Postdischarge Nausea And Vomiting Research Articles

Olanzapine versus standard antiemetic prophylaxis for the prevention of post-discharge nausea and vomiting after propofol-based general anaesthesia: A randomised controlled trial

Background and Aims: Post-discharge nausea and vomiting (PDNV) is a pertinent problem in patients undergoing ambulatory surgery. The objective of this study was to assess the efficacy of the novel drug olanzapine, which has proved its efficiency in patients undergoing highly emetogenic chemotherapy for PDNV prevention. Methods: This randomised controlled trial recruited 106 adult patients (18–65 years) undergoing highly emetogenic daycare surgeries with propofol-based general anaesthesia (GA). Group O received preoperative oral olanzapine 10 mg, and Group C, acting as a control, received 8 mg of intravenous dexamethasone and 4 mg of ondansetron intraoperatively. The primary outcome was nausea (numeric rating scale >3) and/or vomiting 24 h after discharge. Secondary outcomes included nausea and vomiting in the post-anaesthesia care unit (PACU), severe nausea, vomiting and side effects. Normality was assessed using the Shapiro–Wilk test, and the independent samples t-test or the Mann–Whitney U test was used to compare continuous variables. Fisher’s exact test was used to assess any non-random associations between the categorical variables. Results: The incidence and severity of postoperative nausea and vomiting were similar in both groups within PACU (four patients experienced nausea and vomiting, three had severe symptoms in Group O, P = 0.057) and in the post-discharge period (three patients in Group O had nausea and vomiting compared to five patients in Group C, of which four were severe, P = 0.484). The side effects (sedation, dizziness, and light-headedness) were comparable between the two groups. Conclusion: A single preoperative oral olanzapine can be an effective alternative to standard antiemetic prophylaxis involving dexamethasone and ondansetron for preventing PDNV in highly emetogenic daycare surgeries with propofol-based GA.

Postoperative and postdischarge nausea and vomiting following ambulatory eye, head, and neck surgeries: a retrospective cohort study comparing incidence and associated factors.

Ambulatory surgery is often followed by the development of nausea and/or vomiting (N/V). Although risk factors for postoperative nausea and vomiting (PONV) are frequently discussed, the distinction between PONV and postdischarge nausea and vomiting (PDNV) is unclear. This is especially troublesome given the potential consequences of postdischarge nausea and vomiting (PDNV), which include major discomfort and hospital readmission. In this retrospective cohort study, data from 10,231 adult patients undergoing ambulatory ophthalmology or otolaryngology procedures with general anesthesia were collected and analyzed. Binary and multinomial logistic regression was used to assess the association between patient and anesthetic characteristics (including age, body mass index (BMI), American Society of Anesthesiologists Physical Status (ASA P/S) classification, current smoker status, and intra- and postoperative opioid usage) and the odds ratios of experiencing only PDNV, only PONV, or both PONV and PDNV, as compared to not experiencing N/V at all. We found that 17.8% of all patients developed N/V (PONV and/or PDNV). Patients who experienced PONV had a 2.79 (95% confidence interval 2.24-3.46) times greater risk of reporting PDNV. Binary logistic regression found that younger age, opioid use, and female sex were associated with an increased likelihood of experiencing any N/V. Increased use of nitrous oxide and a higher ASA P/S class was associated with elevated likelihood of PONV, but not PDNV or PONV plus PDNV. Patients experiencing N/V in the PACU are observed to develop PDNV disproportionately by a factor of 2.79. The patients have distinct predictors, indicating important opportunities for care improvements beyond current guidelines.

