1. Q427 #710121 10/05 10,000
Adapted from
anesthesiologynews.com
Sponsored by
Postdischarge
Nausea and
Vomiting:
Risk Assessment
& Treatment Strategies
Christian C. Apfel, MD
Assistant Professor
Department of Anesthesiology
and Perioperative Medicine
University of Louisville
Louisville, Kentucky
Marketer of Transderm Scop®
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2. 2
3
3
Christian C. Apfel, MD
Assistant Professor
Department of Anesthesiology
and Perioperative Medicine
University of Louisville
Louisville, Kentucky
Reviewers:
Joseph V. Pergolizzi, Jr, MD
Adjunct Assistant Professor
Johns Hopkins University School of Medicine
Baltimore, Maryland
Senior Partner
Naples Anesthesia and Pain Associates
Naples, Florida
Anthony L. Kovac, MD
Professor
Department of Anesthesiology
University of Kansas Medical Center
Kansas City, Kansas
Luis Sanz, MD
Professor
Georgetown University School of Medicine
Washington, DC
Director, Urogynecology, Urodynamics
and Vaginal Reconstructive Surgery
Virginia Hospital Center
Arlington, Virginia
Postdischarge
Nausea and
Vomiting:
Risk Assessment and
Treatment Strategies
Postdischarge
Nausea and
Vomiting:
Risk Assessment and
Treatment Strategies
DISCLAIMER—This pocket guide is designed to be a summary of
information. While it is detailed, it is not an exhaustive pharmaceuti-
cal review; the entries in this publication present selected facts about
each product. McMahon Publishing Group and Baxter Healthcare
Corporation assume no liability for the use of this review, and the
accuracy of the information contained herein is not guaranteed.
Readers are strongly urged to consult any relevant primary literature
and the complete Prescribing Information available in the package
insert of each drug and appropriate clinical protocols. Copyright ©
2005 McMahon Publishing Group, 545 West 45th Street, New York, NY
10036. Printed in the USA. All rights reserved including the right of
reproduction, in whole or in part, in any form.
AUTHOR/REVIEWER DISCLOSURES
Dr. Apfel has received honoraria for lectures from Fresenius Kabi,
GlaxoSmithKline, Merck, and MGI Pharma. He has acted as a consultant
at advisory board meetings forArakis, GlaxoSmithKline, Merck, and MGI
Pharma. He has participated in research sponsored by Merck and MGI
Pharma. (apfel@ponv.org, www.ponv.org)
Dr. Pergolizzi has received grants/research support from Baxter,
Biowave, CreoMed, GlaxoSmithKline, Novartis, and Purdue. He is a
consultant for Baxter, CreoMed, and GlaxoSmithKline. He is on the
speakers’ bureau for Baxter, CreoMed, GlaxoSmithKline, Organon,
Pfizer, and Purdue.
Dr. Kovac has received grant support from Baxter, GlaxoSmithKline,
Helsinn, Merck, Roche, and Sanofi-Aventis. He has participated on the
speakers’ bureau forAbbott,Baxter,GlaxoSmithKline,Merck,and Roche.
He has served as an advisor forAdolor, GlaxoSmithKline, Helsinn, Merck,
Roche, and Sanofi-Aventis.
Dr. Sanz has no significant relationships to disclose.
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3. 5
Antiemetics for Prevention
Of PDNV . . . . . . . . . . . . . . . . . 12
Tailoring Antiemetic Strategies
To Ambulatory Patients . . . . . 17
Recommendations for
Patients at Home . . . . . . . . . 20
References . . . . . . . . . . . . 21-25
Table of Contents
Incidence of Postdischarge
Nausea and Vomiting (PDNV) . . 7
Relevant Risk Factors for
Postoperative Nausea and
Vomiting (PONV) . . . . . . . . . . . 8
Controversial Risk Factors
For PONV . . . . . . . . . . . . . . . 11
Assessing the Risk
For PONV/PDNV . . . . . . . . . . . 11
4
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4. 7
charge nausea and vomiting (PDNV) has become a
growing problem. Carroll and colleagues found
that 35% of patients experience PDNV and were so
distressed by it that it often delayed resumption of
their normal daily activities.8
Most patients were
waiting for spontaneous resolution of symptoms
and did not contact healthcare professionals for
interventions or antiemetics.9
The problem of
PDNV has not been fully recognized, and the liter-
ature on the subject is still scarce.
