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Postoperative nausea and vomiting
Managing Your OR
Postoperative Nausea and Vomiting “Managing Your OR” focuses on various aspects of aesthetic surgery in the ambulatory surgical setting.
P
ostoperative nausea and vomiting (PONV) is an ever-present feature of the perioperative experience. The type of surgery, the type and duration of anesthesia, and various patient factors all contribute to the condition. Some patients state that they prefer postoperative pain to PONV, and the value of avoiding PONV is demonstrated by questionnaires that document patients’ willingness to pay for prophylaxis personally.1
The list of known factors predisposing patients to PONV suggests why this is a problem in the typical aesthetic surgery practice. Nausea is 2 to 3 times more common in women than men2,3 and 4 times as likely during the first week of the menstrual cycle.4 Nonsmokers have a higher incidence than smokers.2,5 A history of either motion sickness or PONV is a strong predictor of PONV.2,6 The incidence of PONV varies directly with duration of anesthesia. One study examining half-hour increments found an incidence of PONV of approximately 3% for durations of less than 30 minutes; this increased continuously to roughly 30% for durations of 151 to 180 minutes. Durations of more than 180 minutes (19%), however, did not follow this rule.5 General anesthesia—including that involving opioids5 and/or nitrous oxide7—is associated with nausea more often than is propofol when the latter is used as the sole agent,8 propofol being a mild antiemetic drug.9 Paradoxically, opioids may be useful postoperatively, inasmuch as pain may cause nausea.10 Muscle-relaxant reversal agents, such as neostigmine, given in conjunction with an anticholinergic, such as glycopyrrolate, do not appear to contribute.5 Sinclair et al5 found that plastic surgery was associated with a higher incidence of PONV than general surgery. However, this increased incidence appears to be attributable to the remarkably high incidence of PONV in a subpopulation of 41 breast augmentation patients (41%).
This is by far the highest rate of PONV for any type of surgery. Other aesthetic procedures involving the skin and face had an incidence of only about 5%. Although the high rate of PONV among augmentaDarci J. Tom, MD, La Jolla, CA, is a board-certified tion patients is partly due to anesthesiologist. the selection of female nonsmokers, this study suggests a connection between PONV and breast augmentation, a connection that has not yet been explained. PONV is mediated by multiple neural pathways6,11 and a variety of classes of drugs have some efficacy in prophylaxis and treatment. Droperidol, a central dopamine antagonist, is an inexpensive and frequently used firstline agent. It can be effective in small, nonsedating doses between 0.625 and 1.25 mg, delivered intravenously (IV). Larger doses, though more effective, can cause undesirable sedation, especially in the presence of opioids, and increase the ever-present risk of extrapyramidal reactions and dysphoria. Ondansetron (Zofran) and dolasetron (Anzemet), serotonin antagonists, have few if any interactions with other drugs and are apparently free of central nervous system side effects. Many studies demonstrating the efficacy of ondansetron in surgical settings12-14 have evaluated the 8mg dose; however, the 4-mg dose may be equally effective,15 and many practitioners today begin prophylaxis or treatment with 2 to 4 mg of ondansetron IV. The standard dose of dolasetron is 12.5 mg IV, administered 15 minutes before the end of surgery. Metoclopramide (Reglan) stimulates gastric motility. Doses of 0.1 to 0.2 mg/kg IV are appropriate in surgical settings. Higher doses of 1 to 2 mg/kg, given for chemotherapy-induced emesis, are associated with extrapyramidal reactions. Although metoclopramide is as effective as droperidol in some settings, such as cesarean sections,16 it is more often used as an adjunct to droperidol or ondansetron for refractory and breakthrough PONV.
AESTHETIC
SURGERY
JOURNAL
~
JULY/AUGUST
2000
339
Managing Your OR
Scopolamine (Transderm Scop) in transdermal patch form is effective for motion sickness. However, results in perioperative settings have been mixed,17,18 and side effects include dry mouth, dizziness, sedation, and visual disturbances.
5. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:109-118.
Prochlorperazine (Compazine) and promethazine (Phenergan) are phenothiazines that antagonize both histamine (H1) and dopamine receptors. Both are useful in 25- to 50-mg doses delivered intramuscularly (or IV for prochlorperazine), and they are inexpensive. Their dual-receptor activity, however, can result in a wide range of side effects, including dry mouth, dizziness, sedation, orthostatic hypotension, and extrapyramidal reactions. Both of these drugs are available as 25-mg suppositories.
8. Watcha MF, Simeon RM, White PF, Stephens JL. Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients. Anesthesiology 1991;75:204-209.