Evaluation of Post-Operative and Post-Discharge Nausea Vomiting and Associated Risk Factors Among Patients Undergoing Ambulatory Laparoscopic Cholecystectomy in Tertiary Care Hospital

Post-operative nausea and vomiting (PONV)may lead to dehydration, bleeding, wound dehiscence, aspiration pneumonitis, and esophageal rupture. Post-discharge nausea and vomiting (PDNV) is acondition occurred during 24-72 hours of discharge. Both conditions have almost the same risk factors. Objective: To determine the frequency of post-operative and post-discharge nausea and vomiting and its associated factors among patients undergoing ambulatory laparoscopic surgery in a Tertiary Care Hospital. Methods: Total 106 patientsrequiring ambulatory laparoscopic surgery were included. Patient was kept under observation for at least 12 hourstill discharge. Post-discharge time of first incidence of nausea and/or vomiting was recorded. Normality was checked through Shapiro-Wilk test. To compare qualitative variables, chi-square test was used. If following Gaussian distribution, quantitative variables were compared using t-test; otherwise, Mann-Whitney U test was used. Logistic regression was applied to get Odd ratios. P-value ≤0.05 was taken as statistically significant. Results: Ketorolac was given to 104(98.1%) patients and only 2(1.9%) received tramadol. The most common complication was excessive bleeding 4(3.8%). Intraoperative opioids were given to 22(20.8%) patients. Post-operative vomiting and nausea among patients were found as 42(39.6%) and 20(18.9%) respectively. Post-discharge nausea and vomiting in patients were found as 14(13.2%) and 6(5.7%) respectively. Conclusions: Highprevalence of PONV and low prevalence of PDNV among patients who underwent ambulatory surgeries were reported. After ambulatory surgery the risk factors for PONV are observed as operation time>1h, female gender, postoperative pain during activitie, and postoperative pain at rest.

Palonosetron as prophylaxis for post-discharge nausea and vomiting: a prospective, randomised, double-blind, placebo-controlled trial in ambulatory surgery

BackgroundApproximately 25% of ambulatory surgery patients experience post-discharge nausea and vomiting (PDNV). We aimed to investigate whether palonosetron, a long-acting anti-emetic, decreases the incidence of PDNV in high-risk patients. MethodsIn this prospective, randomised, double-blind, placebo-controlled trial, 170 male and female patients undergoing ambulatory surgery under general anaesthesia, with a high predicted risk for PDNV, were randomised to receive either palonosetron 75 μg i.v. (n=84) or normal saline (n=86) before discharge. During the first 3 postoperative days (PODs), we measured outcomes using a patient questionnaire. The primary outcome was the incidence of a complete response (no nausea, vomiting, or use of rescue medication) until POD 2. Secondary outcomes included the incidence of PDNV each day until POD 3. ResultsThe incidence of a complete response until POD 2 was 48% (n=32) in the palonosetron group and 36% (n=25) in the placebo group (odds ratio 1.69 [95% confidence interval: 0.85–3.37]; P=0.131). No significant difference in the incidence of PDNV was observed between the two groups on the day of surgery (47% vs 56%; P=0.31). Significant differences in the incidence of PDNV were found on POD 1 (18% vs 34%; P=0.033) and POD 2 (9% vs 27%; P=0.007). No differences were observed on POD 3 (15% vs 13%; P=0.700). ConclusionsCompared with placebo, palonosetron did not reduce the overall incidence of post-discharge nausea and vomiting up to postoperative day 2. The lower incidence of post-discharge nausea and vomiting on poatoperative days 1 and 2 in the palonosetron group requires further investigation. Clinical trial registrationEudraCT 2015-003956-32.

Postdischarge nausea and vomiting (PDNV) in children: A review and observational study.

Postdischarge nausea and vomiting (PDNV) cause substantial pediatric morbidity with potentially serious postoperative complications. However, few studies have addressed PDNV prevention and treatment in pediatric patients. Here we searched the literature and processed it in a narrative review describing PDNV incidence, risk factors, and management in pediatric patients.. A successful strategy for reducing PDNV considers both the pharmacokinetics of the antiemetic agents and the principle of multimodal prophylaxis, utilizing agents of different pharmacologic classes. Since many highly effective antiemetic agents have relatively short half-lives, a different approach must be used to prevent PDNV. A combination of oral and intravenous medications with longer half-lives, such as palonosetron or aprepitant, can be used. In addition, we designed a prospective observational study with the primary objective of determining PDNV incidence. In our study group of 205 children, the overall PDNV incidence was 14.6% (30 of 205), including 21 children suffering from nausea and 9 suffering from vomiting.