Combined with the knowledge gained from the
study of PONV, this pocket guide seeks to provide
clinically relevant information on the perioperative
management of patients at risk for PDNV. It reviews
risk factors and management strategies that apply
effective antiemetic therapies. All drugs discussed in
this pocket guide are FDA approved, but none are
specifically labeled for the indication of PDNV.
Incidence of Postdischarge
Nausea and Vomiting (PDNV)
In a systematic review on postdischarge symp-
toms after outpatient surgery, Wu and colleagues
found an overall incidence of 8% for emesis and
17% for nausea.10
These incidences are consider-
ably lower than the approximately 20% to 30%
reported for postoperative vomiting11,12
and the
30% to 50% reported for overall PONV.1,2
In a
randomized, controlled trial in Holland, Kalkman
and colleagues found that within the first 72
hours following balanced inhalational anesthesia,
incidences of PONV were 47% for ambulatory
patients and 61% for inpatients.13
Ambulatory
anesthesia is thus associated with a lower
An average of 20% to 30% of patients under-
going general anesthesia suffer from
postoperative nausea, vomiting, or both
(PONV).1-3
Vomiting increases the risk of aspiration
and has been associated with wound dehiscence,
esophageal rupture, subcutaneous emphysema, and
painless loss of vision due to retinal detachment
(Figure 1).4
Although these side effects are rare,
PONV is a major concern for patients, decreasing
patient satisfaction and delaying discharge from the
postanesthesia care unit (PACU); PONV has been
described as a leading cause of unexpected hospi-
tal admission after planned ambulatory surgery.5-7
With the increase in ambulatory surgery, postdis-
6
Figure 1. Painless loss of vision due to
retinal detachment after vomiting.
Reprinted from reference 4. Copyright © 2005 Massachusetts
Medical Society. All rights reserved.
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5. 98
Table 1. Most Proven Patient-Specific
And Anesthetic Risk Factors for PONV*
Risk Factor Comment
Patient
specific
Female
gender
Strongest
factor
* Data on many other risk factors are controversial.
Nonsmoking
status
Mechanism
unclear
History of
PONV
Proven, but
not a good
predictor alone
Anesthesia
specific
Postoperative
opioids
Strongest
factor
Volatile
anesthetics
Dependent on
duration of
exposure
(anesthesia/
surgery)
Nitrous oxide Proven, but
not very strong
incidence of PONV than inpatient anesthesia
(probably due to shorter procedures), but the
incidence is still substantial. More systematic
studies are needed to better assess the incidence,
but it seems clear that PDNV is a real problem.
Relevant Risk Factors for Postoperative
Nausea and Vomiting (PONV)
For PONV, there is consensus that there are 3
main patient-specific and 3 main anesthesia-relat-
ed risk factors (Table 1).
The first and most important patient-specific
risk factor is female gender, which is associated
with a 2- to 3-fold increased risk compared to the
risk seen in males.1-3,14
Nonsmokers suffer nau-
sea and vomiting more frequently than smokers;
however, the mechanism is controversial.1-3,14-16
The third patient-specific risk factor is the indi-
vidual disposition of the patient as reflected by
the patient’s history of motion sickness or
PONV.1,2,14,17
Anesthesia care providers often use
the patient’s history of PONV to estimate the
patient’s risk for PONV. However, the overall
predictive value of a patient’s disposition is not
as sensitive as that obtained by using a simplified
risk score,1,18
and at times a history of PONV fails
to provide a statistically significant result.3
The use of an inhalational anesthetic technique
leads to about twice as much PONV as total I.V.