Dexamethasone (Decadron) in doses of 4 to 10 mg IV has been recommended for prophylaxis and the treatment of PONV in high-risk patients, perhaps in conjunction with a serotonin antagonist.19,20 Intravenous hydration may have a beneficial effect. One meta-analysis has found a role for acupuncture and acupressure in adults.21 A recent finding has shown that supplemental oxygen reduces the incidence of PONV.22 The prophylaxis-vs-treatment question has recently been the subject of a number of meta-analyses and has generated significant controversy.21,23 A recent set of useful guidelines from White,19 a pioneer in outpatient anesthesia, recommends (1) no routine prophylaxis for low-risk patients, (2) prophylaxis with 0.625 to 1.25 mg of droperidol for moderate-risk adult patients, and (3) combination prophylaxis, such as dexamethasone and ondansetron or dolasetron, for high-risk adult patients. White also recommends that ondansetron or dolasetron be given at the end of surgery rather than at the beginning and that breakthrough PONV be treated with a drug from a different group, such as metoclopramide. ■
References 1. Gan TJ, Lubarsky DA, Sloan F, Dear R, Dear G. How much are patients willing to pay for a completely effective antiemetic? [abstract]. Anesthesiology 1998;89:A7.
6. Haynes GR, Bailey MK. Postoperative nausea and vomiting: review and clinical approaches. Southern Med J 1996;89:940-949. 7. Hartung J. Nitrous oxide—it’s enough to make you vomit. Anesthesiology 1993;78:403-405.
9. McCollum JSC, Milligan KR, Dundee JW. The antiemetic action of propofol. Anaesthesia 1988;43:239-240. 10. Andersen R, Krohg K. Pain as a major cause of postoperative nausea. Can Anaesth Soc J 1976;23:366-369. 11. Bitetti J, Weintraub HD. Nausea and vomiting. In: Benumof JL, Saidman LJ, eds. Anesthesia and perioperative complications. St. Louis: Mosby; 1992;396-412. 12. Tramer MR, Reynolds JM, Moore RA, McQuay HJ. Efficacy, doseresponse, and safety of ondansetron in prevention of postoperative nausea and vomiting. Anesthesiology 1997;87:1277-1289. 13. Dupeyron JP, Conseiller C, Levarlet M, Hemingsen C, Schoeffler P, Pedersen M, et al. The effect of oral ondansetron in the prevention of postoperative nausea and vomiting after major gynaecological surgery performed under general anaesthesia. Anaesthesia 1993;48:214218. 14. McKenzie R, Odell S, Rudy T, Joslyn AF. Ondansetron, a selective serotonin type 3 antagonist, reduces nausea and vomiting in females following major gynecologic surgery. Anesthesiology 1990;73:A739. 15. Khalil SN, Kataria B, Pearson K, Conahan T, Kallar S, Zahl K, et al. Ondansetron prevents postoperative nausea and vomiting in women outpatients. Anesth Analg 1994;79:845-851. 16. Chestnut DH, Owen CL, Geiger M, Bates JN, Choi WW, Ostman PL. Metoclopramide versus droperidol for prevention of nausea and vomiting during epidural anesthesia for cesarean section. South Med J 1989;82:1224-1227. 17. Bailey PL, Streisand JB, Pace NL, Bubbers SJ, East KA, Mulder S, Stanley TH. Transdermal scopolamine reduces postoperative nausea and vomiting. Anesthesiology 1990;72:977-980. 18. Bosek V. Transdermal scopolamine does not decrease the incidence of nausea and vomiting after alfentanil anesthesia. Anesthesiology 1990;73:A371. 19. White PF, Watcha MF. Postoperative nausea and vomiting: prophylaxis versus treatment [editorial]. Anesth Analg 1999;89:1337-1339. 20. Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000;90:186-194. 21. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1362-1369.
2. Koivuranta M, Laara E, Snare E, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997;52:443-449.
22. Greif R, Laciny S, Rapf B, et al. Supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Anesthesiology 1999;91:1246-1252.
3. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91:693-700.
23. Fisher DM. The “big little problem” of postoperative nausea and vomiting [editorial]. Anesthesiology 1997;87:1271-1273.
4. Beattie WS, Linblad T, Buckley DN, Forest JB. The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is influenced by the day of the menstrual cycle. Can J Anaesth 1991;38: 298-302.