Prevalence of Nausea-Vomiting and Coping Strategies in Patients Undergoing Outpatient Surgery

PurposeThe present study aimed to determine the prevalence and coping strategies for postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) in patients undergoing outpatient surgery. DesignA descriptive research design was used. MethodsThis descriptive study was carried out with 350 patients who were admitted within the scope of outpatient surgery of the ear, nose, and throat; orthopaedics, urology, and general surgery departments of a university hospital between July 3, 2017 and March 6, 2018. A patient diagnosis form consisting of 34 items developed by the researcher and nausea-vomiting diary were used to collect data. FindingsThe results showed that 30.6% of the patients had PONV and 26.3% had PDNV. Of the 92 patients with postdischarge nausea, 26.1% experienced mild, 44.6% moderate, 20.7% high, and 8.7% severe nausea. Among the strategies for coping with PDNV, the patients preferred resting (49%), going outdoors (23.4%), eating something (17%), and drinking something (10.6%). A statistically significant difference was found between postdischarge nausea and risk factors for nausea-vomiting, such as female gender, history of nausea-vomiting, nausea in the postanesthesia care unit, and opioid use in the postanesthesia care unit (P < .05). ConclusionsThis study shows that approximately a quarter of patients who undergo outpatient surgery will experience nausea and vomiting immediately after surgery as well as at home after discharge. Assessment of risk factors for PONV/PDNV was discovered to be an important factor in the care of perioperative patients. Therefore, the risk scoring system is expected to contribute to reducing PONV/PDNV incidence and improving patient coping strategies and satisfaction.

Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecologic Surgical Patients

PurposePostdischarge nausea, vomiting, and retching often occur after the time of discharge from the postanesthesia care unit (PACU) in patients who have undergone outpatient surgeries. At a large mid-Atlantic Academic Hospital, 40% of gynecologic outpatient surgical patients had postdischarge nausea and vomiting (PDNV). The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool to improve PDNV risk screening in the PACU. DesignThis quality improvement project was part of an evidence-based practice project. MethodsAfter identification and recruitment of key stakeholders and unit champions, a force-field analysis, as part of Lewin's change theory, was completed to identify the driving and restraining forces. All PACU registered nurses received education on the risk assessment protocol using the Apfel risk assessment tool. The Apfel risk assessment tool has been validated to identify five independent risk factors for PDNV in outpatient ambulatory surgical populations. Implementation of the tool with data collection occurred for 8 weeks on all scheduled outpatient breast and gynecologic surgical patients. Staff compliance was measured throughout implementation. FindingsIn patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients, respectively. Compliance with the tool was high with an average compliance rate of 92% for the 8-week data collection period. ConclusionsData analysis demonstrated that the Apfel risk assessment tool adequately predicted the risk for PDNV in outpatient surgical breast and gynecologic patients. Use of Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. In addition, this quality improvement project resulted in increased compliance of the standing follow-up phone call policy. Efforts toward sustainment include expansion to all outpatient surgical populations and implementation of a PDNV prevention and management guideline.

What is the ideal combination antiemetic regimen?

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after surgery. PONV and PDNV have been associated with postoperative complications and hospital discharge delays. Despite the extensive evidence describing the use of several regimens in different surgical populations, the ideal regimen has not been established. Several antiemetic drugs have been evaluated in more than 1000 clinical controlled trials for management of this complex emetogenic pathway, including the 5-hydroxytryptamine (5-HT3) receptor antagonists, dopamine receptor antagonists, neurokinin-type receptor antagonists, antihistaminics, anticholinergics, and corticosteroids, with the 5-HT3 receptor antagonists being the most commonly used for PONV prophylaxis. Because of the complex emetogenic pathway and multifactorial etiology of PONV, a multimodal approach using two or more drugs that act at different neuro-receptor sites is suggested in patients with one or more risk factors to successfully address PONV and reduce its incidence. Nevertheless, the most studied regimens in randomized clinical trials (RCTs) are the combination of serotonin 5-HT3 receptor antagonists with dexamethasone or dopamine receptor antagonists (droperidol). Therefore, the safest and more effective combination regimen appears to be the use of serotonin 5-HT3 receptor antagonist antiemetic drugs with dexamethasone.

Management of postdischarge nausea and vomiting.

