Anaesthesia, 1990, Volume 45, pages 669-671

Ginger root-a

new antiemetic

The effect of ginger root on postoperative nausea and vomiting after major gynaecological surgery

M. E. Bone, MB, ChB, FFARCS, Senior Registrar, D. J. Wilkinson, MB, BS, F F A R C S , Consultant, Department of Anaesthesia, J. R. Young, MRPharms, Department of Pharmacy, St Bartholomew’s Hospital, London E C l A 7BE, J. McNeil, MB, BS, Registrar, S. Charlton, MB, BS, F F A R C S , Senior Registrar, Department of Anaesthesia, Whipps Cross Hospital, London El 1 .

Summary The effectiveness of ginger (Zingiber ofJicinale) as an antiemetic agent was compared with placebo and metoclopramide in 60 women who had major gynaecological surgery in a double-blind, randomised study. There were statistically significantly fewer recorded incidences of nausea in the group that received ginger root compared with placebo ( p < 0.05). The number of incidences of nausea in the groups that received either ginger root or metoclopramide were similar. The administration of antiemetic after operation was significantly greater in the placebo group compared to the other two groups ( p < 0.05).

Key words Surgery; gynaecological. Vomiting; antiemetics.

Nausea and vomiting have long been regarded as some of the most unpleasant sequelae of anaesthesia; effects range from the simply annoying to life threatening electrolyte disturbances and aspiration of stomach contents. There has been no real reduction during the last 50 years in their incidence, which persists at approximately 30%, despite the continued introduction of new antiemetics.’ No available antiemetic offers both good pharmacological effectiveness together with an absence of side effects. Recently, there have been reports of the vertigo-reducing effects of ginger root. Mowbrey and Clayson2 found powdered ginger root to have a significantly better effect than placebo or antihistamines, upon experimentally induced motion sickness in volunteers. Grontved and Hentzer’ found that ginger root reduced the incidence of induced vertigo significantly more than did placebo in a group of volunteers after calorific stimulation of the vestibular system. There were no reports of nausea in any patient who had received ginger root in this latter study. We therefore postulated that a preparation of ginger root may reduce the incidence of nausea and vomiting after operation and this study was undertaken to investigate the effects of ginger root on postoperative emesis compared with placebo and metaclopramide in patients who have major gynaecological surgery. Method

Sixty women who had major gynaecological surgery were included in the study which was approved by the local ethics committee. All patients were ASA grades 1 or 2 and aged between 16 and 65 years. They were informed that the

purpose of the study was to compare a commonly used plant derivative, with possible antiemetic properties, with a standard antiemetic or placebo. Written consent was then obtained. Patients who received opioid analgesia or antiemetics 24 hours before surgery were not studied. Capsules were prepared by the pharmacy department at St. Bartholomew’s Hospital. The active capsule contained powdered ginger root (Zingiber oficinale) 0.5 g and the placebo capsule lactulose 0.5 g. Both were flavoured with a nonactive chemical essence of ginger. Coloured capsules were used for both to disguise their contents. The capsules were unable to be differentiated when swallowed with 20 ml water. Coded syringes for intravenous injection were prepared freshly by an investigator who did not participate in the anaesthesia or assessment. The active injection contained metoclopramide 10 mg and the placebo injection 2 ml sterile water. Patients were premedicated intramuscularly 1.5 hours before operation with papaveretum and hyoscine: 10 mg and 0.2 mg respectively if bodyweight < 50 kg, 15 mg and 0.3 mg respectively if bodyweight 50-70 kg and 20 mg and 0.4 mg if bodyweight > 70 kg. The study drugs were administered in a double-blind, randomised fashion as follows: Group 1, ginger-root 1 g and placebo injection; Group 2, lactulose 1 g and active injection; Group 3, lactulose 1 g and placebo injection. The capsules were taken orally at the time of prernedication and the injection was administered intravenously at induction of anaesthesia. A similar anaesthetic technique was employed throughout. Induction of anaesthesia was with a sleep dose of thiopentone, followed by alcuronium or vecuronium and tracheal intubation. The lungs were ventilated with 66%

Accepted 15 December 1989. 0003-2409/90/080669 + 14 %03.00/0

@ 1990 The Association of Anaesthetists of Gt Britain and Ireland




Table 1. Patients’ demographic data expressed as mean (SEM), details of history of nausea expressed as whole numbers (X), and type and duration of surgery expressed as whole numbers and mean (SEM) respectively. Group 1 (n = 20) Age; years Weight; kg

Group 2 (n = 20)

39.5 (2.4) 62.8 (2.4)

36.6 (2.0) 63.0 (1.8)

Group 3 (n = 20)

45.7 (2.7) 60.6 (2.2)

Nausea after previous general anaesthesia

8 (40%)

Motion sickness

5 (25%)

Vaginal Hysterectomy Repair





Abdominal Hysterectomy Laparotomy Laparoscopy Surgical time, minutes

9 (45%)

4 (20%)

7 6 6

8 5 5

58.3 (14.6)

