Postoperative Nausea and Vomiting: Prevention and Treatment

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Postoperative Nausea and VomitingPrevention and
Treatment

• Phillip E. Scuderi, M.D.
• Department of Anesthesiology
• Wake Forest University School of Medicine
• Winston-Salem, NC 27157-1009

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Postoperative Nausea and VomitingPrevention and
Treatment

• http//www.wfubmc.edu/anesthesia
• pscuderi_at_wfubmc.edu

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Historical Perspective on PONV
Postoperative Nausea and Vomiting Its Etiology,
Treatment, and Prevention Mehernoor F. Watcha and
Paul F. White Anesthesiology 199277162-184
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Definitions
Nausea
Subjectively unpleasant sensation associated with
the awareness of the urge to vomit
Retching
Labored, spasmodic, rhythmic contractions of the
respiratory muscles without expulsion of gastric
contents
Vomiting
Forceful expulsion of gastric contents from the
mouth
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Definitions
Complete Response
No vomiting and no requirement for rescue
antiemetics
Total Response
No vomiting and no nausea
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Topics

• Risk factors
• Pharmacologic approaches to management
• Adjuvants (nonpharmacologic)
• Efficacy versus outcome
• Prevention versus treatment
• Postdischarge nausea and vomiting
• Multimodal management

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Risk Factors
Reasons For Identifying Risk Factors

• Economics of anesthetic agents
• Side effects of antiemetic drugs
• Lacked of increased patient satisfaction

Eberhart LH et al. Acta Anaesthesiol Scand. 2000
44480-488
12
Risk Factors

• Non-anesthetic factors
• Anesthetic related factors
• Postoperative factors

13
Risk Factors
Non-anesthetic Factors

• Age
• Gender
• Body habitus
• Hx motion sickness
• Hx PONV
• Anxiety
• Concomitant disease
• Operative procedure
• Duration of surgery

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Risk Factors
Anesthetic Related Factors

• Preanesthetic medication
• Gastric distension
• Gastric suctioning
• Anesthetic technique
• Anesthetic agents

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Risk Factors
Postoperative Factors

• Pain
• Dizziness
• Ambulation
• Oral intake
• Opioids

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Postoperative Nausea and VomitingAnesthetic
Related Factors

• Nitrous oxide
• NMB reversal
• Propofol

17
Risk FactorsNitrous Oxide and PONV
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Risk FactorsNitrous Oxide and PONV
Omitting nitrous oxide from general anesthesia

• Decreases POV significantly only if the baseline
  risk is high
• Does not affect nausea or complete control of
  emesis
• Increases the incidence of intraoperative
  awareness

Tramer et al. BJA 199676186-193
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Risk Factors Reversal of Neuromuscular Block

• Omitting neostigmine may have a clinically
  relevant antiemetic effect when high doses are
  used
• Omitting NMB antagonism introduces a
  non-negligent risk of residual paralysis even
  when short acting NMB agents are used

Tramer MR, Fuchs-Buder T. BJA 199982379-386
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Risk Factors Propofol and PONV
Analysis by NNT
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Risk Factors Antiemetic Effects of Propofol
22
Risk Factors
Logistic Regression
Palazzo M, Evans R. Logistic regression analysis
of fixed patient factors for postoperative
sickness a model for risk assessment. Br J
Anaesth 199370135-40.
Koivuranta M, Läärä E, Snåre L, Alahuhta S. A
survey of postoperative nausea and vomiting.
Anaesthesia 199752443-49.
Apfel CC, Greim CA, Haubitz I, et al. A risk
score to predict the probability of postoperative
vomiting in adults. Acta Anaesthesiol Scand
199842495-501.
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Risk Factors
Logistic Regression

• Younger age
• Nonsmoking history
• Female
• Hx of motion sickness
• Hx of PONV
• Increased duration of operation

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Risk Factors
Simplified Scoring System

• Female
• Nonsmoking history
• Hx of motion sickness or PONV
• Use of postoperative opioids

