Pharmacological Prophylaxis and Management of Adult Postoperative/Postdischarge Nausea and Vomiting

Effect of dexmedetomidine on postoperative nausea and vomiting in female patients undergoing radical thoracoscopic lung cancer resection

Introduction: Postoperative nausea and vomiting (PONV) is a prevalent postsurgical complication. The objective of our study was to compare the effect of different doses of dexmedetomidine on PONV in female patients undergoing radical thoracoscopic lung cancer resection. Methods: A total of 164 female patients undergoing elective thoracoscopic radical lung cancer surgery were enrolled and assigned to one of four groups. Patients received 0.2 μg/kg/h, 0.4 μg/kg/h, 0.8 μg/kg/h dexmedetomidine and normal saline in the Dex1, Dex2, Dex3 and Control groups, respectively. The primary outcome was the incidence of PONV during 48 h postoperatively. The second outcomes included the incidence of PONV and postoperative vomiting (POV) at four time points postoperatively (T1: PACU retention period; T2: PACU discharge to postoperative 12 h; T3: postoperative 12 h-postoperative 24 h; T4: postoperative 24 h-postoperative 48 h), the area under the curve of PONV grade (PONVAUC), PONV grade, POV grade and other postoperative recovery indicators. Results: The incidence of PONV differed among the four groups. The Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (72.50%). The incidence of PONV at T2 in the Dex1 group (11.90%) and Dex2 group (9.76%) was lower than that in the Control group (42.50%). The incidence of PONV at T3 in the Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (62.50%). The PONVAUC was lower in the Dex2 group than in the Control group. The incidence of POV at T3 in the Dex2 and Dex3 groups was lower than that in the Control group. The consumption of remifentanil, norepinephrine, PACU dwell time, VAS scores, postoperative PCA press frequency, and the time for the first postoperative oral intake were different among the four groups. The regression model shows that the Dex2 group is a protective factor for PONV. Conclusion: Dexmedetomidine can reduce the incidence of PONV and accelerate postoperative recovery in female patients undergoing radical thoracoscopic lung cancer resection. Compared with the other two dosages, 0.4 μg/kg/h dexmedetomidine is preferable. Clinical Trial Registration: chictr.org.cn, identifier ChiCTR2300071831.

Effect of best practice advisory on the administration of contraindicated medications to hospitalized patients with Parkinson's disease and related disorders

Objective

To determine the effect of a Best Practice Advisory (BPA) on the ordering and administration of contraindicated dopamine blocking agents (DBA) to hospitalized patients with Parkinson's disease (PD) and related disorders.

Background

Patients with PD are more likely to require hospitalization and are at increased risk of complications. Administration of contraindicated DBA contributes to worsened outcomes in this patient population. Electronic medical record (EMR) warnings (also referred to as BPA) have been proposed as a way to prevent the administration of contraindicated medications.

Methods

A BPA was launched in January 2020 within the University of Rochester EMR system, which alerts the provider when a contraindicated DBA is ordered in hospitalized patients with PD and related disorders. Patients with PD and related disorders hospitalized at two hospitals affiliated to the University of Rochester during a time period before (t1: 1/1/2019-1/1/2020) and after (t2: 1/8/2020-1/8/2021) the implementation of the BPA were included in this study. Epic SliderDicer was used to collect the data from the University of Rochester EMR. The number of patients who had contraindicated DBA orders and administrations in both time periods, and the number of patients who had the BPA triggered during t2 were obtained. We compared the results before and after the implementation of the BPA.

Results

306 patients with PD and related disorders were hospitalized during t1 and 273 during t2. There was significantly less percentage of patients who had contraindicated DBA orders (41.5% in t1 vs. 17.6% in t2) and patients who had contraindicated DBA administrations (16% in t1 vs. 8.8% in t2) during t2 (p < 0.05 for both comparisons). There was no significant difference between the percentage of patients who had contraindicated DBA orders in t1 and patients with attempted orders (BPA triggered) in t2 (p = 0.27).

