Skip to main content
Download PDF

A risk adapted approach reduces the overall institutional incidence of postoperative nausea and vomiting

Une approche préventive adaptée aux risques réduit l’incidence générale de nausées et de vomissements postopératoires en milieu hospitalier

Canadian Journal of Anesthesia volume 51, Article number: 13 (2004) Cite this article

Abstract

Purpose

Routine prophylactic antiemetic treatment of surgical patients appears justified only in case of an increased risk of postoperative nausea and vomiting (PONV.). The objective of this investigation was to assess the feasibility and efficacy of a dichotomized risk score adapted management of PONV. based on ondansetron prophylaxis and treatment with respect to the overall institutional rate of PONV.

Methods

After estimating the individual PONV. risk by a simplified score, 162 adult patients scheduled for elective surgery received either 4 mg ondansetron intravenously (two to four risk factors = high-risk) or no prophylaxis (zero to one risk factor = low-risk). For antiemetic treatment ondansetron was given intravenously and orally. Incidence of PONV. was recorded during the first 24 hr after recovery.

Results

Data from 159 subjects were analyzed with 44 patients classified as low-risk and 115 patients classified as high-risk. Nine low-risk and 58 high-risk patients experienced PONV. The expected institutional PONV. incidence of 47% was reduced to 36%. Treatment with ondansetron was necessary in seven low-risk and 37 high-risk patients with a complete response rate of 71% (lowrisk) and 43% (high-risk).

Conclusion

Providing antiemetic prophylaxis with ondansetron to high-risk patients strictly based on a simplified risk score can reduce the overall institutional rate of PONV. However, classifying patients into two groups while using ondansetron as the single antiemetic in the high-risk group appears to be of limited efficacy as the incidence of PONV in high-risk patients is still double that of low-risk patients.

Résumé

Objectif

Le traitement antiémétique préventif courant des opérés semble justifié seulement en cas de risque accru de nausées et de vomissements postopératoires (NVPO). Nous voulions évaiuer la faisabilité et l’efficacité d’un traitement, adapté aux scores de risque dichotomique de NVPO, fondé sur une action préventive et thérapeutique avec l’ondansétron en regard du taux global de NVPO à l’hôpital.

Méthode

Après avoir estimé le potentiel individuel de NVPO par un score simplifié, 162 adultes devant subir une intervention chirurgicale réglée ont reçu soit 4 mg d’ondansétron par voie intraveineuse (de deux à quatre facteurs de risque = haut risque) ou aucune prophylaxie (zéro ou un facteur de risque = faible risque). Comme antiémétique, l’ondansétron a été administré par voie intraveineuse et orale. L’incidence des NVPO a été notée pendant les 24 premières heures après la récupération.

Résultats

Les données de 159 sujets ont été analysées dont celles de 44 patients à faible risque et 115 à haut risque. Neuf patients à faible risque et 58 à haut risque ont eu des NVPO. L’incidence attendue de NVPO de 47 % a été réduite à 36 %. Le traitement avec l’ondansétron a été nécessaire chez sept patients à faible risque et 37 à haut risque pour un taux de réponse complet de 71 % (faible risque) et 43 % (haut risque).

Conclusion

L’administration préventive d’antiémétique avec ondansétron aux patients à haut risque, fondée strictement sur un score de risque simplifié, peut réduire le taux global de NVPO à l’hôpital. Mais la répartition des patients en deux groupes et l’utilisation d’ondansétron antiémétique chez les patients à haut risque seulement nous semble d’efficacité limitée, étant donné que l’incidence de NVPO chez ces patients demeure deux fois plus élevée que chez les patients à faible risque.

References

  1. Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs 2000; 59: 213–43.

    PubMed  Article  CAS  Google Scholar 

  2. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Conclusions from cross-valida- tions between two centers. Anesthesiology 1999; 91: 693–700.

    PubMed  Article  CAS  Google Scholar 

  3. Biedler A, Wilhelm W. Postoperative nausea and vomiting (German). Anaesthesist 1998; 47: 145–58.

    PubMed  Article  CAS  Google Scholar 

  4. Gan TJ. Postoperative nausea and vomiting-can it be eliminated? JAMA 2002; 287: 1233–6.

    PubMed  Article  Google Scholar 

  5. Tranter MR. A rational approach to the control of postoperative nausea and vomiting: evidence from sys- tematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues. Acta Anaesthesiol Scand 2001; 45: 4–13.