Incidence of PONV
Apfel CC et al. Anesthesiology 199991693-700.
25
Management of PONVPharmacological Approaches

• Medications
• Dose response
• Comparative efficacy
• Combination therapy
• Timing of administration

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Currently Available Medications

• 5HT3 (serotonin) antagonists - ondansetron
• Butyrophenones - droperidol
• Benzamides - metoclopramide
• Antihistamines - promethazine, dimenhydrinate
• Steroids - dexamethasone
• Phenothiazines- promethazine, prochlorperazine
• Anticholinergics - scopolamine

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5HT3 Antagonists and PONV
Approved for PONV indication
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Prevention of PONVOndansetron Versus Placebo
All patients, 0 - 24 hrs



p 0.010 p lt 0.001
McKenzie et al. Anesthesiology 19937821-28
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Treatment of PONVOndansetron Versus Placebo






p lt 0.001
Scuderi et al. Anesthesiology 1993782-5 Hantler
et al. Anesthesiology 199277A16
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Ondansetron Dose ResponsePrevention
Numbers Needed to be Treated

• Only 4 mg and 8 mg were significantly different
  than placebo
• No further improvement with doses gt8 mg

Tramer et al. Anesthesiology 1997871277-1289
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Ondansetron Dose ResponseTreatment
Numbers Needed to be Treated

• All three doses significantly different than
  placebo
• No significant difference in antiemetic efficacy
  between the three doses of ondansetron

Tramer et al. BMJ 19973141088-1092
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Breakthrough PONVRepeat Dosing With Ondansetron
p 0.074 p 0.342


Kovac et al. J. Clin Anesth 199911453-459
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Prevention of PONVDolasetron Versus Placebo









p lt 0.0003 compared to placebo
Graczyk et al. Anesth Analg 199784325-330
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Treatment of PONVDolasetron Versus Placebo








p lt 0.001 compared to placebo
Kovac et al. Anesth Analg 199785546-552
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Prevention of PONVOndansetron Versus Dolasetron




p lt 0.05 versus placebo and dolasetron 25 mg
p lt 0.05 versus placebo only
Korttila K et al. Acta Anaesthesiol Scand
199741914-922
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Prevention of PONVOndansetron Versus Dolasetron
Postoperative Vomiting
No statistically significant differences among
the groups
Zarate E, et al. Anesth Analg 2000901352-1358
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Prevention of PONVOndansetron Versus Dolasetron
Postoperative Nausea
No statistically significant differences among
the groups
Zarate E, et al. Anesth Analg 2000901352-1358
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Prevention of PONVOndansetron Versus Droperidol
Complete Response








p lt 0 .05 compared to placebo p lt 0.05
compared to ondansetron 4 mg p ,lt0.05 compared
to droperidol 0.625 mg
Fortney et al. Anesth Analg 199886731-738
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Prevention of PONVOndansetron Versus Droperidol
No Nausea
p lt 0 .05 compared to placebo p lt 0.05
compared to droperidol 0.625 mg and
ondansetron 4 mg
?

?
?
Fortney et al. Anesth Analg 199886731-738
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Prevention of PONVOndansetron, Granisetron,
Tropisetron, Metoclopramide

p 0.02 compared to placebo, metoclopramide
Naguib et al. Can J Anesth 199643226-231
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NK-1 AntagonistsPrevention
Gesztesi Z, Scuderi PE, DAngelo R, et al.
Anesthesiology 200093931-937
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Prevention of PONVMetoclopramide

• In summary, metoclopramide, although used as an
  antiemetic for almost 40 years in the prevention
  of PONV, has no clinically relevant antiemetic
  effect . . . it is very likely that the doses
  used in daily clinical practice are too low.

