Chronic Atypical Antipsychotic Use Is Associated With Reduced Need for Postoperative Nausea and Vomiting Rescue in the Postanesthesia Care Unit

Background The relative potencies of alfentanil, fentanyl, and sufentanil as a risk factor for postoperative nausea and vomiting have not been determined. They were compared in a randomized study designed to obtain equipotent plasma concentrations of these three opioids at the beginning of the recovery period. Methods The study included 274 patients treated on an outpatient basis. The steady state opioid plasma concentration providing a predicted 50% reduction of the minimum alveolar concentration of isoflurane was used to determine the relative potency of the opioids. The opioids were prepared in equal volumes at concentrations of alfentanil 150 microg/ml, fentanyl 50 microg/ml, and sufentanil 5 microg/ml and were administered in vol/kg. Anesthesia was induced in a blinded fashion with a bolus of the study opioid (0.05 ml/kg) and 4-6 mg/kg thiopental and was maintained with isoflurane (0.6-1%) in a nitrous oxide-oxygen mixture with a continuous infusion of the study opioid (0.06 ml x kg(-1) x h(-1)). If necessary, up to five additional boluses of opioid (0.02 ml/kg) could be given. This opioid administration protocol was tested by pharmacokinetic simulations. Results The incidence of postoperative nausea and vomiting was not different in the postanesthesia care unit, but in the ambulatory surgery unit it was significantly lower for alfentanil compared with fentanyl and sufentanil (12, 34, and 35%, respectively P < 0.005). Pharmacokinetic modeling showed that the end-anesthesia opioid plasma concentrations were approximately equipotent in the three groups. However, modeling does not support that the difference between groups in the postoperative period can be explained by a more rapid disappearance of alfentanil from the plasma. Conclusions Alfentanil, compared with approximately equipotent doses of fentanyl and sufentanil, is associated with a lower incidence of postoperative nausea and vomiting in outpatients.

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Prophylactic Ondansetron in Prevention of Postoperative Nausea and Vomiting following Pediatric Strabismus Surgery

Anesthesiology ◽

10.1097/00000542-200004000-00021 ◽

2000 ◽

Vol 92 (4) ◽

pp. 1035-1042 ◽

Cited By ~ 57

Author(s):

Senthilkumar Sadhasivam ◽

Dilip Shende ◽

Rashmi Madan

Keyword(s):

Placebo Group ◽

Outcome Measures ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Strabismus Surgery ◽

Nausea And Vomiting ◽

Postanesthesia Care Unit ◽

Assessment Scores ◽

Parental Assessment ◽

Prophylactic Use

Background This study evaluated the antiemetic effectiveness, dose-response, and clinical usefulness of prophylactic ondansetron in the prevention of postoperative nausea and vomiting (PONV) in children undergoing strabismus repair. Method The authors observed 180 children, American Society of Anesthesiologists physical status I or II, 2-12 yr of age, who were undergoing strabismus repair. After induction of anesthesia with halothane and nitrous oxide in oxygen or intravenous thiopental, children received either placebo (saline) or intravenous ondansetron in doses of 25, 50, 75, 100, and 150 /microg/kg (n = 30). The trachea was intubated and ventilation was controlled. Perioperative analgesic and fluid requirements were standardized. Episodes of nausea and vomiting were recorded for the first 24 h postoperatively. Data such as nonsurrogate (parental satisfaction scores and duration of postanesthesia care unit stay) and therapeutic (numbers needed to prevent and harm) outcome measures were collected. Results The incidences of PONV in the placebo and 25-, 50-, 75-, 100-, and 150-,microg/kg ondansetron groups were 83, 77, 47, 30, 30, and 27%, respectively. The incidence was less in the 75(P = 0.002), 100- (P = 0.002), and 150-microg/kg (P < 0.001) ondansetron groups compared with placebo. Duration of stay in the postanesthesia care unit was shorter in the 75-, 100-, and 150-microg/kg ondansetron groups (P < 0.002) compared with the placebo group. Parental assessment scores for the child's perioperative experience and the positive number needed to prevent PONV were also better and favorable in the 75-, 100-, and 150-microg/kg ondansetron groups compared with the placebo group. The incidence (P > 0.99) and severity (P = 0.63) of PONV were similar in the 75- and 150-microg/kg ondansetron groups. Surrogate, nonsurrogate, and therapeutic outcome measures revealed that 75 microg/kg ondansetron provided the same benefits as did 100 and 150 microg/kg. Conclusion The routine prophylactic use of ondansetron at a dose of 75 microg/kg is as effective as 150 microg/kg in preventing PONV and improving the "true" outcome measures after strabismus repair in children.

