnotic doses of thiopentone vs propofol on the incidence of postoperative nausea and vomiting following middle ear surgery

Background : Middle ear surgery is associated with a high incidence of emetic sequelae and propofol has been reported to have antiemetic activity in subhypnotic doses.
Methods : In a double-blind, randomized study, the patients received either thiopentone 1.0 mg.kg^-1 (n=26) or 0.5 mg.kg^-1 propofol (n=26) at the end of middle ear surgery under isoflurane-N₂O-fentanyl-vecuronium anaesthesia. Trained nurses, unaware of the group assignment, assessed postoperative nausea, retching and vomiting up to 24 h after the end of anaesthesia. Droperidol 10μg.kg^-1 was used as a "rescue" antiemetic.
Results : The main result was that the patients in the propofol group did not suffer from retching and vomiting (R&V) during the first 6 h, whereas these symptoms occurred in 46% ( P <0.001) of the patients in the thiopentone group. The patients in the propofol group needed significantly less droperidol during the first 24 h (mean number of doses 0.39 ± 0.57 (SD)) than the patients in the thiopentone group (1.35 ± 1.47, P <0.005). Treatment with propofol was a predictor for lowered incidence of R&V, as well as male gender and negative history of motion sickness.
Conclusion : Propofol at a subhypnotic dose of 0.5 mg.kg^-1 provides prophylaxis against retching and vomiting for the first 6 h postoperatively after middle ear surgery. The incidence of nausea was not reduced by propofol.     

Effects of propofol on ipecacuanha-induced nausea and vomiting

Background : The purpose of this study was to evaluate if propofol has 5-HT₃ antagonistic effects. Ipecacuanha is known to release serotonin (5-HT) in the gastrointestinal tract and therefore ipecacuanha syrup was used to induce nausea and vomiting. The 5-HT₃ antagonist ondansetron was used as a control substance.
Results : During the first 150 min after ingestion of ipecacuanha there were no retchings during the ondansetron infusion ( P = 0.01 vs placebo, P =0.02 vs propofol) and significantly fewer retchings during propofol infusion compared to placebo ( P <0.02). There was no nausea during the ondansetron infusion ( P <0.01 vs placebo and propofol) but the volunteers experienced nausea both during the placebo and propofol infusion (NS).
Conclusion : This study in volunteers has shown that propofol reduces the intensity of retching after oral intake of ipecacuanha syrup. As ipecacuanha releases 5-hydroxytryptamine, it can be concluded that propofol may have a weak 5-HT₃ antagonistic effect.
Method : Ten healthy male volunteers (20–37 years) were studied on three occasions and were randomly allocated to receive a concomitant infusion of propofol (initial bolus 0.1 mg kg^-1 then 1 mg kg^-1h^-1), ondansetron (initial bolus 0.11 mg kg^-1 then 14 μg kg^-1 h^-1) and placebo on either occasion. The infusions started 30 min before oral ingestion of 30 ml of ipecacuanha and continued until 150 min after the intake. The number of retchings was recorded and the intensity of nausea was estimated by the subjects on a visual analog scale.     

Vomiting, retching, headache and restlessness after halothane-, isoflurane- and enflurane-based anaesthesia: An analysis of pooled data following ear, nose, throat and eye surgery

