Surrogate Outcomes: They Don’t Get It

Abstract

In Response: We fully support the notion espoused by Fisher1 that “clinicians (should) make decisions based on meaningful outcomes.” Dr. Fisher suggests that nausea and vomiting are not meaningful outcomes because pancuronium and midazolam reduce nausea and vomiting to zero. True. However, his “reductio ad absurdum” argument could be made about many meaningful outcomes. Is pain the fifth vital sign or merely a surrogate? Like nausea and vomiting, pain scores could be reduced to zero from a combination of midazolam and pancuronium. Does that make pain not a meaningful outcome? We contend that nausea and vomiting are meaningful outcomes. “Throwing up” is universally considered unpleasant. We will not offer a reference, but invite anyone who enjoys vomiting to disprove us by counterexample. Additionally, Anesthesiologists consider postoperative nausea and vomiting (PONV) a relevant outcome2 and have dubbed it our “big little problem.”3 PONV matters to our patients.4,5 Patients are willing to pay US$56–US$100 out of their own pocket for a totally effective antiemetic.6 Similar to the occurrence of severe postoperative pain, inadequate management of PONV may imply medico-legal consequences because PONV is considered at least as troublesome as postoperative pain.4,7 The forceful expulsion of gastric contents in the course of severe vomiting or PONV may lead to life-threatening complications.8 There may be economic consequences of PONV, especially in an outpatient setting, because the occurrence of PONV is a leading factor for unplanned hospital admissions.9,10 Eliminating the “big little problem”3 may be our “big little chance.”11 Peter Kranke Department of Anaesthesia and Critical Care University Hospitals of Würzburg Würzburg, Germany [email protected] Andrew F. Smith Department of Anaesthesia and Lancaster Patient Safety Research Unit Lancaster, UK Swen N. Piper Department of Anesthesiology and Intensive Care Hospital of Ludwigshafen/Rhine Germany Jan Wallenborn Department of Anesthesiology and Intensive Care University Hospitals of Leipzig Leipzig, Germany Norbert Roewer Department of Anaesthesia and Critical Care University Hospitals of Würzburg Würzburg, Germany Leopold H. J. Eberhart Department of Anesthesiology and Intensive Care University Hospitals of Marburg and Gießen Marburg, Germany