anesthesia (TIVA).19
One reason for this difference
may be an antiemetic effect of propofol.20
More
importantly, a detailed analysis of a trial with 1,180
patients showed that the emetogenic effect of
volatile anesthetics is strongly correlated with the
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6. 11
Controversial Risk Factors for PONV
Standard textbooks and reviews include a long
list of risk factors for PONV, many of which have
little supporting data. For example, obesity was
assumed to be a risk factor via various mecha-
nisms, but Kranke and colleagues revealed that
this is not the case.25
Similarly, a systematic review
of use of a gastric tube for abdominal laparotomy
revealed that it does not reduce PONV.26
The role of other factors such as the type of sur-
gery remains controversial. For example, while the
incidences of PONV vary considerably from one type
of surgery to another, it is uncertain whether this is
due to the type of surgery itself or associated inde-
pendent risk factors. If the average incidence of
PONV after various types of surgery is 30% and
females suffer 3 times more PONV than men, then
the average incidence of PONV should be 45% for
females and 15% for males. Hence, by just consider-
ing that gynecologic surgery is performed just in
females, we would expect the average incidence of
PONV in the range of 45%. This distinction is impor-
tant to understand because females undergoing a
short dilation and curettage are at much lower risk
for PONV than if they undergo a 1.5-hour–long knee
arthroscopy with inhalational anesthetics. This exam-
ple may also explain why the type of surgery is a fair-
ly poor predictor with low sensitivity and specificity
compared to a simplified 4-factor risk score.18
Assessing the Risk for PONV/PDNV
Apfel and colleagues have shown that it is possi-
ble to predict the individual patient’s risk for
PONV/PDNV following a balanced inhalational
degree of exposure (Figure 2).21
In patients at very
high risk of PONV, therefore, it may make better
sense to avoid volatile anesthetics in the first place.
Nitrous oxide is also emetogenic but not as much
as the volatile anesthetics.22,23
Opioids also are
associated with increased nausea and vomiting, but
the impact of intraoperative opioids is not quite
clear yet. In contrast, the use of postoperative opi-
oids has been more consistently demonstrated to
increase PONV.1,2,24
10
0 30 60 90 120 150 180
50
40
30
20
10
0
Degree of Exposure (duration of anesthesia, min)
Propofol
Volatile anesthetics
IncidenceofEarlyVomiting(%)and95%CI
y=0.20x + 4.2
R =0.97
2
Figure 2. Increase of postoperative
vomiting due to increased exposure to
volatile anesthetics.
Adapted from reference 21. Copyright © 2002 The Board of
Management and Trustees of the British Journal of Anaesthesia.
Reproduced by permission of Oxford University Press/British
Journal of Anaesthesia.
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7. 1312
43210
100%
80%
60%
40%
20%
0%
PONVRisk
Number of Risk Factors
Number of Risk Factors
Female gender 1 point
Nonsmoking 1 point
PONV history 1 point
Postoperative opioids 1 point
Risk Score 1-4 points
Figure 3. Apfel’s simplified risk score to
predict the patient’s probability for PONV.
PONV, postoperative nausea and vomiting
Based on reference 1.
anesthesia by just considering a 4-factor simplified
risk score: female gender, nonsmoking status, his-
tory of PONV or motion sickness, and use of post-
operative opioids.1
When 0, 1, 2, 3, or 4 risk fac-
tors are present, the patient’s risk translates to 10%,
20%, 40%, 60%, or 80%, respectively (Figure 3).
More importantly, the simplified risk scores seem
to have better predictive characteristics than more
complex scores and are more effective than just
using the type of surgery or even the patient’s his-
tory of PONV.18,27,28
Antiemetics for Prevention of PDNV
Gupta and colleagues found that prophylactic
antiemetics decrease the risk for postdischarge nau-
sea to 0.77 for 4 mg of ondansetron, 0.68 for >1 mg
of droperidol, and 0.55 for 4 to 10 mg of dexa-
methasone.29
While these values are roughly com-
parable to risk reductions estimated in other meta-
analyses of systematic reviews of various antiemet-
ics,30-31
it is apparent that the efficacy of any single
antiemetic is limited.32
Therefore, the results from a
randomized, controlled study by Scuderi and col-
leagues to evaluate multimodal antiemetic manage-
ment for prevention of early postoperative vomit-
ing after laparoscopy were highly encouraging
when they demonstrated an almost complete elim-
ination (98%) of PONV in the PACU.33
This led to the question of which combination is
best and triggered the design of the International
Multicenter Protocol to assess the single and com-
bined benefits of Antiemetic interventions in a
Controlled clinical Trial of a 2×2×2×2×2×2 factorial
design (IMPACT).34
In this double-blind, randomized,
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8. 15
60
50
40
30
20
10
0
IncidenceofPONV(%)
Control
Ond+Dex+Dro
Ond
+Dex
Ond
+Dro
Dex
+Dro
Ond Dex Dro
Number of Antiemetics
Figure 4. Effect of 1, 2, or 3 antiemetics on
the incidence of PONV in 5,161 patients.
