Department of Anesthesiology, Medical s: Nausea and vomiting,
*Professor Address reprint requests to Dr. Kallar at the Department of Anesthesiology, Medical College of Virginia, Virginia Commonwealth University, Box 103, MCV Station, Richmond, VA 23298-0103, USA. 0 2992 Butterworth-Heinemann J. Glirn. Wnesth. 4(Suppl B):B6S-19S,
vol. 4 (Suppl
Nausea and vomiting foliowing surgery in the ambulatory care laciiisy is a signifkant problem.’ With the use of newer ane tics, the time to full recovery of consciousness is decreasing. Conseque postoperative nausea and vomiting are more obvious and objectionable to the patient. The time to ambulation and subsequent discharge from the unit is prolonged because of nausea and vomiting. They are a significant cause of unexected hospital admission from the postanestbesia care unit (PAGU). In 977 pediatric patients, vomiting was the most common complication, with B2% of patients requiring hospital admission.” Contributing factors affecting the incidence of postoperative nausea and vomitin,g are listed in T&e 1. The conditionAis more common in children and tends to decrease with age. The incidence is equal between sexes until puberty, when it becomes more common in females. A history of motion sickness and previous experience of nausea and vomit’ inere crease the likelihood of developing postoperative emetic symptoms. seems to be a relationship between the incidence of nausea and vomiting and the day of the menstrual cycle. 3,4 A fourfold increase in nausea and vomiting has been noted when laparoscopic surgery was performed around the time of menses. Estrogen levels of women who experienced nausea and vomiting after ovum retrieval and other laparoscopic procedures have been shown to be significantly greater than for those patients who experienced no emetic symptoms. Opioid analgesics are known to cause postoperative nausea and vomiting. However, nausea often accompanies pain in the postoperative period and can be relieved in 80% of cases when pain relief is achieved by the intravenous (IV) use of opi0ids.j Several studies have concluded that an opioid-based anesthetic technique (fentanyl or alfentanii) results in earlier ambulation and patient discharge.e,‘* Regional or monitored anesthesia care causes a low incidence of poscoperative nausea and vomiting and enables earlier discharge of patients.H After laparoscopy, nausea and vomiting was present in 38% of general *V Soni, R Burney: Anesthetic 1981;55:A145.
tuba! ligation [Abstract].
_ Contributing Factors to Postoperative and Vomiting
age Female gender Early pregnancy His&+ oi’motion sickness Previous nausea and vomiting Day of menstrual cycle
Morbid obesity Excessive anxiety Noncompliance
atient should be kept warm using a ket, administered adequate IV fiuids, and moved very slowly. ~aso~~ar~gea~ suction should be minimized to avoid stimulating t A number of drugs have been us operative nausea and vomiting i Promethazine, cyclizine, benzquinami azine, and hydroxyzine have met wi success.1x,19 A combination of metocl 20 mg IV, and droperidol, 0.5 t 1..O mg IV, has been shown to be more effective an metoclopramide alone.20,*1 Metoclopramide, 10 g aione or in combination with 300 mg of cimet e, was significantly more effective compared with control or cimelidinedoe.;6 not _ prolong realone groups. 22 Metoclopramide
Nitrous oxide Etomidate, ketamine Neostigmine Ovum retrieval Laparoscopy Strabismus correction Orchiopexy Ear surgery o&operative factors Pain Sudden movement Hypotension
Generai vs region2 anesthesia
patients but in only 4% of those who had ural block
ide has also been ive nausea e incidence observed
and vomiting. of postoperative oxide
as a cause
A significant emesis was
nausea and ?jomiting: Mallar
covery, but occasional side effects, including drowsiness, lassitude, and agitation, have been observed. More serious symptoms of severe dysphoria and akathisia have been reported following metoclopramide 10 mg IV.z3 Droperidoi is an effective antiemetic. le 2. Drug Therapy Vomiting
the use of nitrous
oxide.11s12 8f the induction drugs, etomidate and ketamine have a significantly higher nce of postoperative nausea and vomiting when ared with thiopental and methohexital. Propofol een shown :o have the lowest incidence compared with othe, r induction drugs.13 A significant ine incidence of postoperative emesis was tients who received neostigmine to antagonize neuromuscular block. l4 The relationship between the incidence of postoperative nausea and vomiting and the type of surgical procedure has been well documented in several studies. In adult female patients, the incidence is highest in ovum retrieval (54%) and laparoscopic procedures (3~3%).:~ In pediatric patients, the incidence is highest with strabismus surgery and orchiopexy.16,17 Postoperative factors contributing to nausea and vomiting include pain, sudden movement, and hypotension.
Benzquinamide Cyclizine Hydroxine Prochlorperazine Promethazine Droperidol
*CD Alexander, JN Skupski, EM Brown: The role of nitrous oxide in postoperative nausea and vomiting [Abstract]. Anesth Anaig 19&4;63:A175.
Effective antiemetic Restlessness, anxiety, acute dystonia have been reported If given during f