Henzi I, Walder B, and Tramer, MR. Metoclopramide
in the prevention of postoperative nausea and
vomiting a quantitative systematic review of
randomized, placebo-controlled studies. BJA
199983761-771
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Prevention of PONVDexamethasone

• In conclusion, in the surgical setting, a single
  prophylactic dose of dexamethasone is antiemetic
  compared with placebo without evidence of
  clinically relevant toxicity in otherwise healthy
  patients. Late efficacy (i.e., up to 24 hours)
  seems to be most pronounced.

Henzi I, Walder B, and Tramer, MR. Dexamethasone
for the prevention of postoperative nausea and
vomiting a quantitative systematic review.
Anesth Analg 200090186-194
Eberhart LH. Morin AM. Georgieff M. Dexamethasone
for prophylaxis of postoperative nausea and
vomiting. A meta-analysis of randomized
controlled studies. Anaesthesist. 2000 49713-20
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Prevention of PONVDexamethasone

• Dose ranging
• Major gynecological surgery

P lt0.05 compared with placebo and 1.25 mg
Liu K, et al. Anesth Analg 1999891316-1318
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Prevention of PONVCombination Therapy
Ondansetron/Dexamethasone

• McKenzie R, et al. Comparison of ondansetron with
  ondansetron plus dexamethasone in the prevention
  of postoperative nausea and vomiting. Anesth
  Analg 199479961-964
• Lopez-Olaondo L, et al. Combination of
  ondansetron and dexamethasone in the prophylaxis
  of postoperative nausea and vomiting. BJA
  199676835-840
• Eberhart LH. Morin AM. Georgieff M. Dexamethasone
  for prophylaxis of postoperative nausea and
  vomiting. A meta-analysis of randomized
  controlled studies. Anaesthesist. 2000 49713-20

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Prevention of PONVCombination Therapy
Ondansetron/Droperidol

• Pueyo FJ, et al. Combination of ondansetron and
  droperidol in the prophylaxis of postoperative
  nausea and vomiting. Anesth Analg 199683117-122
• McKenzie R, et al. Droperidol/ondansetron
  combination controls nausea and vomiting after
  tubal banding. Anesth Analg 1996831218-1222
• Klockgether-Radke A, et al. Ondansetron,
  droperidol and their combination for the
  prevention of post-operative vomiting in
  children. Eur J Anesthesiology. 199714362-367
• Eberhart LH. Morin AM. Bothner U. Georgieff M.
  Droperidol and 5-ht3-receptor antagonists, alone
  or in combination, for prophylaxis of
  postoperative nausea and vomiting. A
  meta-analysis of randomized controlled trials.
  Acta Anaesthesiologica Scandinavica.
  2000441252-7

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Prevention of PONVTiming of Administration
Ondansetron

• Sun et al. The effect of timing on ondansetron
  administration in outpatients undergoing
  otolaryngologic surgery. Anesth Analg
  199784331-336
• Chen et al. The effect of timing of dolasetron
  administration on its efficacy as a prophylactic
  antiemetic in the ambulatory setting. Anesth
  Analg 200193906-911
• Wang et al. The effect of timing of dexamethasone
  administration on its efficacy as a prophylactic
  antiemetic for postoperative nausea and vomiting.
  Anesth Analg 200091136-139

Dolasetron
Dexamethasone
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Management of PONVAdjuvants (Nonpharmacologic)

• P-6 acupuncture point stimulation
• Supplemental oxygen
• Aggressive perioperative rehydration
• Preemptive analgesia

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P-6 Acupuncture Point Stimulation

• Zarate E, Mingus M, White PF, Chiu JW, Scuderi
  PE, et al. The use of transcutaneous acupoint
  electrical stimulation for preventing nausea and
  vomiting after laparoscopic surgery. Anesth Analg
  200192629-35.

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Supplemental Oxygen

• Greif R, Laciny S, Rapf B, et al. Supplemental
  oxygen reduces the incidence of postoperative
  nausea and vomiting. Anesthesiology
  1999911246-52.
• Goll V, Ozan A, Greif R, et al. Ondansetron is no
  more effective than supplemental intraoperative
  oxygen for prevention of postoperative nausea and
  vomiting. Anesth Analg 200192112-17.

