Postoperative Nausea and Vomiting—
Can It Be Eliminated?
Tong J. Gan, MB
POSTOPERATIVENAUSEAANDVOM- paratus,cerebellum,solitarytract Risk Factor Identification
tient, surgical, and anesthetic factors.
that female sex, a history of motion sick- shorter-acting anesthetic drugs, have re- the presence of 0, 1, 2, 3, or all 4 of these patients,3,4 and pediatric populations are tiemetic in adults, with an adverse effect during anesthesia, including opioids, ni- trous oxide, and volatile inhalational an- perazine, are effective but associated with PONV is rarely fatal, it is an unpleasant postoperative symptom (BOX). Even
risk factors, are presented in the FIGURE.
charge, decrease patient satisfaction, and Combination Antiemetics
mines, cyclizine is effective, although it one study, patients were willing to spend ing on different receptors can further re- Physiology of and
Author Affiliation: Department of Anesthesiology,
Pharmacology for PONV
Duke University Medical Center, Durham, NC.
Financial Disclosure: Dr Gan has received grant
support and honoraria from Abbott, Aventis, GlaxoSmithKline, Novartis, and Roche.
Corresponding Author and Reprints: Tong J. Gan, MB,
fects.16,17 It is important to distinguish Department of Anesthesiology, Duke University Medi- cal Center, Box 3094, Durham, NC 27710 (e-mail: ter is an ill-defined area located in the [email protected]).
Contempo Updates Section Editor: Janet M. Torpy,
2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 13, 2002—Vol 287, No. 10 1233
greater effectiveness than a single agent.20 asone (Ͻ8 mg) appears to be safe, largerdoses and prolonged use may cause ad- Box. Recommended Strategies for Minimizing the Incidence
of Postoperative Nausea and Vomiting
and can develop following relatively brief corticosteroids.24 In a recent warning by Antiemetics (consider combination therapy) Total intravenous anesthesia with propofolAdequate hydration Effective analgesia incorporating local anesthetics and inhibitors of Intraoperative supplemental oxygen (FIO Ն *Although opioids are emetogenic, optimal analgesia should be the goal and can be achieved by incorporating preoperative education, local anesthetics, and inhibitors of cyclooxygen- ase 2. Optimal analgesia may include an opioid.
Medicines Control Agency, part of theDepartment of Health in the UnitedKingdom, did not mandate electrocar- Figure. Risk Factors for PONV and Guidelines for Prophylactic Antiemetic Therapy
diographic monitoring with the use ofdroperidol perioperatively.26 In the 31years of droperidol use, there has not Patient Factors
Surgical Factors
tion, arrhythmias, or cardiac arrest.
trapolate that use of multiple (Ͼ2) drug combinations will further enhance ef-fectiveness, published evidence isscarce. Scuderi et al26 showed that mul-timodal management incorporatingcombination antiemetics and propo- Mild to Moderate Risk
Moderate to High Risk
Very High Risk
sponse rate. A high concentration ofoxygen as an antiemetic is a use that few appreciate.27,28 Greif et al27 used intra- intraoperatively. The use of 80% oxy-gen intraoperatively as a component ofgeneral anesthesia significantly re- Based on references 3 and 38. PONV indicates postoperative nausea and vomiting. Percentages denote risk ofdeveloping PONV. Consideration should be given to avoid risk factors associated with PONV and other strat- egies (Box) to further reduce the incidence. Serotonin antagonists may be preferred antiemetics in operative settings where nursing labor costs are directly related to the length of postanesthesia care unit stay.
1234 JAMA, March 13, 2002—Vol 287, No. 10 (Reprinted)
2002 American Medical Association. All rights reserved.
centration or the decrease in nitrous ox- sea and vomiting or adverse effects of an- are more likely to be directly related to stay in an office-based setting and, to a fective after discharge. There is a lack of effective over-the-counter antiemetics.
sia care unit stay may not have a signifi- ing staff can be reduced. In light of the pofol’s action as an antiemetic has not ther investigation of the cost-effective- ness of other therapies is required.