Postdischarge nausea and vomiting (PDNV) occurs in at least 30% of patients leaving hospital, especially after day-case surgery. A significant number of ambulatory patients may develop PDNV associated with the use of analgesics for postsurgical pain. A validated PDNV prediction score and international evidence-based consensus guidelines for PONV/PDNV management are available. High-risk patients benefit from a predischarge PDNV risk assessment and the use of adapted pharmacological intervention (combination of long- and short-acting antiemetics and access to antiemetics at home). Patient education is often overlooked in this context. All clinicians involved in the ambulatory surgery care process should participate in the development of institutional protocol for PONV/PDNV management. Constant quality control and patients' feedback should be integrated as part of an efficient implementation strategy.

Postoperative Nausea and Vomiting in Pediatric Patients.

Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review.

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children.

Because nausea is difficult to evaluate in children, vomiting is used as the objective clinical end point in managing pediatric postoperative nausea and vomiting and postdischarge nausea and vomiting (PDNV). The recently developed pictorial Baxter Retching Faces (BARF) scale has content, construct, and convergent validity in quantifying pediatric nausea intensity. We determined its clinical usefulness in assessing pediatric postoperative nausea and vomiting and PDNV, establishing the lowest age associated with consistently reliable use, the score at which patients identify a need for therapy, and the minimum clinically relevant change in scores, and examined its test-retest reliability. We obtained subject ratings of the severity of their nausea using the BARF and visual analog scales in the preoperative, postanesthesia care unit and postdischarge phases. Changes in nausea were rated on a 5-point Likert scale, along with responses to queries of a need for rescue antiemetics at these time points. Children ≥6 years of age had a consistently reliable ability to use the BARF scale (132/132 [100%] vs 59/76 [77.6%] for children ≥6 and <6 years of age, respectively, Fisher exact test, P < .001). The BARF scale had excellent performance in predicting patient-perceived need for antiemetics, with a score of 4 having 80.0% sensitivity and 85.6% specificity. The minimum clinically relevant difference in BARF scores was 1.47 (95% confidence interval, 0.84-2.1). The intraclass correlation coefficient was 0.56 (95% confidence interval, 0.34-0.73).The BARF scale identified 60 of 192 (31.3%) children as having postoperative nausea in the postanesthesia care unit, with severe nausea (score >6) in 13 (6.7%). Emesis occurred in 8 (4.1%). Rescue antiemetics were administered to 16 (8.3%), including 2 with severe emesis (≥3 episodes) but in only 2 of 11 (18.2%) with severe nausea without vomiting. PDNV was reported in 39 of the 99 who returned diaries (39.4%), with nausea in 34 (34.3%), severe nausea in 15 (15.2 %), and emesis in 16 (16.2%). The pictorial BARF scale is easy to use in the clinical setting by children ≥6 years of age, has a minimum clinically relevant difference of 1.47, with scores of 4 or higher associated with a patient-identified need for rescue antiemetics. Assessment of postoperative nausea by the BARF scale has shown that clinically significant nausea occurs frequently in children but is not always treated unless accompanied by vomiting.

Post-discharge nausea and vomiting after total intravenous anaesthesia and standardised PONV prophylaxis for ambulatory surgery.

The incidence of post-discharge nausea and vomiting (PDNV) after ambulatory anaesthesia using total intravenous anaesthesia with a risk-stratified anti-emetic approach is not well documented in the literature. In this study, we outline such an approach. The goal was to achieve an acceptably low rate of PDNV both immediately and the day after surgery. With ethics committee approval, adult patients undergoing outpatient surgery received a Propofol-based general anaesthetic plus standardised PONV-prophylaxis corresponding to their Apfel risk-score (0-4); ondansetron (risk-score 2), additional dexamethasone (risk-score 3), and additional droperidol (risk-score 4). On post-operative days one and two, patients scored PDNV and pain (numeric rating scale (NRS); 0 = none at all; 10 = worst imaginable). On post-operative day two, patients indicated the level of interference of PDNV and/or pain with their quality of life. Data are descriptive (%) or mean. There were 222 patients included (age 43 years, 44% female, anaesthesia time 95 min). On the day of surgery, 69.4% of patients did not experience any nausea, 10.4% complained about severe (NRS > 6) nausea, 6.3% experienced vomiting or retching. On the first and second postoperative day, nausea was absent in 88.7% of patients and 97.3%, respectively. Quality of life was impacted (NRS ≥ 4) more by pain (32.8% of cases), than by PDNV (13.6%). Acceptably low rates of PDNV were achieved with the proposed standardised approach to PDNV prophylaxis. For almost 90% of patients, PDNV was not an issue the first day after surgery. Pain after discharge was a more common problem.