Conclusion

The results of this study increase the evidence of the potential benefit of EMR warnings for the optimization of inpatient medication management in patients with PD and related disorders. In particular, our results suggest that EMR warnings help reduce the administration of contraindicated medications, which is a known contributing factor for hospital complications in this patient population.

The effectiveness of ramosetron and ondansetron for preventing postoperative nausea and vomiting after arthroscopic rotator cuff repair: a randomized controlled trial

Background

Arthroscopic rotator cuff repair is a painful procedure, and treatment of emetic events associated with drugs used in the current multimodal pain management remains challenging. This study aimed to evaluate the effectiveness of ramosetron or ondansetron to relieve postoperative nausea and vomiting (PONV) and pain after arthroscopic rotator cuff repair.

Methods

In total, 122 consecutive patients undergoing arthroscopic rotator cuff repair were randomly allocated into three groups: ramosetron group (n = 39), ondansetron group (n = 43), and control group (n = 40). Then, 0.3 mg of ramosetron or 8 mg of ondansetron was administered intravenously at the end of surgery according to group. All patients received general anesthesia and multimodal pain management protocol including preemptive analgesic medication, fentanyl-based intravenous patient-controlled analgesia, and postoperative analgesic medication. Incidence of emetic events, rescue antiemetic requirements (10 mg of metoclopramide, IV), complete response, pain level, and side effects were recorded in three periods: 0–6, 6–24, and 24–48 h postoperatively. The severity of nausea and pain was evaluated using a visual analog scale.

Results

The ramosetron group tended to have a lower incidence and severity of nausea during the 6- to 24-h postoperative period and fewer rescue antiemetic drug requirements during the 0- to 48-h period than the control group, showing statistical significance. Additionally, the frequency of complete response of the ramosetron and ondansetron groups was significantly higher than that of the control group. No difference was found among the groups in the pain level except during the 0- to 6-h period. The two groups have a higher complete response during the 6- to 24-h period than the control group.

Conclusions

Ramosetron use led to a lower incidence, mild severity of nausea, and reduced use of rescue antiemetic drug after arthroscopic rotator cuff repair during the 6- to 24-h postoperative period than the control.

Level of evidence

Level I, randomized controlled trials, treatment study

[Comparison of post-operative nausea and vomiting with intravenous versus inhalational anesthesia in laparotomic abdominal surgery: a randomized clinical trial]

BACKGROUND

Postoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients' characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV.

METHODS

A single-blinded prospective randomized clinical trial on 105 patients aged 18-65 years was carried out. Patients were divided in two groups of Total Intravenous Anesthesia (TIVA) and Inhalational anesthesia. The incidence and severity of PONV were examined at 0, 2, 6, 12, and 24hours after the surgery. The use of a rescue antiemetic was also evaluated.

RESULTS

Fifty point nine percent of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p <0.001). The incidence of vomiting was reported in 11.3% of the Inhalational group and 3.8% of the TIVA group (p=0.15), and 24.5% of patients in the Inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p=0.043).

CONCLUSION

The incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug, and the severity of nausea in patients were significantly lower in the TIVA group.

Comparison of post-operative nausea and vomiting with intravenous versus inhalational anesthesia in laparotomic abdominal surgery: a randomized clinical trial

Background

Postoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients' characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV.

Methods

A single-blinded prospective randomized clinical trial on 105 patients aged 18 − 65 years was carried out. Patients were divided into two groups of Total Intravenous Anesthesia (TIVA) and inhalational anesthesia. The incidence and the severity of PONV were examined at 0, 2, 6, 12 and 24 hours after the surgery. The use of a rescue antiemetic was also evaluated.

Results

50.9% of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p <  0.001). The incidence of vomiting was reported in 11.3% of the inhalational group and 3.8% of the TIVA group (p =  0.15). 24.5% of patients in the inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p =  0.043).

Conclusion

The incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug and the severity of nausea in patients were significantly lower in the TIVA group.