Future Development
The natural ligand of the neurokinin 1(NK-1) receptor, substance P, is found Complementary Techniques
Cost-effectiveness of Antiemetics
in the nucleus tractus solitarius and the out actually needing it, while others will radialis and palmaris longus tendons.
inefficient use of resources.41 In a cost- laxis with ondansetron in all patients is Postdischarge Nausea
and Vomiting
this trend is increasing.36 Postoperative effective and associated with greater pa- 2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 13, 2002—Vol 287, No. 10 1235
antiemetics should be considered (Box).
fied, avoidable risk factors should be re- REFERENCES
1. Bonica J, Crepps W, Monk B, Bennett B. Post-
16. Tramer MR, Phillips C, Reynolds DJ, et al. Cost-
effects of propofol in the area postrema of rats. Anesth anesthetic nausea, retching and vomiting. Anesthe- effectiveness of ondansetron for postoperative nau- sea and vomiting. Anaesthesia. 1999;54:226-234.
32. Lee A, Done ML. The use of nonpharmacologic
2. Cohen MM, Duncan PG, DeBoer DP, Tweed
17. Zarate E, Watcha MF, White PF, et al. A com-
techniques to prevent postoperative nausea and vom- WA. The postoperative interview: assessing risk fac- parison of the costs and efficacy of ondansetron ver- iting. Anesth Analg. 1999;88:1362-1369.
tors for nausea and vomiting. Anesth Analg. 1994; sus dolasetron for antiemetic prophylaxis. Anesth 33. Kotani N, Hashimoto H, Sato Y, et al. Preopera-
tive intradermal acupuncture reduces postoperative 3. Apfel CC, Laara E, Koivuranta M, et al. A simplified
18. Tramer MR. A rational approach to the control
pain, nausea and vomiting, analgesic requirement, and risk score for predicting postoperative nausea and vom- of postoperative nausea and vomiting: evidence from sympathoadrenal responses. Anesthesiology. 2001; iting: conclusions from cross-validations between two systematic reviews. Acta Anaesthesiol Scand. 2001; centers. Anesthesiology. 1999;91:693-700.
34. Enqvist B, Bjorklund C, Engman M, Jakobsson J.
4. Gan TJ, Ginsberg B, Grant AP, Glass PS. Double-
19. Henzi I, Walder B, Tramer MR. Dexamethasone
Preoperative hypnosis reduces postoperative vomit- blind, randomized comparison of ondansetron and in- for the prevention of postoperative nausea and vom- ing after surgery of the breasts: a prospective ran- traoperative propofol to prevent postoperative nausea iting. Anesth Analg. 2000;90:186-194.
domized and blinded study. Acta Anaesthesiol Scand.
and vomiting. Anesthesiology. 1996;85:1036-1042.
20. Habib AS, Gan TJ. Combination therapy for post-
5. Rose JB, Watcha MF. Postoperative nausea and
operative nausea and vomiting—a more effective pro- 35. Ernst E, Pittler MH. Efficacy of ginger for nausea
vomiting in paediatric patients. Br J Anaesth. 1999; phylaxis? Ambulatory Surgery. 2001;9:59-71.
and vomiting. Br J Anaesth. 2000;84:367-371.
21. McKenzie R, Uy NTL, Riley TJ, Hamilton DL. Dro-
36. Centers for Disease Control and Prevention. Vi-
6. Ved SA, Walden TL, Montana J, et al. Vomiting and
peridol/ondansetron combination controls nausea and tal and Health Statistics, Ambulatory and Inpatient recovery after outpatient tonsillectomy and adenoid- vomiting after tubal banding. Anesth Analg. 1996; Procedures in the United States. Washington, DC: US ectomy in children. Anesthesiology. 1996;85:4-10.
Dept of Health and Human Services; 1996.
7. Shende D, Bharti N, Kathirvel S, Madan R. Com-
22. Pueyo FJ, Carrascosa F, Lopez L, et al. Combina-
37. Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Post-
bination of droperidol and ondansetron reduces PONV tion of ondansetron and droperidol in the prophy- operative nausea and vomiting after discharge from after pediatric strabismus surgery more than single drug laxis of postoperative nausea and vomiting. Anesth outpatient surgery centers. Anesth Analg. 1995;80: therapy. Acta Anaesthesiol Scand. 2001;45:756- 23. Habib AS, El-Moalem HE, Gan TJ. Should 5-HT3
38. Gan TJ, Franak R, Reeves J. Comparison of on-
8. Visser K, Hassink EA, Bonsel GJ, et al. Random-
receptor antagonists be combined with droperidol or dansetron orally disintegrating tablet (ODT) versus pla- ized controlled trial of total intravenous anesthesia with dexamethasone for PONV prophylaxis? Anesthesiol- cebo for the prevention of postdischarge nausea and propofol versus inhalation anesthesia with isoflurane- vomiting following ambulatory surgery. Anesth Analg. nitrous oxide. Anesthesiology. 2001;95:616-626.