An update on the management of postoperative nausea and vomiting.

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.

Comparative Pharmacology and Guide to the Use of the Serotonin 5-HT3 Receptor Antagonists for Postoperative Nausea and Vomiting.

Since the introduction of the serotonin 5-hydroxy tryptamine 3 (5-HT3) receptor antagonists in the early 1990s, the incidence of postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) has decreased, yet continues to be a problem for the surgical patient. The clinical application of the 5-HT3 receptor antagonists has helped define the approach and role of these antiemetics in the prevention and treatment of PONV and PDNV. Pharmacological and clinical differences exist among these medications resulting in corresponding differences in effectiveness, safety, optimal dosage, time of administration, and use as combination and rescue antiemetic therapy. The clinical application of the 5-HT3 receptor antagonist antiemetics has improved the prevention and treatment of PONV and PDNV. The most recent consensus guidelines for PONV published in 2014 outline the use of these antiemetics. The 5-HT3 receptor antagonists play an important role to help prevent PONV and PDNV in perioperative care pathways such as Enhanced Recovery After Surgery (ERAS). Comparisons and guidelines for use of the 5-HT3 receptor antagonists in relation to the risk for PONV and PDNV are reviewed.

A Prospective Study of Nausea and Vomiting After Breast Cancer Surgery

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) continue to be common and disturbing complications experienced after surgery, particularly in women and especially in women undergoing breast cancer surgery. The purpose of this study was to assess the incidence and risk factors associated with PONV and PDNV from preoperative to 48 hours postoperatively in 97 women scheduled for breast cancer surgery. Prospective, comparative design. After informed consent was obtained, women scheduled for breast cancer surgery were evaluated for incidence of vomiting, as well as the presence and severity of nausea from the preoperative holding area for 48 hours following surgery. Vomiting was assessed as both a nominally scaled, binary variable (Yes/No) and as a continuous variable to measure separate emetic events. Nausea was measured on an 11point verbal numeric scale with 0 being the absence of nausea and 10 representing the highest level of nausea ever experienced. Twenty-nine (29.8%) women experienced nausea, and nine (9%) women experienced nausea and vomiting while in the post-anesthesia care unit despite close attention to the need for prophylactic antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experience PONV. Women who received intravenous acetaminophen did not experience less PONV in this study. PDNV occurred more frequently than PONV, with 34 women (35%) reporting occurrence after discharge. About 13 women who did not experience PONV while in the PACU subsequently experienced PDNV after leaving the hospital, evidence for the importance of patient discharge teaching regarding these symptoms. Although clinical guidelines are necessary, our observation is that nurses in the PACU setting continuously challenge themselves to individualize the combination of medications and activities for each patient to reduce PONV after surgery.

Validation of a prediction model for post-discharge nausea and vomiting after general anaesthesia in a cohort of Swedish ambulatory surgery patients.

In ambulatory surgery, post-discharge nausea and vomiting (PDNV) has been identified as a significant problem occurring in more than one-third of patients. To validate a simplified PDNV score in a Swedish population. Prospective observational study. Two county hospitals in Sweden: Sundsvall from June 2012 to May 2013 and Sunderbyn from January to October 2014. Adult patients undergoing ambulatory surgery under general anaesthesia. Postoperative outcomes with a focus on nausea and vomiting were collected at 2, 4, and 6 h after surgery and on the first three postoperative days. The simplified PDNV score, calculated before discharge, included the factors: female sex, age less than 50 years, history of postoperative nausea and vomiting, postoperative nausea and opioids given postoperatively. The prediction performance of the simplified PDNV score was evaluated in terms of discrimination (area under receiver-operating characteristics curve) and calibration plots and was compared with that of the original development study. A total of 559 patients were asked to participate, of which 431 were included in the final study cohort. The overall risk of postoperative nausea and vomiting and PDNV were 18.8 [95% confidence interval (CI), 15.4-22.8]% and 28.1 (95% CI, 24.0-32.5)%, respectively. The discrimination capacity of the simplified PDNV score in our study was similar to that of the original dataset [area under the curve 0.693 (95% CI, 0.638-0.748) vs. 0.706 (0.681-0.731), absolute difference 0.013]. The slope of the calibration curve was 0.893, with a constant of 0.021 (R-square 0.884). In a Swedish cohort of patients, the simplified PDNV score performs well in discriminating between patients who will experience post-discharge nausea and/or vomiting after ambulatory surgery. Our results indicate that the simplified PDNV score is as valid in other cohorts as it was in the original development cohort.