Scopolamine Use in the Perioperative Patient: A Systematic Review

Scopolamine is an antiemetic agent used for postoperative nausea and vomiting prevention; however, it has anticholinergic effects (eg, bradycardia, dry mouth, dizziness, visual disturbances). Avoiding scopolamine use in specific populations is crucial to prevent adverse effects and harm to patients. This systematic review describes the anticholinergic effects of scopolamine in perioperative patient populations. After searching the available literature, we reviewed the eligible articles to determine whether they met the inclusion criteria (eg, full text, English language, included a discussion of scopolamine's anticholinergic effects in perioperative patients). Twenty-six articles were included in this review. We used The Johns Hopkins Research Evidence Appraisal Tool to appraise the literature. The results of this literature review reveal that clinicians should avoid administering scopolamine to certain perioperative patient populations (ie, pediatric, older adult).

Partnership with Interventional Pulmonologist: An Anesthesiologist's Perspective

Via the emergence of new bronchoscopic technologies and techniques, there is enormous growth in the number of procedures being performed in nonoperating room settings. This, coupled with a greater focus from the Centers for Medicare and Medicaid Services for mandated anesthesiology oversight of procedural sedation for bronchoscopy by the pulmonologists has led to a more frequent working partnership between interventional pulmonologists and anesthesiologists. This article offers the interventional pulmonologist insight into how the anesthesiologist thinks and approaches anesthetic care delivery.

Comparison of ondansetron, tropisetron, and palonosetron for the prevention of postoperative nausea and vomiting after middle ear surgery

Background

Postoperative nausea and vomiting (PONV) are 2 of the most frequent adverse effects of anesthesia. PONV prolongs hospital stays and also delays the recovery of patients.

Objective

In this study, the effects of ondansetron, tropisetron, and palonosetron on PONV in patients who had undergone middle ear surgeries such as mastoidectomy or tympanoplasty were compared.

Methods

The study included 165 American Society of Anesthesiologists grade 1 and 2 patients aged 18 to 65 years. Patients were randomized into 3 groups by a closed envelope method. Neither the patients nor the nurses administering the treatments knew which patient belonged to which group. The anesthetic technique was standardized for all groups. During skin closure, 0.075 mg palonosetron, 5 mg tropisetron, and 8 mg ondansetron were administered intravenously to the palonosetron, tropisetron, and ondansetron groups, respectively. After completion of the surgery, the patients were followed for 48 hours. Diclofenac sodium (100 mg IM) was administered to patients experiencing pain and metoclopramide chloride (10 mg IM) was administered to patients with nausea or vomiting. Potential side effects such as headache and constipation were recorded in the postanesthesia care unit and ear, nose, and throat clinic.

Results

There was no significant difference in the effects of all 3 antiemetic agents on the severity of PONV (P = 0.081). At 48 hours postoperatively, the incidence of PONV was significantly lower in the palonosteron group (38.2%) than the ondansetron group (63.6%) and tropisetron group (61.8%) (P = 0.011). At 48 hours postoperatively, the incidence of postoperative nausea was significantly lower in the palonosetron group (32.7%) than in the ondansetron group (63.6%) and the tropisetron group (56.4%) (P = .003). The incidence of PONV between hours 12 and 24 postoperatively was significantly higher in the ondansetron group (27.3%) than in the palonosetron group (9.1%) (P = 0.013). The antiemetic requirement in the first hour after surgery was significantly higher in the tropisetron group (25.5%) than in the palonosetron group (7.3%) (P = .019).

Conclusions

The results of the current study support those of earlier studies that suggest that palonosetron was statistically more effective than the other 2 formulations in the prevention of PONV in patients who have undergone middle ear surgery. (Curr Ther Res Clin Exp. 2019; 80:XXXXXX).

