British Journal of Anaesthesia 1992; 69 (Suppl. 1): 33S-39S
POSTOPERATIVE NAUSEA AND VOMITING IN DAY-CASE SURGERY B. V. WETCHLER
NAUSEA AND VOMITING
Opioid analgesics Opioid analgesics are highly effective in both the prevention and treatment of postoperative pain. Controversy surrounds the use of opioid analgesics in the day-case patient because they may increase postoperative nausea and vomiting. The use of an opioid and nitrous oxide anaesthesia is associated with a greater incidence of nausea and vomiting than an i.v. or inhalation anaesthetic . However, there are several studies which suggest that an opioid supplemented anaesthetic technique (fentanyl 1.5-21lg kg- 1 i.v. or alfentanil 6-81lg kg- 1 i.v.) results in earlier ambulation and discharge from the day-case unit [15,21,55,64]. Pain Andersen and Krohg established, in an inpatient population, a relationship between postoperative pain and the frequency of nausea in the early postsurgical period . Complete pain relief without simultaneous relief of nausea was unusual. Patients who had inadequate pain relief and continued to have nausea after the first analgesic injection (50 % of the patients) were relieved of both complaints after a supplementary dose of an opioid. Only 10 % of patients complained of postoperative nausea without accompanying pain. J akobsson and colleagues noted that pain increases postoperative nausea and vomiting . However, Parnass, McCarthy and Ivankovich, when evaluating the role of pain on postoperative nausea and vomiting
Anaesthetic agent and technique Lonie and Harper noted a significant decrease in the incidence of postoperative nausea and vomiting in outpatients undergoing laparoscopic surgery when nitrous oxide was omitted from the anaesthetic regimen . In female patients undergoing minor gynaecological procedures (dilatation and curettage, cone biopsy, and laser ablation of vulvar lesions), Melnick and Johnson found a decrease in nausea and vomiting when nitrous oxide was omitted from isoflurane and oxygen anaesthesia . Recent studies on women undergoing laparoscopic surgery did not suggest that nitrous oxide was a prime causative factor in the incidence of postoperative nausea and vomiting [20, 53] (table I). The mechanism of vomiting associated with nitrous oxide may be related to reduced middle ear pressure during recovery, stimulating the vestibular system by placing traction on the round window membrane . Montgomery, Vaghadia and Blackstock studied this problem and found no association between postoperative reduction in middle ear pressure and postoperative vomiting in outpatient paediatric patients after nitrous oxide and halothane anaesthesia . None of the studies that examined the relationship of nausea and vomiting after laparoscopy with the use of nitrous oxide considered the day of menstrual I. Nitrous oxide as a factor in nausea and vomiting. Percentage of patients experiencing nausea and vomiting who received or did not receive nitrous oxide (N 20)
Patients with nausea and vomiting ('/0) Study Lonie and Harper (34) Melnick and Johnson (38) Sengupta and Plantevin [53) Hovorka and colleagues (20)
29% 25";;, 51 % (nausea) 18 % (vomiting) 34%
4% 3.2% 39%
(Br. J. Anaesth. 1992; 69 (Suppl. 1): 33S-39S) KEY WORDS Surgery: day care. Vomiting: nausea.
V. WETCHLER, M.D., Department of Anesthesiology, Methodist Medical Center of Illinois, 221 NE Glen Oak, Peoria, IL 61636, U.S.A.
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Nausea and emesis are the most common side effects in the postanaesthesia care unit (PACU). Contributory factors include opioid analgesic drugs, pain, the anaesthetic agent or technique, sudden movement or positional changes, a history of motion sickness, hypotension, obesity, the site of surgical operation, day of menstrual cycle and oestrogen level. Admission to hospital from a day-case unit may result not only from uncontrolled nausea and vomiting, but also from prolonged somnolence after treatment with potent antiemetics .
in day-case patients undergoing arthroscopic knee procedures, found the incidence of postoperative nausea and vomiting was similar between patients with and without pain .
BRITISH JOURNAL OF ANAESTHESIA II. Aleal/ (SD) recovery roo III (RR) tillle and nausea and ~'ollliting in patients undergoing different opera/iollS. 1