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Supplemental Oxygen
Greif et al. Anesthesiology 1999911246-1252
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Supplemental Oxygen
Goll et al. Anesth Analg 200192112-117
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Intravenous Fluid Therapy
Incidence of Postop Nausea

High Infusion 20 ml/kg Low Infusion 2 ml/kg
Yogendran S, et al. Anesth Analg 199580682-686
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Pain and PONV
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Efficacy Versus Outcome
Question

• Is there evidence to support the hypothesis
  that the demonstrated efficacy of antiemetics in
  the prevention (or treatment) of postoperative
  nausea and vomiting actually results in
  improvement in objective measures of outcome?

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Surrogate End PointsAre They Meaningful

• Appropriate end points
• Duration of PACU stay
• Incidence of unplanned admissions
• Patient satisfaction

Fisher. Anesthesiology 199481795-796
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Measures of Outcome

• Mortality
• Morbidity
• Patient satisfaction
• Cost

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Risk of Mortality and Adverse Outcome in a
Tertiary Care Population
Patient Safety in Anesthesia Practice. Morel and
Eichorn (ed)
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Complications of PONV

• Electrolyte imbalance
• Tension on sutures, evisceration
• Venous hypertension, bleeding
• Aspiration
• Delayed discharge (outpatients)
• Dehydration
• Unanticipated admission

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Unanticipated Admissions
Overall Admission Rate 0.01 PONV Admission Rate
0.002
Gold et al. JAMA 19892623008-3010
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Cost Savings From the Management of PONV

• Analysis of strategies to decrease
  postanesthesia care unit costs
• 1. Supplies and medications account for 2 of
  PACU charges
• 2. Personnel account for almost all PACU
  charges
• 3. PACU staffing is determined by peak PACU
  patient load
• 4. Peak PACU patient load is determined by OR
  scheduling
• 5. Elimination of PONV would decrease PACU stay
  by less than 4.8 which would not be
  sufficient to decrease the level of PACU
  staffing

Dexter et al. Anesthesiology 19958294-101
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Subject Preference Following Surgery
Preoperative
Orkin FK. Anesth Analg 199274S225
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Patient Preference Following Surgery
Preoperative
Macario et al. Anesth Analg, 199989652-658
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Patient Satisfaction With Outpatient Surgery
Postoperative
Tarazi and Philip. Am J Anesthesiology
199825154-157
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Efficacy Versus Outcome
Question

• Is there evidence to support the hypothesis
  that the demonstrated efficacy of antiemetics in
  the prevention (or treatment) of postoperative
  nausea and vomiting actually results in
  improvement in objective measures of outcome?

Answer
Other than improvement in patient satisfaction,
it is difficult to demonstrate improvement in
other objective measures of outcome
66
Prevention Versus Treatment
Question

• Does routine administration of prophylactic
  antiemetics improve outcome when compared to
  rapid symptomatic treatment of postoperative
  nausea and/or vomiting?

Routine habitual or mechanical (i.e., mindless)
performance of an established procedure
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Hypothesis

• No improvement in objective measures of outcome
  result from the routine administration of
  prophylactic antiemetics when compared to rapid
  symptomatic treatment of symptoms should they
  occur postoperatively.

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Efficacy Endpoints

• Incidence of vomiting
• Predischarge
• Postdischarge
• Rescue antiemetics
• Nausea
• PACU entry
• Time of discharge

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Outcome Endpoints

• Time to discharge
• Rate of unanticipated admission
• Patient satisfaction with control of PONV
• Patient satisfaction with outpatient experience
• Time required for patient to return to normal
  daily activity

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Methods

• Prospective, randomized, placebo-controlled for
  both prophylaxis and treatment
• IRB approved, informed consent
• Patients stratified by risk factors
• Adults (18 - 65 yrs) undergoing outpatient
  surgery under general anesthesia
• Anesthetic regimen not controlled
• Ondansetron used for prophylaxis and treatment
• Droperidol as rescue