340
AESTHETIC
SURGERY
JOURNAL
~
JULY/AUGUST
Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/109085 doi:10.1067/maj.2000.109085
2000
Volume 20, Number 4
Postoperative Nausea and Vomiting “Managing Your OR” focuses on various aspects of aesthetic surgery in the ambulatory surgical setting.
P
ostoperative nausea and vomiting (PONV) is an ever-present feature of the perioperative experience. The type of surgery, the type and duration of anesthesia, and various patient factors all contribute to the condition. Some patients state that they prefer postoperative pain to PONV, and the value of avoiding PONV is demonstrated by questionnaires that document patients’ willingness to pay for prophylaxis personally.1
The list of known factors predisposing patients to PONV suggests why this is a problem in the typical aesthetic surgery practice. Nausea is 2 to 3 times more common in women than men2,3 and 4 times as likely during the first week of the menstrual cycle.4 Nonsmokers have a higher incidence than smokers.2,5 A history of either motion sickness or PONV is a strong predictor of PONV.2,6 The incidence of PONV varies directly with duration of anesthesia. One study examining half-hour increments found an incidence of PONV of approximately 3% for durations of less than 30 minutes; this increased continuously to roughly 30% for durations of 151 to 180 minutes. Durations of more than 180 minutes (19%), however, did not follow this rule.5 General anesthesia—including that involving opioids5 and/or nitrous oxide7—is associated with nausea more often than is propofol when the latter is used as the sole agent,8 propofol being a mild antiemetic drug.9 Paradoxically, opioids may be useful postoperatively, inasmuch as pain may cause nausea.10 Muscle-relaxant reversal agents, such as neostigmine, given in conjunction with an anticholinergic, such as glycopyrrolate, do not appear to contribute.5 Sinclair et al5 found that plastic surgery was associated with a higher incidence of PONV than general surgery. However, this increased incidence appears to be attributable to the remarkably high incidence of PONV in a subpopulation of 41 breast augmentation patients (41%).
This is by far the highest rate of PONV for any type of surgery. Other aesthetic procedures involving the skin and face had an incidence of only about 5%. Although the high rate of PONV among augmentaDarci J. Tom, MD, La Jolla, CA, is a board-certified tion patients is partly due to anesthesiologist. the selection of female nonsmokers, this study suggests a connection between PONV and breast augmentation, a connection that has not yet been explained. PONV is mediated by multiple neural pathways6,11 and a variety of classes of drugs have some efficacy in prophylaxis and treatment. Droperidol, a central dopamine antagonist, is an inexpensive and frequently used firstline agent. It can be effective in small, nonsedating doses between 0.625 and 1.25 mg, delivered intravenously (IV). Larger doses, though more effective, can cause undesirable sedation, especially in the presence of opioids, and increase the ever-present risk of extrapyramidal reactions and dysphoria. Ondansetron (Zofran) and dolasetron (Anzemet), serotonin antagonists, have few if any interactions with other drugs and are apparently free of central nervous system side effects. Many studies demonstrating the efficacy of ondansetron in surgical settings12-14 have evaluated the 8mg dose; however, the 4-mg dose may be equally effective,15 and many practitioners today begin prophylaxis or treatment with 2 to 4 mg of ondansetron IV. The standard dose of dolasetron is 12.5 mg IV, administered 15 minutes before the end of surgery. Metoclopramide (Reglan) stimulates gastric motility. Doses of 0.1 to 0.2 mg/kg IV are appropriate in surgical settings. Higher doses of 1 to 2 mg/kg, given for chemotherapy-induced emesis, are associated with extrapyramidal reactions. Although metoclopramide is as effective as droperidol in some settings, such as cesarean sections,16 it is more often used as an adjunct to droperidol or ondansetron for refractory and breakthrough PONV.
AESTHETIC
SURGERY
JOURNAL
~
JULY/AUGUST
2000
339
Managing Your OR
Scopolamine (Transderm Scop) in transdermal patch form is effective for motion sickness. However, results in perioperative settings have been mixed,17,18 and side effects include dry mouth, dizziness, sedation, and visual disturbances.
5. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:109-118.
Prochlorperazine (Compazine) and promethazine (Phenergan) are phenothiazines that antagonize both histamine (H1) and dopamine receptors. Both are useful in 25- to 50-mg doses delivered intramuscularly (or IV for prochlorperazine), and they are inexpensive. Their dual-receptor activity, however, can result in a wide range of side effects, including dry mouth, dizziness, sedation, orthostatic hypotension, and extrapyramidal reactions. Both of these drugs are available as 25-mg suppositories.
8. Watcha MF, Simeon RM, White PF, Stephens JL. Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients. Anesthesiology 1991;75:204-209.