Effect of the Dexamethasone-Ondansetron Combination Versus Dexamethasone-Aprepitant Combination to Prevent Postoperative Nausea and Vomiting

Objective

Postoperative nausea and vomiting (PONV) is a common problem associated with general anaesthesia. The incidence can be as high as 80% in high-risk patients. Our primary objective was to compare the efficacy of the combination of dexamethasone-ondansetron and dexamethasone-aprepitant in patients undergoing laparoscopic surgery.

Methods

Seventy 18 to 60 years old patients scheduled for laparoscopic surgery were included in the study. Sixty-seven patients completed the study. Patients in the dexamethasone-aprepitant group (group DA, n=35) received 40 mg of aprepitant orally 1-2 hours before the induction of anaesthesia and 2 mL saline intravenously (iv) within the last 30 minutes of surgery; patients in the dexamethasone-ondansetron group (group DO, n=35) received oral placebo identical to aprepitant 1-2 hours before the induction of anaesthesia and 4 mg ondansetron iv within the last 30 minutes of surgery. All patients received 8 mg dexamethasone iv after the induction of anaesthesia. The primary outcome was a complete response (no postoperative nausea, retching and vomiting and no need for rescue antiemetic); the secondary outcomes were the incidence of nausea, retching, vomiting, the need of rescue antiemetic and opioid consumption within 24 hours after surgery.

Results

A complete response was not significantly different between the groups (group DO: 67%, DA: 69%) at 24 hours (p=0.93). The incidence of PONV and postoperative opioid consumption was similar between the groups.

Conclusion

The study was designed to evaluate whether the combination of dexamethasone-aprepitant is better than the combination of dexamethasone-ondansetron regarding the complete response for PONV in patients undergoing laparoscopic surgery. The results however showed that dexamethasone-aprepitant has not improved the complete response for PONV compared to dexamethasone-ondansetron.

Effect of the Dexamethasone-Ondansetron Combination Versus Dexamethasone-Aprepitant Combination to Prevent Postoperative Nausea and Vomiting

Objective

Postoperative nausea and vomiting (PONV) is a common problem associated with general anaesthesia. The incidence can be as high as 80% in high-risk patients. Our primary objective was to compare the efficacy of the combination of dexamethasone-ondansetron and dexamethasone-aprepitant in patients undergoing laparoscopic surgery.

Methods

Seventy 18 to 60 years old patients scheduled for laparoscopic surgery were included in the study. Sixty-seven patients completed the study. Patients in the dexamethasone-aprepitant group (group DA, n=35) received 40 mg of aprepitant orally 1-2 hours before the induction of anaesthesia and 2 mL saline intravenously (iv) within the last 30 minutes of surgery; patients in the dexamethasone-ondansetron group (group DO, n=35) received oral placebo identical to aprepitant 1-2 hours before the induction of anaesthesia and 4 mg ondansetron iv within the last 30 minutes of surgery. All patients received 8 mg dexamethasone iv after the induction of anaesthesia. The primary outcome was a complete response (no postoperative nausea, retching and vomiting and no need for rescue antiemetic); the secondary outcomes were the incidence of nausea, retching, vomiting, the need of rescue antiemetic and opioid consumption within 24 hours after surgery.

Results

A complete response was not significantly different between the groups (group DO: 67%, DA: 69%) at 24 hours (p=0.93). The incidence of PONV and postoperative opioid consumption was similar between the groups.

Conclusion

The study was designed to evaluate whether the combination of dexamethasone-aprepitant is better than the combination of dexamethasone-ondansetron regarding the complete response for PONV in patients undergoing laparoscopic surgery. The results however showed that dexamethasone-aprepitant has not improved the complete response for PONV compared to dexamethasone-ondansetron.

Postoperative nausea and vomiting after general anesthesia for oral and maxillofacial surgery

Background

Postoperative nausea and vomiting (PONV) is one of the most common postoperative complications. Despite this, few papers have reported the incidence and independent risk factors associated with PONV in the context of oral and maxillofacial surgery (OMFS). Therefore, we sought to determine the incidence of PONV, as well as to identify risk factors for the condition in patients who had undergone OMFS under general anesthesia.

