COMMENTARY

Study Identifies Who Is at Risk for Postdischarge Nausea and Vomiting After Ambulatory Surgery

Junping Chen, MD, PhD

Disclosures

October 12, 2012

Who Is at Risk for Post-discharge Nausea and Vomiting After Ambulatory Surgery?

Apfel CC, Philip BK, Cakmakkaya OS, et al
Anesthesiology. 2012;117:475-486

Study Summary

Owing to aggressive prophylactic treatment, the incidences of nausea and vomiting in the postanesthesia care unit (PACU) have decreased. However, the problem of postdischarge nausea and vomiting (PDNV) is still pervasive, and many anesthesiologists lack awareness of it.

In this study, Apfel and colleagues established a new risk score to predict the risk for PDNV. They developed a data set by assessing PDNV for 2 days in 2170 patients who underwent general anesthesia in an ambulatory setting. After the data set was validated using logistic regression analysis, 5 independent predictors were identified: female sex, age younger than 50 years, history of nausea or vomiting after anesthesia, opioid administration, and nausea in the PACU. The incidence of PDNV is approximately 10%, 20%, 30%, 50%, 60%, or 80% when 0, 1, 2, 3, 4, or 5 of these predictors are present, respectively.

Viewpoint

The prevalence and severity of PDNV after general anesthesia may be substantially underestimated. This study showed that almost 37% of patients developed nausea and vomiting after discharge. Other studies also indicated that the incidence of PDNV can be as high as 50%.[1,2]

Of note, in this multicenter prospective cohort study, the incidences of nausea and vomiting in the PACU (19.9% and 3.9%, respectively) were substantially lower than that of PDNV (36.6% and 11.9%, respectively). This was not surprising because intraoperatively administered ondansetron has a short plasma half-life of about 3 hours.

In addition, laparoscopic surgery comprises a large percentage of ambulatory procedures. Laparoscopy is not an independent risk factor for PDNV but is a risk factor for nausea and vomiting immediately after surgery,[3] possibly because this type of surgery is associated with increased arterial carbon dioxide and bicarbonate levels that may stabilize in the PACU; as a result, the emetogenic effect is no longer relevant after patients are discharged.

PDNV is particularly hazardous for ambulatory surgery patients because they no longer have access to intravenous antiemetic rescue medication, and this may affect their recovery and other postoperative therapies. Apfel and colleagues' study not only enriches our knowledge about PDNV but also provides us with a simple and practical means to predict the chance of PDNV. By identifying at-risk patients using the PDNV risk score, anesthesiologists can justify the use of nonemetogenic anesthetics, such as propofol-based total intravenous anesthesia, and tailor a long-acting prophylactic regimen, such as dexamethasone, aprepitant, palonosetron, or transdermal scopolamine (or a combination of those medications), before discharge from the surgical center.

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