Reply from the authors

Abstract

Editor—We read the letter by Dr Park and we were very pleased by his friendly words. We are also pleasantly surprised by a postoperative nausea and vomiting (PONV) incidence of 34% in high-risk patients. It would be interesting to know more about the definition of a ‘high-risk patient’ in that study. Dr Park describes a situation in which postoperative opioid patient-controlled analgesia (PCA) is used as the only risk factor triggering PONV prophylaxis. Since postoperative opioid use is indeed an important risk factor for PONV, it correctly triggers prophylaxis. There is, however, room for improvement in estimating PONV risk based on the other known risk factors or even better: using a risk score. According to Dr Park’s description, there is currently no guideline for PONV prophylaxis in Korea, so a possible reason for this insufficient risk estimation might be that some of our Korean colleagues are not aware that there are PONV risk factors other than postoperative opioid use. Workload and lack of manpower, as mentioned by Dr Park, are also well-known reasons for non-adherence to guidelines. If a guideline for PONV management would be implemented in Korea, adherence to this guideline could possibly be improved using a decision support system (DSS). When designing a DSS, however, one should carefully consider the properties required to facilitate success. These were well described in a review and include (among others) automatic appearance of reminders, specific advice, and integration in an electronic medical record.1Kawamoto K Houlihan CA Balas EA Lobach DF Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success.Br Med J. 2005; 330: 765doi:10.1136/bmj.38398.500764.8FCrossref PubMed Google Scholar The guideline described in our article was the departmental guideline as it was at the time of data collection.2Kooij FO Vos N Siebenga P Klok T Hollmann MW Kal JE Automated reminders decrease postoperative nausea and vomiting incidence in a general surgical population.Br J Anaesth. 2012; 108: 961-965doi:10.1093/bja/aes024Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar This evidence-based guideline was based on research with regard to optimal risk estimation, and also optimal medication prophylaxis.3Apfel CC Kranke P Eberhart LH et al.Comparison of predictive models for postoperative nausea and vomiting.Br J Anaesth. 2002; 88: 234-240doi:10.1093/bja/88.2.234Abstract Full Text Full Text PDF PubMed Scopus (269) Google Scholar 4Apfel CC Korttila K Abdalla M et al.A factorial trial of six interventions for the prevention of postoperative nausea and vomiting.N Engl J Med. 2004; 350: 2441-2451doi:10.1056/NEJMoa032196Crossref PubMed Scopus (1145) Google Scholar Other possible interventions, such as total i.v. anaesthesia, locoregional anaesthesia if possible, and metoclopramide, were not mentioned in the article but were incorporated in the guideline. This guideline was implemented after a consensus process and we feel that it is a practical and applicable one. There are other options as well though. For example, in another hospital, we agreed to add one prophylactic intervention for each positive risk factor. We feel that it is important to weigh all known risk factors and prophylactic options and decide which ones to use in which preferential order using a consensus process. As a guide for that process, comprehensive guidelines of PONV management are available. The most extensive being the SAMBA guideline.5Gan TJ Meyer TA Apfel CC et al.Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting.Anesth Analg. 2007; 105: 1615-1628doi:10.1213/01.ane.0000295230.55439.f4Crossref PubMed Scopus (515) Google Scholar In summary, we think that it is an excellent initiative to develop a Korean guideline for the management of PONV and wish Dr Park wisdom and success in doing so. Once the guideline has been developed and implemented, it is even better to use automated reminders in supporting it. None declared.