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Frequency of PACU Treatment by Risk Factors and
Group
Scuderi et al. Anesthesiology. 199990360-371
72
Efficacy of Prophylaxis Overall
Scuderi et al. Anesthesiology. 199990360-371
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Efficacy of Prophylaxis - Group E
Scuderi et al. Anesthesiology. 199990360-371
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Outcomes - Treatment vs Prophylaxis Patient
Satisfaction, Time to Discharge
Scuderi et al. Anesthesiology. 199990360-371
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Outcomes - Treatment Vs ProphylaxisActivities of
Daily Living
Geometric mean - time in hr
Scuderi et al. Anesthesiology. 199990360-371
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Outcomes - Treatment Vs ProphylaxisActivities of
Daily Living
Survival analysis of indices of normal daily
activity showing fraction of patients not able to
perform one or more of the activities which could
be performed before surgery
Ondansetron prophylaxis
1.0
0.9
Placebo prophylaxis
0.8
0.7
Fraction of patients
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
20
40
60
80
100
120
Time from PACU Discharge (hours)
Scuderi et al. Anesthesiology. 199990360-371
77
Prevention Versus Treatment
Question

• Does routine administration of prophylactic
  antiemetics routine administration of
  prophylactic antiemetics improve outcome when
  compared to rapid symptomatic treatment of
  postoperative nausea and/or vomiting?

Answer
Routine administration of prophylactic
antiemetics does reduce the incidence of emesis
both before and after discharge however, it does
not improve objective measures of outcome
following outpatient surgery except in patients
at the highest risk for symptoms
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Post Discharge Nausea and Vomiting

• Incidence
• Severity
• Contributing factors
• Prevention
• Treatment

79
Strabismus SurgeryPostdischarge Vomiting
Significantly different from metoclopramide
(p0.003) and placebo (p0.025)
Scuderi PE, et al. JCA 19979551-558
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68
Scuderi PE, et al. JCA 19979551-558
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Post Discharge Nausea and Vomiting

• Scuderi PE, Weaver RG, Mims GR III, James RL.
  Ondansetron for the prevention of postdischarge
  vomiting following outpatient strabismus surgery
  in children. Anesthesiology 200093A37
• Gan TJ, Franiak R, Reeves J, Hartle AJ.
  Ondansetron disintegrating tablets (ODT) reduces
  post-discharge emesis and increases patient
  satisfaction. Anesthesiology 200093A34

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Postdischarge VomitingOndansetron versus Placebo
Scuderi PE, et al. Anesthesiology 200093A37
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Postdischarge VomitingOndansetron versus Placebo
Gan TJ, et al. Anesthesiology 200093A34
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Multimodal Management of PONVHypothesis

• A multi-modal approach to the management of PONV
  can result in a zero incidence of vomiting (and
  perhaps nausea) in the immediate postoperative
  period (i.e., PACU)

Scuderi at al. Anesth Analg 200091408-414
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Multimodal Management of PONVExperimental Model

• Female patients undergoing outpatient laparoscopy
• ASA I, II, or III
• Less than 150 of ideal body weight
• Design Randomized, placebo controlled, single
  blind
• Interventions Multimodal management, single dose
  ondansetron, placebo

Scuderi at al. Anesth Analg 200091408-414
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Multimodal Management of PONVAlgorithm for
Management

• Anxiolysis
• Aggressive rehydration
• Propofol-based anesthetic
• Avoid known triggering agents
• Multiple antiemetics
• Preemptive analgesia