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Effect of Antiemetic Therapy on Recovery and Hospital Discharge Time

Anesthesiology ◽

10.1097/00000542-199511000-00007 ◽

1995 ◽

Vol 83 (5) ◽

pp. 956-960 ◽

Cited By ~ 59

Author(s):

Peter J. Davis ◽

Francis X. McGowan Jr. ◽

Ira Landsman ◽

Karen Maloney ◽

Paul Hoffmann

Keyword(s):

Length Of Stay ◽

Hospital Discharge ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Nausea And Vomiting ◽

Antiemetic Therapy ◽

Hospital Length Of Stay ◽

Postanesthesia Care Unit ◽

Discharge Time ◽

Dental Surgery

Abstract Background Postoperative nausea and vomiting continue to be a significant problem for pediatric ambulatory surgery patients. Although ondansetron has been demonstrated to be effective in the prophylactic treatment of postoperative nausea and vomiting (surrogate end point) no one has demonstrated a benefit of antiemetic therapy on patient recovery, postanesthesia care unit length of stay, and hospital length of stay (nonsurrogate end points). In a double-blind manner, the effects of ondansetron, droperidol, and placebo on the incidence of emesis, postanesthesia care unit stay, and hospital discharge time were evaluated in children undergoing dental surgery.

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Substance P (Neurokinin-1) Antagonist Prevents Postoperative Vomiting after Abdominal Hysterectomy Procedures

Anesthesiology ◽

10.1097/00000542-200010000-00009 ◽

2000 ◽

Vol 93 (4) ◽

pp. 931-937 ◽

Cited By ~ 63

Author(s):

Zsuzsanna Gesztesi ◽

Phillip E. Scuderi ◽

Paul F. White ◽

William Wright ◽

Ronald H. Wender ◽

...

Keyword(s):

Patient Satisfaction ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Abdominal Hysterectomy ◽

Nausea And Vomiting ◽

Gynecologic Surgery ◽

Postanesthesia Care Unit ◽

Interaction Study ◽

Dose Ranging ◽

Neurokinin 1

Background The safety and antiemetic efficacy of CP-122,721, a novel neurokinin-1 antagonist, was evaluated when administered alone or in combination with ondansetron. Methods Using a randomized, double-blind, placebo-controlled study design, CP-122,721 was initially compared with placebo and subsequently to ondansetron alone and in combination for prophylaxis against postoperative nausea and vomiting in 243 women undergoing abdominal hysterectomy. In the dose-ranging studies (n = 86), patients received either CP-122,721 100 mg (vs. placebo) or 200 mg (vs. placebo) orally 60-90 min before induction of anesthesia. In the interaction study (n = 157), patients received CP-122,721 200 mg or placebo 60-90 min before induction of anesthesia, and ondansetron 4 mg or saline 2 ml intravenously 15-30 min before the end of surgery. Patients assessed their level of nausea and pain on arrival in the postanesthesia care unit and at 0.5-, 1-, 1.5-, 2-, 4-, 8-, 12-, and 24-h intervals postoperatively. Emetic episodes, need for rescue antiemetic-antinausea medication, postoperative complications, and patient satisfaction were recorded. Results In the initial dose-ranging study, only 10% of the patients experienced emesis within the first 8 h after surgery with CP-122,721 200 mg compared with 50% in the placebo group. CP-122,721 200 mg also decreased the need for rescue medication (25% vs. 48%). CP-122,721 100 mg was less effective than 200 mg in decreasing the incidence of repeated episodes of emesis. In the interaction study, 6% of the patients receiving CP-122,721 200 mg orally experienced emesis less than 2 h after surgery compared with 17% with ondansetron alone. With combined therapy, only 2% experienced emesis. In addition, the median times for 75% of patients to remain free from postoperative nausea and vomiting were 82, 75, and 362 min in the ondansetron, CP-122,721, and combination groups, respectively. Conclusions Oral CP-122,721 200 mg decreased emetic episodes compared with ondansetron (4 mg intravenously) during the first 24 h after gynecologic surgery; however, there was no difference in patient satisfaction.