7 (35%)

3 (15%)

9 4 5

53.8 (5.9)

51.7 (6.2)

Table 2. Numbers of patients in groups 1, 2 and 3 with sedation, abnormal movements, itching and eye disturbances at the assessment times, expressed as whole numbers. ~~~~~~


Group 1 (n = 20)

Group 2 (n = 20)

Group 3 (n = 20)

16 II 5 2

15 14 7 1

14 12 6 2


Recovery 4 hours 12 hours 24 hours Abnormal movemenls

Recovery 4 hours 12 hours 24 hours

0 0 0 0

Itching Recovery 4 hours 12 hours 24 hours

1 1 0

as none, mild, moderate or severe. Nausea and vomiting was treated with metoclopramide 10 mg intramuscularly at the discretion of the nursing staff or upon request of the patient. Papaveretum or paracetamol was administered on request for postoperative pain. All patients remained in bed on the day of surgery. Statistical analysis. A one-way analysis of variance was used for parametric data and the Chi-squared test and Kruskal-Wallis test for nonparametric data. Results

The demographic data were similar in all groups and there were no significant differences in the number of patients who had experienced nausea and vomiting after a previous anaesthetic or who gave a history of motion sickness (Table 1). The type and duration of surgery performed were comparable in all groups (Table 1). IntFa-operative supplements of papaveretum were administered to similar numbers of patients in each group as follows: group 1, 1 1 patients received a mean dose of 9.1 mg (SEM 0.6); group 2, 10 patients a mean dose of 7.5 mg (SEM 0.8); group 3, 13 patients a mean dose of 7.6 mg (SEM 0.7). The total number of recorded incidences of nausea at the four assessment times in group 1 was 23 (28%), and 24 (30%) in group 2. These were statistically significantly fewer than the 41 incidences (51 YO)of nausea in the control group (p < 0.05). Failed treatment, that is the occurrence of any emetic sequelae on any occasion during the study period was found in 14 patients (70%) in group 3 compared to 9 (45%) in group 1 and 10 in group 2 (50%). Figure 1 shows the incidence and severity of nausea at the four assessment times. More patients scored greater degrees of nausea in the placebo group compared to those









Eye disturbances

Recovery 4 hours 12 hours 24 hours



= 2




N,O and 1% enflurane in oxygen. The study injection was then administered. Analgesia was provided with supplements of papaveretum, and increments of relaxant were given as required. Fluid loss was replaced with compound sodium lactate solution at a rate of 5-10 ml/kg/hour and blood was transfused as clinically indicated. On completion of surgery, residual neuromuscular blockade was antagonised with neostigmine 2.5 mg and atropine 1.2 mg, administered intravenously over 30 seconds. The patients were assessed by one of the investigators after recovery from anaesthesia, and directly questioned for the occurrence of the following symptoms in the recovery room and at 4, 12 and 24 hours after operation: nausea, vomiting, retching, sedation, abnormal movements, pain, itching and eye disturbances. Nausea and pain were graded










Time (hours)



Fig. 1. The incidence and grade of nausea in groups 1, 2 and 3 at the four assessment times. 0 , none; m, mild; m, moderate; severe.

Forum Table 3. The postoperative use of analgesia in groups 1, 2 and 3

expressed as whole numbers.

None Oral paracetamol

Intramuscular papaveretum

Group 1 (n = 20)

Group 2 (n = 20)

Group 3 (n = 20)



2 13


5 3 14


who had received either ginger o r metoclopramide during the earlier assessment times, although the numbers did not achieve statistical significance. The postoperative administration of metoclopramide was significantly greater in the placebo group compared to the other groups (p < 0.05); none received metoclopramide in group 1, one in group 2 and six in group 3. There was no difference between groups in the incidence of sedation o r other symptoms after-operation (Table 2). All patients were normotensive after operation and remained in bed on the day of surgery. The assessment of pain was similar in all groups and there were no intergroup difference in postoperative opioid requirements (Table 3). Discussion The authors were interested in the recent reports of the vertigo-reducing effects of ginger root and particularly of the lack of nausea present in any patient who had received it after experimentally induced motion s i c k n e ~ s . ~The ,~ beneficial effects of ginger date back to the 9th and 10th centuries4 and Lewis and LewisS in their review of the therapeutic properties of plants, include the fluid extract of the rhizome ginger (Zingiber ojicinale) among the natural products that alleviate the symptoms of gastrointestinal distress. The aromatic and carminative properties of ginger and its possible absorbent properties suggest that its action is on the gastrointestinal tract itself.&* It may increase gastric motility and absorb neutralising toxins and acids, effectively blocking gastrointestinal reactions and subsequent nausea feedback. Ginger has n o reported side effectsy We therefore postulated that a preparation of ginger root may reduce nausea after operation. Several factors are known to summate to provoke postoperative nausea and vomiting. These include age, weight and sex together with the individual's predisposition to motion sickness and previous experience of postoperative sickness.','*." An opioid premedication has been shown to lead to an increase in nausea and vomiting after operation.I2 Various anaesthetic agents and techniques have also been i m p l i ~ a t e d , 'as ~ . ~have ~ certain postoperative factors that include the presence of hypotension, early mobilisation and visceral and pelvic pain. The above factors were comparable in each treatment group in the present study. There is controversy about the prophylactic administration of a n t i e r n e t i ~ s , ' ~despite ,~~ the overall incidence of postoperative nausea and vomiting remaining a t around 30% . I Widespread prophylaxis would probably be acceptable if antiemetics were innocuous. However, the high incidence of side effects of all standard antiemetic drugs gives rise to justified caution against their indiscriminate use. Hyoscine is the most effective of the anticholinergics in the prevention of nausea and vomiting, although when given with morphine as a premedicant any antiemetic effect is outlasted by the emetic properties of morphine. The