Methods

A total of 372 patients' charts were reviewed, and the following potential risk factors for PONV were analyzed: age, sex, body mass index, smoking status, history of PONV and/or motion sickness, duration of anesthesia, amount of blood loss, nasogastric tube insertion and retention and postoperative opioid used. Univariate analysis was performed, and variables with a P-value less than 0.1 were entered into a multiple logistic regression analysis, wherein P-values < 0.05 were considered significant.

Results

The overall incidence of PONV was 25.26%. In the multiple logistic regression analysis, the following variables were independent predictors of PONV: age < 30 years, history of PONV and/or motion sickness, and anesthesia duration > 4 h. Furthermore, the number of risk factors was proportional to the incidence of PONV.

Conclusions

The incidence of PONV in patients who have undergone OMFS varies from center to center depending on patient characteristics, as well as on anesthetic and surgical practice. Identifying the independent risk factors for PONV will allow physicians to optimize prophylactic, antiemetic regimens.

Predicting postoperative vomiting among orthopedic patients receiving patient-controlled epidural analgesia using SVM and LR

Patient-controlled epidural analgesia (PCEA) has been applied to reduce postoperative pain in orthopedic surgical patients. Unfortunately, PCEA is occasionally accompanied by nausea and vomiting. The logistic regression (LR) model is widely used to predict vomiting, and recently support vector machines (SVM), a supervised machine learning method, has been used for classification and prediction. Unlike our previous work which compared Artificial Neural Networks (ANNs) with LR, this study uses a SVM-based predictive model to identify patients with high risk of vomiting during PCEA and comparing results with those derived from the LR-based model. From January to March 2007, data from 195 patients undergoing PCEA following orthopedic surgery were applied to develop two predictive models. 75% of the data were randomly selected for training, while the remainder was used for testing to validate predictive performance. The area under curve (AUC) was measured using the Receiver Operating Characteristic curve (ROC). The area under ROC curves of LR and SVM models were 0.734 and 0.929, respectively. A computer-based predictive model can be used to identify those who are at high risk for vomiting after PCEA, allowing for patient-specific therapeutic intervention or the use of alternative analgesic methods.

A prospective randomized study of the effectiveness of aromatherapy for relief of postoperative nausea and vomiting

INTRODUCTION

Postoperative nausea and vomiting (PONV) is a major concern for patients having surgery under general anesthesia as it causes subjective distress along with increased complications and delays in discharge from the hospital. Aromatherapy represents a complementary and alternative therapy for the management of PONV.

PURPOSE

The objective of this study was to compare the effectiveness of aromatherapy (QueaseEase, Soothing Scents, Inc, Enterprise, AL) versus an unscented inhalant in relieving PONV.

METHODS

One hundred twenty-one patients with postoperative nausea were randomized into a treatment group receiving an aromatic inhaler and a control group receiving a placebo inhaler to evaluate the effectiveness of aromatherapy.

FINDINGS

Initial and follow-up nausea assessment scores in both treatment and placebo groups decreased significantly (P < .01), and there was a significant difference between the two groups (P = .03). Perceived effectiveness of aromatherapy was significantly higher in the treatment group (P < .001).

CONCLUSIONS

Aromatherapy was favorably received by most patients and represents an effective treatment option for postoperative nausea.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Neurochemical mechanisms and pharmacologic strategies in managing nausea and vomiting related to cyclic vomiting syndrome and other gastrointestinal disorders

Nausea and vomiting are common gastrointestinal complaints which could be triggered by stimuli in both the peripheral and central nervous systems. They may be considered as defense mechanisms when threatening toxins/agents enter the gastrointestinal tract or there is excessive retention of gastrointestinal contents due to obstruction. The pathophysiology of nausea and vomiting is complex and much still remains unknown. Therefore, treatments are restricted or ineffective in many cases. Nausea and vomiting with functional etiologies including cyclic vomiting syndrome are challenging in gastroenterology. In this article, we review potential pathways, neurochemical transmitters, and their receptors which are possibly involved in the pathophysiology of nausea and vomiting including the entity cyclic vomiting syndrome.