Dex, dexamethasone; Dro, droperidol; Ond, ondansetron;
PONV, postoperative nausea and vomiting
Based on reference 23.
14
controlled study with over 5,000 patients, Apfel
and colleagues compared the single and com-
bined effects of 4 mg of ondansetron, 4 mg of
dexamethasone, 1.25 mg of droperidol, TIVA
using propofol, air instead of nitrous oxide, and
remifentanil (Ultiva®
, Abbott) instead of fentanyl
to prevent nausea and vomiting.23
The study
revealed that all 4 interventions—ondansetron,
dexamethasone, droperidol, and TIVA—were
equally effective and that each reduced the risk
for nausea and vomiting by about a quarter. In
addition, all antiemetic strategies worked inde-
pendently, and each combination was equally
effective (Figure 4).
Postdischarge nausea and vomiting is a problem
of the late postoperative period, so antiemetics
with a shorter duration of action may not have a
sufficiently long-lasting effect. The shorter half-life
of droperidol might also be the reason why Gupta
and colleagues found that 0.625 mg of droperidol
was not quite as effective as 1.25 mg for the preven-
tion of PDNV.29
It should be mentioned that the
FDA has issued a black box warning against the use
of droperidol because of concerns about potential-
ly lethal arrhythmias. However, more recent data
from White and colleagues and Charbit and col-
leagues indicate that the QT prolongations of low-
dose droperidol are comparable to other drugs
given perioperatively and thus are unlikely to be of
clinical relevance.35,36
Despite that, it may no longer
be medicolegally safe to use droperidol.
An equally inexpensive and perhaps safer alter-
native appears to be 4 mg of dexamethasone.23
Dexamethasone appears to have a slow onset
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9. 17
White and colleagues were able to observe a
reduction in the incidence of early emesis follow-
ing abdominal hysterectomy to only 6%.42
Aprepitant (Emend®
, Merck) has recently been
approved for CINV, and it might be as effective for
nausea and vomiting after general anesthesia.
Tailoring Antiemetic Strategies
To Ambulatory Patients
Another important finding of IMPACT was that
the relative risk reduction for each intervention
(26%) was apparently independent for a wide range
of absolute risks.23
Thus, interventions that compa-
rably reduce relative risk will produce the greatest
absolute risk reduction in patients most likely to
experience PONV. For example, a single interven-
tion in a patient with an 80% risk for PONV will
reduce the risk to about 60%; this is an approximate
20% absolute risk reduction, which translates into a
number-needed-to-treat of about 5 for 1 patient to
benefit. Conversely, the absolute risk reduction in a
patient with a baseline risk of 10% is about 2.5%.
This corresponds to a number-needed-to-treat of
about 40, which would probably not justify the
expense and risk of prophylactic treatment. Thus,
the efficacy of an intervention critically depends on
the patient’s baseline risk. This analysis is certainly
equally important for PDNV and emphasizes the
need for a valid risk assessment.
Prophylactic antiemetic strategies therefore
should be tailored according to a patient’s risk.43-45
For example, Pierre and colleagues used the simpli-
fied and validated Apfel score1,27,28
to stratify pa-
tients with low risk to receive no prophylaxis, with
(and should thus be given early after induction),
but its duration of action covers at least 24 hours.
Scopolamine itself has a short half-life, but the
meta-analysis by Kranke and colleagues has shown
that the scopolamine patch (Transderm Scop®
,
Baxter Healthcare) has a slow onset and a long
duration of action that might be similar to that
described for dexamethasone.31
Based on the
results of the Kranke review, the characteristics of
the patch might provide favorable pharmacokinet-
ics for the prevention of PDNV. A new study under
way should provide more insight into the character-
istics of this agent.
Another alternative would be the use of a longer-
acting serotonin antagonist such as dolasetron
(Anzemet®
, Sanofi-Aventis) or granisetron (Kytril®
,
Roche). Of note, several studies have demonstrated
that 0.1 mg of granisetron is not sufficient to prevent
PONV, which may be the reason that the approved
dose for the prevention of PONV is 1 mg.37-39
Palonosetron (Aloxi®
, MGI Pharma/Helsinn) has the
longest half-life (40 h) of the serotonin antagonists,
and, in contrast to other serotonin antagonists, has
been shown to be effective in the prevention of
delayed (24-120 h) chemotherapy-induced nausea
and vomiting (CINV), which suggests it operates
under additional antiemetic mechanisms.40,41
It thus
appears suitable for the prevention of PDNV, but
specific studies are needed before recommenda-
tions can be made.