Revisiting transdermal scopolamine for postoperative nausea and vomiting

Revisiting transdermal scopolamine for postoperative nausea and vomiting Joseph V Pergolizzi,1&ndash;3 Robert B Raffa,4 Gianpietro Zampogna,5 Hani Michael Annabi,6 Thomas J Pallaria,7 Robert Taylor,5,6 1Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 2Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, 3Association of Chronic Pain Patients, Houston, TX, 4Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, 5NEMA Research, Bonita Springs, FL, 6Public Health Department, Johns Hopkins University Krieger School of Arts and Sciences, Baltimore, MD, 7Department of Anesthesia, Barnabas Health-Newark Beth Israel Medical Center, Newark, NJ, USA Abstract: Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) in ambulatory patients remain serious problems that affect a substantial subset of surgical patients. Guidelines recommend that patients be stratified for risk, and patients at moderate-to-high risk be administered prophylactic PONV/PDNV therapy. Risk stratification on the four-point Apfel scale assigns one point for each of the following: female sex, nonsmoking status, history of PONV or motion sickness, and the use of postoperative opioids. Patients who score 2 or higher are considered to be at moderate-to-high risk. Other risk factors have been evaluated and discussed in the literature, such as type and duration of surgery. Surprisingly, although PONV/PDNV is more common in the first 24 hours after anesthesia, it may occur for days following surgery, and so, continuous treatment is advantageous. Transdermal scopolamine is a well-established agent with a history of safety and efficacy for PONV/PDNV prevention. Scopolamine is an anticholinergic agent that is generally well tolerated; side effects tend to be mild to moderate. The most frequently reported side effects with transdermal scopolamine are visual disturbances and dry mouth. Once adhered to the skin, the patch administers an initial dose and then a continuous dose of medication over 72 hours. Transdermal scopolamine is easy to administer, safe, effective, and relatively cost-effective, and it should be considered as an important tool to help prevent PONV/PDNV, whether administered as monotherapy or in combination with other agent(s). Keywords: transdermal scopolamine, postoperative nausea and vomiting, antiemetic

Postdischarge Nausea and Vomiting Remains Frequent After Le Fort I Osteotomy Despite Implementation of a Multimodal Antiemetic Protocol Effective in Reducing Postoperative Nausea and Vomiting

To assess the prevalence of postdischarge nausea and vomiting (PDNV) after Le Fort I osteotomy with and without the use of a multimodal antiemetic protocol shown to decrease postoperative nausea and vomiting (PONV). Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution formed the intervention cohort for an institutional review board-approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol. The comparison group consisted of consecutive patients who underwent similar surgical procedures at the same institution before protocol implementation. All patients were asked to complete a postdischarge diary documenting the occurrence of nausea and vomiting. Those who completed the diaries were included in this analysis. Data were analyzed with the Fisher exact test and the Wilcoxon rank sum test. A P value less than .05 was considered significant. Diaries were completed by 85% of patients in the intervention group (79 of 93) and 75% of patients in the comparison group (103 of 137). Patients in the intervention (n = 79) and comparison (n = 103) groups were similar in the proportion of patients with validated risk factors for PDNV, including female gender, history of PONV, age younger than 50 years, opioid use in the postanesthesia care unit (PACU), and nausea in the PACU (P = .37). The prevalence of PDNV was unaffected by the antiemetic protocol. After discharge, nausea was reported by 72% of patients in the intervention group and 60% of patients in the comparison group (P = .13) and vomiting was reported by 22% of patients in the intervention group and 29% of patients in the comparison group (P = .40). Modalities that successfully address PONV after Le Fort I osteotomy might fail to affect PDNV, which is prevalent in this population. Future investigation will focus on methods to minimize PDNV.