The effect of aromatherapy on postoperative nausea in women undergoing surgical procedures

Postoperative nausea and vomiting (PONV) is a common source of patient discomfort and decreased satisfaction. Aromatherapy has been identified as a complementary modality for the prevention and management of PONV. The purpose of this study was to assess the effect of aromatherapy on the severity of postoperative nausea (PON) in women undergoing surgical procedures in the postanesthesia care unit. Women complaining of PON received traditional antiemetics, inhalation of peppermint oil, or saline vapor. A visual analog scale was used to rate nausea at the first complaint; at 5 minutes after intervention; and, if nausea persisted, at 10 minutes after intervention. At both 5 and 10 minutes, statistical analysis showed no significant differences between intervention and nausea rating. Obtaining eligible subjects was challenging. Although many women consented, most received intraoperative antiemetics and did not report nausea postoperatively.

[Postoperative nausea and vomiting in major trauma surgery]

OBJECTIVE

Postoperative nausea and vomiting (PONV) are common complications during the postoperative period, causing important discomfort to the patient and also can increase morbidity. The objective of our article is to predict the prevalence of postoperative nausea and vomiting, the factors that have an influence on its appearance, and to obtain a predictive model based on prognostic factors.

METHOD

A prospective observational study was conducted on 201 patients who underwent major Orthopaedic and Trauma surgery during the year 2008. A questionnaire was designed to collect the required data as established previously by a standardized protocol, in which was requested, patient demographics, intraoperative and postoperative data, as well as details on any antiemetic treatment that was needed in the recovery ward.

RESULTS

A total of 39.8% patients suffered PONV. Of the females, 46.6% suffered PONV, and 75% had previous history of PONV. A higher prevalence was observed in patients who were subjected to more aggressive surgery. There was a concentration of cases between 5 pm and 7 pm, and also at 8 am. The predictive model was obtained from this formula: Y= -1,334 + 0,753*S + 1,5602*NVP + 0,769*IQa

CONCLUSIONS

The prevalence of PONV in this study has been high, as more a third of the studied population suffered from it. The predictive model should help determine the specific risk of each patient of suffering from PONV, thus being able to define a therapeutic strategy during the preoperative period as well as during the postoperative period. Being female, a previous history of PONV, and undergoing an aggressive surgical procedure are risk factors. Patient mobilization and family visits increase the number of PONV episodes.

Does ramosetron reduce postoperative emesis and pain after TKA?

BACKGROUND

Current pain management protocols involving many anesthetic and analgesic drugs reportedly provide adequate analgesia after TKA. However, control of emetic events associated with the drugs used in current multimodal pain management remains challenging.

QUESTIONS/PURPOSES

We determined (1) whether ramosetron prophylaxis reduces postoperative emetic events; and (2) whether it influences pain levels and opioid consumption in patients managed with a current multimodal pain management protocol after TKA.

METHODS

We randomized 119 patients undergoing TKA to receive either ramosetron (experimental group, n = 60) or no prophylaxis (control group, n = 59). All patients received regional anesthesia, preemptive analgesic medication, continuous femoral nerve block, periarticular injection, and fentanyl-based intravenous patient-controlled analgesia. We recorded the incidence of emetic events, rescue antiemetic requirements, complete response, pain level, and opioid consumption during three periods (0-6, 6-24, and 24-48 hours postoperatively). The severity of nausea was evaluated using a 0 to 10 VAS.

RESULTS

The ramosetron group tended to have a lower incidence of nausea with a higher complete response and tended to have less severe nausea and fewer rescue antiemetic requirements during the 6- to 24-hour period. However, the overall incidences of emetic events, rescue antiemetic requirements, and complete response were similar in both groups. We found no differences in pain level or opioid consumption between the two groups.