Dexamethasone (Decadron) in doses of 4 to 10 mg IV has been recommended for prophylaxis and the treatment of PONV in high-risk patients, perhaps in conjunction with a serotonin antagonist.19,20 Intravenous hydration may have a beneficial effect. One meta-analysis has found a role for acupuncture and acupressure in adults.21 A recent finding has shown that supplemental oxygen reduces the incidence of PONV.22 The prophylaxis-vs-treatment question has recently been the subject of a number of meta-analyses and has generated significant controversy.21,23 A recent set of useful guidelines from White,19 a pioneer in outpatient anesthesia, recommends (1) no routine prophylaxis for low-risk patients, (2) prophylaxis with 0.625 to 1.25 mg of droperidol for moderate-risk adult patients, and (3) combination prophylaxis, such as dexamethasone and ondansetron or dolasetron, for high-risk adult patients. White also recommends that ondansetron or dolasetron be given at the end of surgery rather than at the beginning and that breakthrough PONV be treated with a drug from a different group, such as metoclopramide. ■
References 1. Gan TJ, Lubarsky DA, Sloan F, Dear R, Dear G. How much are patients willing to pay for a completely effective antiemetic? [abstract]. Anesthesiology 1998;89:A7.
6. Haynes GR, Bailey MK. Postoperative nausea and vomiting: review and clinical approaches. Southern Med J 1996;89:940-949. 7. Hartung J. Nitrous oxide—it’s enough to make you vomit. Anesthesiology 1993;78:403-405.
9. McCollum JSC, Milligan KR, Dundee JW. The antiemetic action of propofol. Anaesthesia 1988;43:239-240. 10. Andersen R, Krohg K. Pain as a major cause of postoperative nausea. Can Anaesth Soc J 1976;23:366-369. 11. Bitetti J, Weintraub HD. Nausea and vomiting. In: Benumof JL, Saidman LJ, eds. Anesthesia and perioperative complications. St. Louis: Mosby; 1992;396-412. 12. Tramer MR, Reynolds JM, Moore RA, McQuay HJ. Efficacy, doseresponse, and safety of ondansetron in prevention of postoperative nausea and vomiting. Anesthesiology 1997;87:1277-1289. 13. Dupeyron JP, Conseiller C, Levarlet M, Hemingsen C, Schoeffler P, Pedersen M, et al. The effect of oral ondansetron in the prevention of postoperative nausea and vomiting after major gynaecological surgery performed under general anaesthesia. Anaesthesia 1993;48:214218. 14. McKenzie R, Odell S, Rudy T, Joslyn AF. Ondansetron, a selective serotonin type 3 antagonist, reduces nausea and vomiting in females following major gynecologic surgery. Anesthesiology 1990;73:A739. 15. Khalil SN, Kataria B, Pearson K, Conahan T, Kallar S, Zahl K, et al. Ondansetron prevents postoperative nausea and vomiting in women outpatients. Anesth Analg 1994;79:845-851. 16. Chestnut DH, Owen CL, Geiger M, Bates JN, Choi WW, Ostman PL. Metoclopramide versus droperidol for prevention of nausea and vomiting during epidural anesthesia for cesarean section. South Med J 1989;82:1224-1227. 17. Bailey PL, Streisand JB, Pace NL, Bubbers SJ, East KA, Mulder S, Stanley TH. Transdermal scopolamine reduces postoperative nausea and vomiting. Anesthesiology 1990;72:977-980. 18. Bosek V. Transdermal scopolamine does not decrease the incidence of nausea and vomiting after alfentanil anesthesia. Anesthesiology 1990;73:A371. 19. White PF, Watcha MF. Postoperative nausea and vomiting: prophylaxis versus treatment [editorial]. Anesth Analg 1999;89:1337-1339. 20. Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000;90:186-194. 21. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1362-1369.
2. Koivuranta M, Laara E, Snare E, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997;52:443-449.
22. Greif R, Laciny S, Rapf B, et al. Supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Anesthesiology 1999;91:1246-1252.
3. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91:693-700.
23. Fisher DM. The “big little problem” of postoperative nausea and vomiting [editorial]. Anesthesiology 1997;87:1271-1273.
4. Beattie WS, Linblad T, Buckley DN, Forest JB. The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is influenced by the day of the menstrual cycle. Can J Anaesth 1991;38: 298-302.
340
AESTHETIC
SURGERY
JOURNAL
~
JULY/AUGUST
Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/109085 doi:10.1067/maj.2000.109085
2000
Volume 20, Number 4