67 1

phenothiazines are sedative and the butyrophenones can cause extrapyramidal side effects, hypotension and sedation. Antihistamine drugs also cause prolonged sedation. Alternative methods to pharmacological means have been assessed and there are reports of the potential benefits offered by acupuncture1' and acupressure.lH However, such findings cannot be easily explained and it has been suggested that further studies are required. This study assessed the effectiveness of ginger as an antiemetic after major gynaecological surgery and compared it t o placebo a n d a frequently used antiemetic. Ginger root has the major advantage over other substances in that it does not have any recorded side effects. The capsule preparation was readily taken by the patients. We found that ginger root significantly reduced the incidence of postoperative emetic sequelae compared to placebo and had the same effect as metoclopramide. Further work on the use of ginger root as an antiemetic agent during anaesthesia is required. References 1. PALAZZO MGA, STRUNIN L. Anaesthesia and emesis I: etilogy. Canadian Anaesthetists' Society Journal 1984; 31: 178-87.

2. MOWBREY DB, CLAYSON DE. Motion sickness, ginger and psychophysics. Lancet 1982; 1: 665-7. 3. GRONTVED A, HENTZER E. Vertigo-reducing effect of ginger root. A controlled clinical study. Journal of Oto-Rhino-Laryngology and its Related Specialities 1986; 48: 282-6. 4. GREENISH HG. A textbook of Materia Medica, 3rd edn. 1920: 375-9. 5. LEWISWH, LEWISMP. Medical botany: plants uffecting mank health. New York: John Wiley and Son Inc. 1977. 6. OWLA, PRATTR, ALTSCHULE MD, eds. The U.S. dispensatory and physicians pharmacology. 26th edn. Philadelphia: J. B. Lippincott Co., 1967. 7. TREASE GE, EVANS WC. Pharmacognosy. Baltimore: Williams and Wilkins, 1972. 8. MUSSER RD, ONEILLJJ. Pharmacology and Therapeutics, 4th edn. New York: The McMillan Co., 1969. 9. REYNOLDS JEF. Martindale. The extra pharmocapoeia. 28th edn. London: Pharmaceutical Press, 1982. 10. MCKENZIER, WADHWA RK, UY NTL, PHITAYAKORN P, TANTISIRA B, SINCHIOLOC, TAYLORFH. Antiemetic effectiveness of intramuscular hydroxyzine compared with intramuscular droperidol. Anesthesia and Analgesia 198I; 60: 783-8. 11. PURKIS IE. Factors that influence postoperative vomiting. Canadian Anaesthetists' Society Journal 1964; 11: 335-53. 12. RIDINGJE. Post-operative vomiting. Proceedings of the Royal Society of Medicine 1960; 53: 671-7. 13. JANHUNEN L, TAMMISTO T. Postoperative vomiting after different modes of general anaesthesia. Annales Chirurgiae et Gynaecologiae Fenniae 1972; 61: 152-9. 14. BONICAJJ, CREPPSW, MONKB, BENNETTB. Post anesthetic operative nausea, retching and vomiting. Evaluation of cyclizine (Marezine) suppositories for treatment. Anesthesiology 1958; 1 9 532-40. 15. ADRIANI J, SUMMERS FW, ANTONY SO. Is the prophylactic use of antiemetics in surgical patients justified? Journal of the American Medical Association 1961; 175: 666-71. 16. MADEJ TH, SIMPSONKH. Comparison of the use of domperidone, droperidol and metoclopramide in the prevention of nausea and vomiting following major gynaecological surgery. British Journal of Anaesthesia 1986; 5 8 884-7. 17. DUNDEEJW, CHESTNUTTWN, GHALYRG, LYNASAGA. Traditional Chinese acupuncture: a potentially useful antiemetic? British Medical Journal 1986; 293: 583-4. 18. FRY ENS. Acupressure and postoperative vomiting. Anaesthesia 1986; 41: 661-2.

Ginger root--a new antiemetic. The effect of ginger root on postoperative nausea and vomiting after major gynaecological surgery.

The effectiveness of ginger (Zingiber officinale) as an antiemetic agent was compared with placebo and metoclopramide in 60 women who had major gynaec...
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