CONCLUSIONS

Ramosetron reduced postoperative emetic events only during the 6- to 24-hour postoperative period and did not affect pain relief. More efficient measures to reduce emetic events after TKA should be explored.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Postoperative nausea and vomiting in adults: implications for critical care

Postoperative nausea and vomiting is a dreaded, uncomfortable, and unpleasant patient experience that is also a factor contributing to adverse outcomes in postoperative recovery. The key to management of this concern is to identify high-risk patients and to develop a systematic method of assessment, intervention, and evaluation within the perianesthesia care continuum. This discussion outlines the wide range of pharmacological and alternative therapies that are available in clinical practice with a case study to illustrate incorporation of these interventions in critically ill patients.

Prevention and management of postoperative nausea and vomiting in adults

In early 2007, patients at our small community hospital's outpatient surgery center experienced postoperative nausea and postoperative nausea and vomiting (PONV) at a rate of 27% to 35%. Many record reviews and a written survey of nurses in the postanesthesia care unit and same day surgery center revealed that little or no risk assessment and no consistent prophylaxis or treatment were in use by nurses, physicians, or anesthesia care providers. After a review of the literature and discussions with anesthesia care providers, we developed and put into practice a risk assessment tool and perioperative care path. A formal evaluation to assess the effectiveness of the plan was performed one year after implementation. We found that the rates of PONV had decreased to 16%. AORN J 90 (September 2009) 391-413. (c) AORN, Inc, 2009.

Long-term stability of tramadol hydrochloride and droperidol mixture in 5% dextrose infusion polyolefin bags at 5+/-3 degrees C

OBJECTIVE

To investigate the stability of tramadol hydrochloride 100mg associated with droperidol 2.5mg in 100ml of 5% dextrose solution stored at 5+/-3 degrees C.

METHODS

Solutions of 5% dextrose 100ml in polyolefin bags (n=5) containing approximately tramadol hydrochloride 100mg associated with droperidol 2.5mg were prepared under aseptic conditions and stored about 32 days at 5+/-3 degrees C. The tramadol hydrochloride and droperidol concentrations were measured by high performance liquid chromatography (HPLC). Visual inspection was performed and pH was measured periodically during the storage. Stability of the solutions was defined as the common regression line 95% lower confidence limit of the concentration remaining superior to 90% of the initial concentration as recommended by the Food and Drug Administration (FDA).

RESULTS

No colour change or precipitation in the solutions was observed. Tramadol hydrochloride 100mg associated with droperidol 2.5mg in 100 ml of 5% dextrose infusions was stable when stored at 5+/-3 degrees C during 32 days. Throughout this period, the lower confidence limit of the estimated regression line of concentration-time profile remained above 90% of the initial concentration. There was no significant change in pH during storage.

CONCLUSION

Under the conditions of this study, tramadol hydrochloride 100mg associated with droperidol 2.5mg in 100 ml of 5% dextrose infusions stored up to 32 days at 5+/-3 degrees C remain stable and may be prepared in advance by CIVAS to improve safety and management.

The effects of stimulation of acupressure point p6 on postoperative nausea and vomiting: a review of literature

Postoperative nausea and vomiting (PONV) can complicate and delay patient recovery from general and neuraxial anesthesia. Even with a new generation of anesthetic drugs and antiemetics, a high number of patients are affected by PONV. PONV has a multifactor etiology, but there are ways to reduce its occurrence. Although it is not a traditionally recognized method, stimulation of acupressure points, specifically P6, has been identified as a potentially effective method of reducing PONV. This study is a state of the science paper reviewing research on both pharmacologic and nonpharmacologic prophylaxis and various methods of acupressure. It was conducted to add information to the currently available knowledge regarding PONV in hopes of stimulating the use of acupressure for treatment of PONV. The study is divided into six categories: pathophysiology of PONV, background studies of PONV, nonpharmacologic prophylaxis, pharmacological prophylaxis, acupressure and related techniques, and benefits of routine antiemetic prophylaxis.