Scuderi at al. Anesth Analg 200091408-414
87
Multimodal Management of PONVAlgorithm for
Management
I. PREOPERATIVE A. Anxiolysis - 10-30 mcg/kg
midazolam B. Fluid - 10 ml/kg minimum II.
INDUCTION A. PreO2 B. Droperidol 10
mcg/kg C. Decadron 8 mg D. Propofol - 2 mg/kg
200 mcg/kg/min E. Remifentanil - 1 mcg/kg 1
mcg/kg/min F. Intubate 90-120 seconds G.
Gastric decompression
Scuderi at al. Anesth Analg 200091408-414
88
Multimodal Management of PONVAlgorithm for
Management
III. MAINTENANCE A. Propofol 200
mcg/kg/min x 5 min, then 150 mcg/kg/min x 5 min,
then 100 mcg/kg/min x 5 min, then 75 mcg/kg/min
until 10 minutes prior to end of surgery, then
D/C B. Remifentanil 1 mcg/kg/min until
intubated, then 0.5 mcg/kg/min until trocar,
then 0.25 mcg/ kg/min titrated to effect or
BIS D/C 2-3 minutes prior to end of surgery
C. Ketorolac 30 mg IV after induction D.
Ondansetron 1 mg at end of surgery E.
Fentanyl 25 mcg IV 10 minutes prior to end of
surgery
Scuderi at al. Anesth Analg 200091408-414
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Multimodal Management of PONVAlgorithm for
Management
IV. PACU A. PONV rescue Dramamine 25 mg
IV B. Pain rescue Fentanyl 25 mcg prn C.
Fluids 25 ml/kg total for OSC stay
Scuderi at al. Anesth Analg 200091408-414
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Multimodal Management of PONVResults
Group I vs II Group I vs III Group II vs III
Scuderi at al. Anesth Analg 200091408-414
91
Multimodal Management of PONVSummary

• 60 patients, no emesis in PACU
• 3 patients with nausea score gt0 (mean 3.5)
• 1 rescue for nausea (nausea score 3)
• Time to discharge ready improved
• No difference in unscheduled day hospital
  admissions
• 7 patients with emesis after discharge
• All patients were satisfied with control of PONV

Scuderi at al. Anesth Analg 200091408-414
92
Multimodal Management of PONVSimplified
Algorithm

• I. INDUCTION
• A. PreO2
• B. Propofol 2 - 4 mg/kg
• C. Opioid prn
• D. Neuromuscular blockade prn
• C. Droperidol 10 mcg/kg
• D. Decadron 8 mg

• II. MAINTENANCE
• A. Propofol 50 mcg/kg/min
• B. Potent inhalation agent
• C. Nitrous oxide prn
• E. NMB reversal prn
• III. EMERGENCE
• A. Ondansetron 1 mg IV
• B. Suction oropharynx
• C. Extubate when awake

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Multimodal Management of PONVSimplified
Algorithm
Cost Analysis
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Multimodal Management of PONVConclusions

• Elimination of PONV in outpatients is possible
  with multi-modal management
• Algorithm may be institution and/or procedure
  specific
• Identification of the optimal management
  algorithm may require several iterations
• Elimination of PONV may not improve objective
  measures of outcome

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General Recommendations

• Use generic drugs for routine prophylaxis
• For high risk patients use combination
  prophylaxis
• Consider propofol infusion as part of anesthetic
• Prevent and control pain
• Treat breakthrough symptoms with 5HT3 antagonists
• Dont repeat dose with 5HT3 antagonists
• Treat with different classes of antiemetics

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Nitrous Oxide and PONV
99
Reversal of Neuromuscular Block

• Joshi GP et al. The effects of antagonizing
  residual neuromuscular blockade by neostigmine
  and glycopyrrolate on nausea and vomiting after
  ambulatory surgery. Anesth Analg 1999 89628-31
• Chhibber AK et al. Effects of anticholinergics on
  postoperative vomiting, recovery, and hospital
  stay in children undergoing tonsillectomy with or
  without adenoidectomy. Anesthesiology 1999
  90697-700
• Hovorka J et al. Reversal of neuromuscular
  blockade with neostigmine has no effect on the
  incidence or severity of postoperative nausea and
  vomiting. Anesth Analg 1997 851359-61
• Tang J et al. Comparison of rocuronium and
  mivacurium to succinylcholine during outpatient
  laparoscopic surgery. Anesth Analg 1996 82994-8
• Watcha et al. Effect of antagonism of
  mivacurium-induced neuromuscular block on
  postoperative emesis in children. Anesth Analg
  1995 80713-717
• Ding et al. Use of mivacurium during laparoscopic
  surgery effect of reversal drugs on
  postoperative recovery. Anesth Analg 1994
  78450-454
• King MJ et al. Influence of neostigmine on
  postoperative vomiting. BJA 1988 61403-6