    Article  Google Scholar 

  6. Scuderi PE, James RL, Harris L, Mints GR III. Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999; 90: 360–71.

    PubMed  Article  CAS  Google Scholar 

  7. Apfel CC, Roewer N, Korttila K. How to study postoperative nausea and vomiting. Acta Anaesthesiol Scand 2002; 46: 921–8.

    PubMed  Article  CAS  Google Scholar 

  8. Watcha MF. The cost-effective management of postoperative nausea and vomiting (Editorial). Anesthesiology 2000; 92: 931–3.

    PubMed  Article  CAS  Google Scholar 

  9. Sennaraj B, Shende D, Sadhasivam S, Ilavajady S, Jagan D. Management of post-strabismus nausea and vomiting in children using ondansetron: a value-based comparison of outcomes. Br J Anaesth 2002; 89: 473–8.

    PubMed  Article  CAS  Google Scholar 

  10. Sadhasivam S, Saxena A, Kathirvel S, Kannan TR, Trikha A, Mohan V. The safety and efficacy of prophylactic ondansetron in patients undergoing modified radical mastectomy. Anesth Analg 1999; 89: 1340–5.

    PubMed  Article  CAS  Google Scholar 

  11. Eberhart LU, Mauch M, Morin AM, Wulf H, Geldner G. Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postopera- tive nausea and vomiting. Anesthesia 2002; 57: 1022–7.

    Article  CAS  Google Scholar 

  12. Apfel CC, Kranke P, Eberhart LU, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. Br J Anaesth 2002; 88: 234–40.

    PubMed  Article  CAS  Google Scholar 

  13. Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of postoperative nausea and vomiting. Anesthesia 1997; 52: 443–9.

    Article  CAS  Google Scholar 

  14. Pierre S, Benais H, Pouymayou J. Apfel’s simplified score may favourably predict the risk of postoperative nausea and vomiting. Can J Anesth 2002; 49: 237–42.

    PubMed  Article  Google Scholar 

  15. Apfel CC, Kranke P, Katz MR, et al. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. Br J Anaesth 2002; 88: 659–68.

    PubMed  Article  CAS  Google Scholar 

  16. Scuderi PE, James RL, Harris L, Mints GR III. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Anaig 2000; 91: 1408–14.

    Article  CAS  Google Scholar 

  17. Kovac AL, O’Connor TA, Pearman MH, et al. Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomiting: a randomized, double-blind, placebo- controlled multicenter trial. J Clin Anesth 1999; 11: 453–9.

    PubMed  Article  CAS  Google Scholar 

  18. Tramer MR, Moore RA, Reynolds DJ, McQuay HJ. A quantitative systematic review of ondansetron in treatment of established postoperative nausea and vomiting. BMJ 1997; 314: 1088–92.

    PubMed  CAS  Google Scholar 

Download references

Author information

Affiliations

  1. Klinik für Anaesthesiologie und Intensivmedizin, Universitätskliniken des Saarlandes, 66421, Homburg/Saar, Germany

    Andreas Biedler & Wolfram Wilhelm

  2. Klinik für Anaesthesiologie, Julius-Maximilians-Universität, Würzburg, Germany

    Julius Wermelt & Christian C. Apfel

  3. Klinik für Anaesthesiologie der Medizinischen Fakultät der RWTH, Aachen, Germany

    Oliver Kunitz & Andrea Müller

  4. GlaxoSmithKline, München, Germany

    Jürgen Dethling

  5. Department of Anesthesiology and the Outcomes Reseach Institute, University of Louisville, Louisville, Kentucky, USA

    Christian C. Apfel

Authors
  1. Andreas Biedler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Julius Wermelt
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Oliver Kunitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrea Müller
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wolfram Wilhelm
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jürgen Dethling
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Christian C. Apfel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andreas Biedler.

Additional information

This study was supported by GlaxoSmithKline, Germany.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Biedler, A., Wermelt, J., Kunitz, O. et al. A risk adapted approach reduces the overall institutional incidence of postoperative nausea and vomiting. Can J Anesth 51, 13 (2004). https://doi.org/10.1007/BF03018540

Download citation

  • Accepted:

  • DOI: https://doi.org/10.1007/BF03018540

Keywords

  • Ondansetron
  • Motion Sickness
  • Postoperative Nausea
  • Antiemetic Prophylaxis
  • Emetic Episode