A new class of antiemetics, substance P (neu-
rokinin-1[NK1])-receptor antagonists, may be signif-
icantly more effective than traditional antiemetics,
especially against vomiting. Using CP-122721,
16
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10. 19
medium risk to receive 0.625 mg of droperidol, and
with high risk to receive TIVA, 4 mg of dexa-
methasone, and 0.625 mg of droperidol.46
Compared with the data from their previous survey,
the overall incidence of PONV decreased from
49.5% to 14.3%.27,46
Another risk-adapted approach
would be to use dexamethasone as a first-line treat-
ment; dexamethasone was shown in IMPACT to be
as effective as droperidol or ondansetron as first-line
therapy (Figure 4),23
and it is not recommended for
rescue treatment due to its slow onset of action.44
However, considering the limited access to
healthcare professionals when nausea or vomiting
occurs after discharge, a more aggressive approach
might be warranted to prevent PDNV. This could be
done by using a regional anesthetic technique or
nonsteroidal analgesics when possible to decrease
opioid-induced PONV.47
More importantly, when
general anesthesia is needed, the simplified 4-factor
risk score can be used to match the number of risk
factors with the number of antiemetic interventions
(Table 2).30,31,37,38,40,42,44
For example, no prophylax-
is would be given for patients with no risk factors.
Patients with 1 risk factor would receive 4 mg of
dexamethasone I.V. after induction of anesthesia.
Patients with 2 risk factors would receive, in addi-
tion, either TIVA, transdermal scopolamine, or a
long-acting serotonin antagonist. Patients with 3 risk
factors could receive TIVA with 4 mg of dexametha-
sone and either transdermal scopolamine or a long-
acting serotonin antagonist. And finally, patients at
very high risk with 4 risk factors could receive TIVA
with dexamethasone along with 2 of the following
3 options: transdermal scopolamine, a long-acting
18
Table 2. Aggressive Risk-Adapted
Approach To Prevent PDNV
Number
Of Risk
Factors
Risk
For N/V
Suggested Intervention*
0 10% Wait and see
* The principle of this strategy is that patients with 1 risk factor
receive 1 antiemetic (intervention), patients with 2 risk factors
receive 2 antiemetics, patients with 3 risk factors receive 3
antiemetics, and patients with 4 risk factors receive 4 antiemetics.
5-HT3, serotonin; NK1, neurokinin-1; N/V, nausea and vomiting;
TIVA, total I.V. anesthesia
1 20% 4 mg dexamethasone
2 40% 4 mg dexamethasone
plus 1 of the following:
scopolamine patch,
long-acting 5-HT3
antagonist, or TIVA
3 60% TIVA plus 4 mg
dexamethasone plus
1 of the following:
scopolamine patch or
long-acting 5-HT3
antagonist
4 80% TIVA plus 4 mg
dexamethasone plus
2 of the following:
scopolamine patch,
long-acting 5-HT3
antagonist, NK1 antagonist
(aprepitant)
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11. 21
Finally, because it is known that patients rarely
contact healthcare providers when PDNV occurs, it
is highly recommended that the anesthesia provider
call the patient at home to verify whether every-
thing is all right, recovery is progressing well, and
whether any interventions or help are necessary.
References
1. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N.
A simplified risk score for predicting postoperative
nausea and vomiting: conclusions from cross-validations
between two centers. Anesthesiology. 1999;91:693-700.
2. Koivuranta M, Läärä E, Snare L, Alahuhta S.A survey of
postoperative nausea and vomiting. Anaesthesia.
1997;52:443-449.
3. Stadler M, Bardiau F, Seidel L,Albert A, Boogaerts JG.
Difference in risk factors for postoperative nausea and
vomiting. Anesthesiology. 2003;98:46-52.
4. Zhang GS, Mathura JR, Jr. Painless loss of vision after
vomiting. N Engl J Med. 2005;352:e16,April 28, 2005.