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Randomized Controlled Trial of Total Intravenous Anesthesia with Propofol versus Inhalation Anesthesia with Isoflurane–Nitrous Oxide

Anesthesiology ◽

10.1097/00000542-200109000-00012 ◽

2001 ◽

Vol 95 (3) ◽

pp. 616-626 ◽

Cited By ~ 155

Author(s):

Klazina Visser ◽

Elly A. Hassink ◽

Gouke J. Bonsel ◽

Jeroen Moen ◽

Cor J. Kalkman

Keyword(s):

Nitrous Oxide ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Nausea And Vomiting ◽

Total Intravenous Anesthesia ◽

Postanesthesia Care Unit ◽

Number Needed To Treat ◽

Anesthetic Techniques ◽

Inhalational Anesthesia ◽

Intravenous Anesthesia

Background To assess the incidence of postoperative nausea and vomiting after total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide, the authors performed a randomized trial in 2,010 unselected surgical patients in a Dutch academic institution. An economic evaluation was also performed. Methods Elective inpatients (1,447) and outpatients (563) were randomly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air. Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers. Cost data of anesthetics, antiemetics, disposables, and equipment were collected. Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed. Results Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15% among inpatients (from 61% to 46%, P < 0.001) and by 18% among outpatients (from 46% to 28%, P < 0.001). This effect was most pronounced in the early postoperative period. The cost of anesthesia was more than three times greater for propofol TIVA. Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for inpatients (P < 0.001) and 160 min after isoflurane versus 150 min after TIVA for outpatients (P = 0.039). Duration of hospitalization was equal in both arms. Conclusion Propofol TIVA results in a clinically relevant reduction of postoperative nausea and vomiting compared with isoflurane-nitrous oxide anesthesia (number needed to treat = 6). Both anesthetic techniques were otherwise similar. Anesthesia costs were more than three times greater for propofol TIVA, without economic gains from shorter stay in the postanesthesia care unit

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Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000003725 ◽

2021 ◽

Author(s):

Helene Beloeil ◽

Matthias Garot ◽

Gilles Lebuffe ◽

Alexandre Gerbaud ◽

Julien Bila ◽

...

Keyword(s):

Relative Risk ◽

Adverse Events ◽

Cognitive Dysfunction ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Opioid Consumption ◽

Nausea And Vomiting ◽

Postanesthesia Care Unit ◽

Balanced Anesthesia ◽

Remifentanil Group

Background It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. Methods Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. Results The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay. Conclusions This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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The Post-Anesthesia Care Unit

10.2310/anes.18368 ◽

2018 ◽

Author(s):

Evan R Bohnenblust

Keyword(s):

Neuromuscular Blockade ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Scoring Systems ◽

Nausea And Vomiting ◽

Postanesthesia Care Unit ◽

Emergence Delirium ◽

Residual Neuromuscular Blockade ◽

Hemodynamic Compromise ◽

Standards And Guidelines

physiologic changes caused by both recent administration of anesthesia as well as the preceding surgical intervention. This general overview of the postanesthesia care unit (PACU) summarizes the most current standards and guidelines for patient care and monitoring. It also details the causes and treatment of the most common complications observed in PACU, such as postoperative nausea and vomiting, hemodynamic compromise, and respiratory insufficiency. Other relevant topics such as residual neuromuscular blockade and emergence delirium are also addressed. Finally, this chapter concludes with a discussion of the development of commonly used discharge scoring systems, including a discussion of the differences between the ambulatory and inpatient surgery populations. Each of these sections discusses current trends in management as supported by the latest literature and guidelines. This review contains 1 figure, 6 tables, and 50 references Key Words: Aldrete scoring, delayed awakening, emergence delirium, postanesthesia care unit, postanesthesia care unit discharge criteria, postoperative nausea and vomiting, postoperative respiratory failure, residual neuromuscular blockade, sugammadex

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The Association of CYP2D6 Genotype and Postoperative Nausea and Vomiting in Orthopedic Trauma Patients

Biological Research For Nursing ◽

10.1177/1099800412449181 ◽

2012 ◽

Vol 15 (4) ◽

pp. 382-389 ◽

Cited By ~ 22

Author(s):

Susan W. Wesmiller ◽

Richard A. Henker ◽

Susan M. Sereika ◽

Heidi S. Donovan ◽

Li Meng ◽

...

Keyword(s):

Postoperative Nausea ◽

Significant Risk ◽

Postoperative Nausea And Vomiting ◽

Poor Metabolizers ◽

Nausea And Vomiting ◽

Postanesthesia Care Unit ◽

Surgical Trauma ◽

Trauma Patients ◽

Cyp2d6 Genotype ◽

Phenotype Classification

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18–70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman®allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.

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The effect of smoking on postoperative nausea and vomiting

Anaesthesia ◽

10.1046/j.1365-2044.2000.01727-14.x ◽

2000 ◽

Vol 55 (10) ◽

pp. 1032-1032 ◽

Cited By ~ 1

Author(s):

R. Thomas

Keyword(s):

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Nausea And Vomiting

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