24. Virik K, Karapetis C, Droufakou S, Harper P. Avas-
9. Hill RP, Lubarsky DA, Phillips-Bute B, et al. Cost-
cular necrosis of bone: the hidden risk of glucocorti- 39. Zarate E, Mingus M, White PF, et al. The use of
effectiveness of prophylactic antiemetic therapy with coids used as antiemetics in cancer chemotherapy. Int transcutaneous acupoint electrical stimulation for pre- ondansetron, droperidol, or placebo. Anesthesiol- J Clin Pract. 2001;55:344-345.
venting nausea and vomiting after laparoscopic sur- 25. Food and Drug Administration. FDA strength-
gery. Anesth Analg. 2001;92:629-635.
10. Macario A, Weinger M, Carney S, Kim A. Which
ens warnings for droperidol. Available at: http://www 40. Bailey PL, Streisand JB, Pace NL, et al. Transder-
clinical anesthesia outcomes are important to avoid? mal scopolamine reduces nausea and vomiting after Anesth Analg. 1999;89:652-658.
.html. Accessibility verified January 24, 2002.
outpatient laparoscopy. Anesthesiology. 1990;72: 11. Gan T, Sloan F, Dear G, et al. How much are pa-
26. Scuderi PE, James RL, Harris L, Mims GR III. Mul-
tients willing to pay to avoid postoperative nausea and timodal antiemetic management prevents early post- 41. Watcha MF. The cost-effective management of
vomiting? Anesth Analg. 2001;92:393-400.
operative vomiting after outpatient laparoscopy. Anesth postoperative nausea and vomiting [editorial]. Anes- 12. Watcha MF, White PF. Postoperative nausea and
vomiting: its etiology, treatment, and prevention [re- 27. Greif R, Laciny S, Rapf B, et al. Supplemental oxy-
42. Scuderi PE, James RL, Harris L, Mims GR III. An-
view]. Anesthesiology. 1992;77:162-184.
gen reduces the incidence of postoperative nausea and tiemetic prophylaxis does not improve outcomes af- 13. Henzi I, Walder B, Tramer MR. Metoclopramide
vomiting. Anesthesiology. 1999;91:1246-1252.
ter outpatient surgery when compared to symptom- in the prevention of postoperative nausea and vom- 28. Goll V, Akca O, Greif R, et al. Ondansetron is no
atic treatment. Anesthesiology. 1999;90:360-371.
iting: a quantitative systematic review of random- more effective than supplemental intraoperative oxy- 43. Gillis R, Helke C, Hamilton B, et al. Evidence that
ized, placebo-controlled studies. Br J Anaesth. 1999; gen for prevention of postoperative nausea and vom- substance-P is a neurotransmitter of baro- and che- iting. Anesth Analg. 2001;92:112-117.
moreceptor afferents in nucleus tractus solitarius.
14. Fortney JT, Gan TJ, Graczyk S, et al. A compari-
29. Tramer M, Moore A, McQuay H. Propofol an-
J Brain Res. 1980;181:476-481.
son of the efficacy, safety, and patient satisfaction of aesthesia and postoperative nausea and vomiting: 44. McLean S, Ganong A, Seymour PA, et al. Char-
ondansetron versus droperidol as antiemetics for elec- quantitative systematic review of randomized con- acterization of CP-122,721; a nonpeptide antagonist tive outpatient surgical procedures. Anesth Analg. trolled studies. Br J Anaesth. 1997;78:247-255.
of the neurokinin NK1 receptor. J Pharmacol Exp Ther. 30. Gan TJ, Glass PS, Howell ST, et al. Determina-
15. Ahmed AB, Hobbs GJ, Curran JP. Randomized,
tion of plasma concentrations of propofol associated 45. Gesztesi Z, Scuderi PE, White PF, et al. Sub-
placebo-controlled trial of combination antiemetic pro- with 50% reduction in postoperative nausea. Anes- stance P (neurokinin-1) antagonist prevents postop- phylaxis for day-case gynaecological laparoscopic sur- erative vomiting after abdominal hysterectomy pro- gery. Br J Anaesth. 2000;85:678-682.
31. Cechetto DF, Diab T, Gibson CJ, Gelb AW. The
cedures. Anesthesiology. 2000;93:931-937.
1236 JAMA, March 13, 2002—Vol 287, No. 10 (Reprinted)
2002 American Medical Association. All rights reserved.



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