SAMBA Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: An Executive Summary for Perianesthesia Nurses

POSTOPERATIVE NAUSEA AND VOMITING (PONV) remains one of the most common, and most distressing postoperative complications. Despite advances in pharmacological and nonpharmacological prophylactic and rescue interventions, postoperative vomiting (POV) occurs in approximately 30% of surgical patients, while the incidence of nausea is around 50%. The incidence of PONV in high risk patients may run as high as 80%. 1 Gan T.J. Diemunsch P. Habib A.S. et al. Consensus guidelines for the management of postoperative nausea and vomiting. [Erratum appears in Anesth Analg. 2014 Mar;118(3):689]. Anesth Analg. 2014; 118: 85-113 Crossref PubMed Scopus (920) Google Scholar , 2 Kapur P.A. Editorial: The Big “Little Problem”. Anesth Analg. 1991; 73: 243-245 Crossref PubMed Google Scholar , 3 Odom-Forren J. Hooper V. Moser D.K. et al. Postdischarge Nausea and Vomiting: Management Strategies and Outcomes Over 7 Days. J Perianesth Nurs. 2013; 29: 275-284 Abstract Full Text Full Text PDF Scopus (22) Google Scholar , 4 Odom-Forren J. Jalota L. Moser D.K. et al. Incidence and predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth. 2013; 25: 551-559 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar , 5 Samuels J.D. Perioperative nausea and vomiting: much ado about nothing?. Aesthetic Plast Surg. 2013; 37: 634-635 Crossref PubMed Scopus (3) Google Scholar , 6 Sussanne B. Arwestrom C. Baker A. Bertero C. Nurses’ experiences in the relief of postoperative nausea and vomiting. J Clin Nurs. 2010; 19: 1865-1872 Crossref PubMed Scopus (8) Google Scholar Although relatively short-lived in nature, patients identify PONV as one of the most dreaded postoperative complications, many fearing PONV more than postoperative pain. 1 Gan T.J. Diemunsch P. Habib A.S. et al. Consensus guidelines for the management of postoperative nausea and vomiting. [Erratum appears in Anesth Analg. 2014 Mar;118(3):689]. Anesth Analg. 2014; 118: 85-113 Crossref PubMed Scopus (920) Google Scholar , 2 Kapur P.A. Editorial: The Big “Little Problem”. Anesth Analg. 1991; 73: 243-245 Crossref PubMed Google Scholar , 5 Samuels J.D. Perioperative nausea and vomiting: much ado about nothing?. Aesthetic Plast Surg. 2013; 37: 634-635 Crossref PubMed Scopus (3) Google Scholar Protracted PONV is associated with increased cost of care, most commonly related to extended PACU length of stay (LOS) and increased unplanned hospital admissions. Unrelieved postdischarge nausea and vomiting (PDNV) has been associated with delayed return to work/normal activities of daily living, and often contributes to emergency department visits and associated hospital readmission. 1 Gan T.J. Diemunsch P. Habib A.S. et al. Consensus guidelines for the management of postoperative nausea and vomiting. [Erratum appears in Anesth Analg. 2014 Mar;118(3):689]. Anesth Analg. 2014; 118: 85-113 Crossref PubMed Scopus (920) Google Scholar , 3 Odom-Forren J. Hooper V. Moser D.K. et al. Postdischarge Nausea and Vomiting: Management Strategies and Outcomes Over 7 Days. J Perianesth Nurs. 2013; 29: 275-284 Abstract Full Text Full Text PDF Scopus (22) Google Scholar , 4 Odom-Forren J. Jalota L. Moser D.K. et al. Incidence and predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth. 2013; 25: 551-559 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Vallire D. Hooper, PhD, RN, CPAN, FAAN, is a Manager, Nursing Research, Mission Hospital, Asheville, NC