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Propofol and PONV
Analysis by NNT
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Management of PONVEfficacy

• Medications
• Dose response
• Combination therapy
• Comparative efficacy
• Timing of administration
• Anesthetic related factors

• Nonpharmacologic approaches
• Breakthrough PONV
• Efficacy versus outcome
• Prevention versus treatment
• Multimodal management

102
Postop P.O. Intake Requirement

• Schreiner,M.S. Nicolson,S.C. Martin,T.
  Whitney,L. Should children drink before discharge
  from day surgery? Anesthesiology 199276528-533

103
Costs of Care
104
Cost Savings From the Management of PONV
105
Postoperative SatisfactionEffect of PONV
Postoperative
Cause of dissatisfaction
nausea and vomiting 71
Madej et al. BJA 198658884-887
106
Postoperative Patient Satisfaction
107
Prevention Versus Treatment
The Safety and Efficacy of Prophylactic
Ondansetron in Patients Undergoing Modified
Radical Mastectomy
Sadhasivam S, Saxena A, Kathirvel S, Kannan TR,
Yrikha A, Mohan V. Anesth Analg 1999 891340-1345

• Randomized, prospective, double blind
• 54 Female patients undergoing modified radical
  mastectomy
• Standard anesthetic - thiopental, vecuronium
• Ondansetron 4 mg or placebo at end of surgery

108
Prevention Versus Treatment
Routine Prophylaxis

• Does reduce the incidence of emesis both before
  and after discharge
• Does not improve objective measures of outcome
  following outpatient surgery except in patients
  at the highest risk for symptoms

109
Prevention Versus Treatment
Scoring System

• 0 no nausea or vomiting
• 1 nausea alone
• 2 vomiting once
• 3 vomiting 2 or more times in 30 min

Treatment
A score of 3 or persistent nausea (gt2 hr)
required Treatment initially with metoclopramide
150 mcg/kg
Sadhasivam S, et al. Anesth Analg 1999
891340-1345
110
Postdischarge VomitingOndansetron versus Placebo
111

Postoperative Nausea and Vomiting Prevention and
Treatment
Phillip E. Scuderi, M.D.
Department of Anesthesiology Wake Forest
University School of Medicine Winston-Salem,
North Carolina pscuderi_at_wfubmc.edu http//www.wfub
mc.edu/anesthesia
112
Editorial The Big Little Problem
Patricia A. Kapur, M.D. Section Editor
Ambulatory Anesthesia and Analgesia
Thus, although there is reason to be hopeful, it
is too early to tell whether ondansetron will
prove to be a significant improvement over extant
therapies for the vexing problem of perioperative
nausea and emesis.
Anesth Analg 199173243-245
113
Risk Factors Reversal of Neuromuscular Block

• Joshi GP et al. The effects of antagonizing
  residual neuromuscular blockade by neostigmine
  and glycopyrrolate on nausea and vomiting after
  ambulatory surgery. Anesth Analg 1999 89628-31
• Chhibber AK et al. Effects of anticholinergics on
  postoperative vomiting, recovery, and hospital
  stay in children undergoing tonsillectomy with or
  without adenoidectomy. Anesthesiology 1999
  90697-700
• Hovorka J et al. Reversal of neuromuscular
  blockade with neostigmine has no effect on the
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Complete Control of Emesis
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Complete Control of Nausea
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