Background: Isoflurane has exceeded halothane and enflurane in usage. A literature search, however, revealed no data comparing the effects on emesis, headache and restlessness of these three agents.
Methods: With hospital ethics committee approval and patient consent, a prospective, randomised, double-blind study of 556 patients undergoing ENT and eye surgery was undertaken to evaluate the effects of halothane, isoflurane and enflurane on vomiting, retching, headache and restlessness until 24 h after anaesthesia. Balanced general anaesthesia was administered comprising benzodiazepine premedication, induction with thiopentone-atracurium-morphine (ENT patients) or fentanyl (eye patients), controlled ventilation and maintenance with either halothane 0.4–0.6 vol% (n = 186), isoflurane 0.6–0.8 vol% (n = 184) or enflurane 0.8–1 vol% (n=186) in nitrous oxide 67% and oxygen.
Results: The three study groups were comparable, and comprised comparable subgroups having ear, nose, throat, intraocular and non-intraocular surgery. During early recovery from anaesthesia, the respective requirements for halothane, isoflurane and enflurane for analgesia (7%, 9% and 10%), frequency of emesis (6%, 8% and 8%), antiemetic requirements (1%, 1% and 2%), restlessness-pain scores and time spent in the recovery ward (27 SD 10, 31 SD 12 and 26 SD 9 min) were similar. During the ensuing 24-h postoperative period, patients who had isoflurane experienced emesis less often than those who had halothane (36% vs 46%, P <0.025) but did so with similar frequency to those who had enflurane (46% vs 41%). Antiemetic requirements were least in those given isoflurane (isoflurane 12%, halothane and enflurane 23% each, P <0.005), but headache and analgesic requirements were similar.
Conclusion: Isoflurane induces less postoperative emesis than halothane, but headache is similarly frequent after anaesthesia with any of these agents.     

The physiological motor patterns produced by neurons in the nucleus retroambiguus in the rat and their modulation by vagal,peripheral chemosensory,and nociceptive stimulation

The nucleus retroambiguus (NRA) is a neuronal cell group in the medullary ventrolateral tegmentum, rostrocaudally between the obex and the first cervical spinal segment. NRA neurons are premotor interneurons with direct projections to the motoneurons of soft palate, pharynx, and larynx in the nucleus ambiguus in the lateral medulla as well as to the motoneurons in the spinal cord innervating diaphragm, abdominal, and pelvic floor muscles and the lumbosacral motoneurons generating sexual posture. These NRA premotor interneurons receive very strong projections from the periaqueductal gray (PAG) in the context of basic survival mechanisms as fight, flight, freezing, sound production, and sexual behavior. In the present study in rat we investigated the physiological motor patterns generated by NRA neurons, as the result of vagal, peripheral chemosensory, and nociceptive stimulation. The results show that the NRA contains phasic respiratory modulated neurons, as well as nonphasic tonically modulated neurons. Stimulation in the various rostrocaudal levels of the NRA generates site‐specific laryngeal, respiratory, abdominal, and pelvic floor motor activities. Vagal and peripheral chemosensory stimulation induces both excitatory and inhibitory modulation of phasic NRA‐neurons, while peripheral chemosensory and nociceptive stimulation causes excitation and inhibition of nonphasic NRA‐neurons. These results are in agreement with the concept that the NRA represents a multifunctional group of neurons involved in the output of the emotional motor system, such as vomiting, vocalization, mating, and changes in respiration.     

从《金匮要略》探讨橘皮功效及应用

橘皮在《金匮要略》中的运用共出现三次,涉及橘枳姜汤、橘皮汤和橘皮竹茹汤三方。主要从《金匮要略》治疗胸痹和呕吐哕均使用橘皮且临床胃痞患者常有胸闷表现入手,结合现代临床应用及实验研究,联系经脉循行、气机升降理论,试图用一元观点概括橘皮治疗胸痹和呕吐哕以及咳嗽等病症的病机,分析可能是取其能降阳明胃经之气,使在上之浊阴下降,同时亦能降太阴肺经之气。     

Treatment of postoperative emetic symptoms with granisetron in women undergoing abdominal hysterectomy: a randomized, double-blind, placebo-controlled, dose-ranging study

Background

Postoperative emetic symptoms (nausea, retching, and vomiting) frequently occur in women undergoing general anesthesia for abdominal hysterectomy. In a previous report by us, granisetron, a selective serotonin receptor antagonist, was more effective than the traditional antiemetics, droperidol and metoclopramide, for the treatment of postoperative emetic symptoms in this population.

Objective

The aim of this study was to determine the optimal dose of granisetron for the treatment of emetic symptoms following abdominal hysterectomy.

Methods

This randomized, double-blind, placebo-controlled, dose-ranging study was conducted at Toride Kyodo General Hospital (Toride, Japan). Female patients aged 33 to 66 years experiencing postoperative emetic symptoms after abdominal hysterectomy were eligible for the study. Patients received IV granisetron at 1 of 4 doses (10, 20, 40, or 100 μg/kg) or placebo; they were then observed for 24 hours. Emetic symptoms and the need for a rescue antiemetic were recorded by nursing staff, who were blinded to treatment assignment.

Results

A total of 100 patients (mean [SD] age, 45 [7] years [range, 33-66 years]) were enrolled (n = 20 in each group). No significant differences in patient demographic characteristics were observed between the groups. The number of patients in whom complete control of postoperative emetic symptoms, defined as being free of emetic symptoms and not needing rescue antiemetic medication for 24 hours after study drug administration, was established was significantly greater in 3 of the granisetron groups than in the placebo group (6 patients [30%]): granisetron 10 μg/kg, 7 patients (35%; P= NS); granisetron 20 μg/kg, 17 patients (85%; P = 0.001); granisetron 40 μg/kg, 17 patients (85%; P = 0.001); and granisetron 100 μg/kg, 16 patients (80%; P = 0.002). No clinically significant adverse events attributable to the study drug were observed in any group.

Conclusion

In this study of patients who experienced emetic symptoms after undergoing general anesthesia for abdominal hysterectomy, granisetron at doses ≥20 μg/kg was effective in the treatment of established postoperative emetic symptoms.     

Surgical management of gastro-oesophageal reflux in children

Gastro-oesophageal reflux (GOR) in newborns does not necessarily represent a clinical disease, but rather a somewhat delayed physiological development that corrects with time. Gastro-oesophageal reflux disease (GORD) is defined as secondary symptoms and complications arising from gastro-oesophageal reflux. GORD requires aggressive medical management in an attempt to reverse complications and hopefully achieve long-term cure. Supportive or medical treatment is sufficient in mild cases, but GORD is best managed surgically when severe disease or complications are present. Investigations to support the diagnosis and assess the severity usually include: upper gastrointestinal endoscopy, pH study and upper gastrointestinal contrast study. A combined pH and impedance study may become the gold standard investigative tool with increased experience in children. Surgical procedures for GORD aims to augment or correct some of the mechanisms which prevent GOR. The Nissen fundoplication is the most frequently performed operation, but several other fundoplications are also used. Symptom control can be achieved with improvement in quality of life, but recurrence rates can be high in patients with neurological impairment or generalized bowel dysmotility.     

Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication

Background: Children with feeding disorders requiring Nissen fundoplication may develop gagging and retching following gastrostomy feedings. We developed a “pureed by gastrostomy tube” (PBGT) diet in an attempt to treat these symptoms and provide adequate nutrition and hydration. Methods: Children post– fundoplication surgery with symptoms of gagging and retching with gastrostomy feedings were selected from our interdisciplinary feeding team. An individualized PBGT diet was designed to meet the child's nutrition goals. The child's weight gain was recorded at each follow‐up visit. A telephone survey was performed to determine parents' perceptions of the child's symptoms and oral feeding tolerance. Results: Thirty‐three children (mean age, 34.2 months) participated in the trial. Average weight gain on the PBGT diet was 6.2 g/d. Seventeen children (52%) were reported to have a 76%–100% reduction in gagging and retching. Twenty‐four children (73%) were reported to have a ≥50% decrease in symptoms. No child had worsened symptoms on the PBGT diet. Nineteen children (57%) were reported to have an increase in oral intake on the PBGT diet. Conclusions: A PBGT diet is an effective means of providing nutrition to children with feeding disorders. In children post–fundoplication surgery, a PBGT diet may decrease gagging and retching behaviors.