5. Macario A,Weinger M, Carney S, Kim A.Which clinical
anesthesia outcomes are important to avoid? The per-
spective of patients. Anesth Analg. 1999;89:652-658.
6. Darkow T, Gora-Harper ML, Goulson DT, Record KE.
Impact of antiemetic selection on postoperative nausea
and vomiting and patient satisfaction. Pharmacotherapy.
2001;21:540-548.
7. Gold BS, Kitz DS, Kecky JH, Neuhaus JM. Unanticipated
admission to the hospital following ambulatory surgery.
JAMA. 1989;262:3008-3010.
8. Carroll NV, Miederhoff P, Cox FM, Hirsch JD.
Postoperative nausea and vomiting after discharge
from outpatient surgery centers. Anesth Analg.
1995;80:903-909.
9. Fetzer SJ, Hand MA, Bouchard PA, Smith HB, Jenkins MB.
Self-care activities for postdischarge nausea and vomiting.
J Perianesth Nurs. 2005;20:249-254.
serotonin antagonist, and the NK1-antagonist
aprepitant (currently available only as oral dose,
expert opinion, off-label use).
Recommendations for Patients at Home
Intravenous routes are generally not available for
patients at home. Gan and colleagues have shown
that 8 mg of ondansetron in the form of orally dis-
integrating tablets (Zofran ODT®
, GlaxoSmithKline),
which dissolve instantly on the tongue without liq-
uid, reduces PDNV and improves patient satisfac-
tion.48
However, oral medications might not work
for the treatment of established PDNV. Rectal
administration of prochlorperazine or promethazine
suppositories might be an option, though there are
no studies to support their effectiveness for the
treatment of PDNV. Also, it must be considered that
rectal absorption is variable and both drugs can lead
to sedation, which might not necessarily improve
patient satisfaction with the postoperative recovery.
Thus, the use of the previously mentioned scopo-
lamine patch appears to be a practical alternative,
though it may need a few hours before providing its
full antiemetic properties.
Numerous studies have shown that stimulation of
the Chinese acupuncture point P6 (Nei Guan) at the
volar side of the wrist can reduce nausea and vom-
iting.49
White and colleagues have found that the
ReliefBand®
(Abbott), a device that provides electri-
cal stimulation to the P6 point, reduces PONV,50
but
more importantly, they were able to show that the
ReliefBand is also effective for the treatment of
established nausea and vomiting, especially in
combination with ondansetron.51
20
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12. 23
nausea. Anesthesiology. 1997;87:779-784.
21. Apfel CC, Kranke P, Katz MH, 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;88:659-668.
22. Divatia JV,Vaidya JS, Badwe RA, Hawaldar RW. Omission
of nitrous oxide during anesthesia reduces the incidence
of postoperative nausea and vomiting: a meta-analysis.
Anesthesiology. 1996;85:1055-1062.
23. Apfel CC, Korttila K,Abdalla M, et al.A factorial trial of six
interventions for the prevention of postoperative nausea
and vomiting. N Engl J Med. 2004;350:2441-2451.
24. Cohen MM, Duncan PG, DeBoer DP,Tweed WA. The
postoperative interview: assessing risk factors for nausea
and vomiting. Anesth Analg. 1994;78:7-16.
25. Kranke P, Apfel CC, Papenfuss T, et al.An increased body
mass index is no risk factor for postoperative nausea and
vomiting: a systematic review and results of original data.
Acta Anaesthesiol Scand. 2001;45:160-166.
26. Cheatham ML, Chapman WC, Key SP, Sawyers JL.
A meta-analysis of selective versus routine nasogastric
decompression after elective laparotomy. Ann Surg.
1995;221:469-478.
27. Pierre S, Benais H, Pouymayou J.Apfel’s simplified score
may favourably predict the risk of postoperative nausea
and vomiting. Can J Anesth. 2002;49:237-242.
28. Apfel CC, Kranke P, Eberhart LHJ, Roos IA, Roewer N.
A comparison of predicting models for postoperative
nausea and vomiting. Br J Anaesth. 2002;88:234-240.
29. Gupta A,Wu CL, Elkassabany N, Krug CE, Parker SD,
Fleisher LA. Does the routine prophylactic use of
antiemetics affect the incidence of postdischarge nausea
and vomiting following ambulatory surgery?: a systematic
review of randomized controlled trials. Anesthesiology.
2003;99:488-495.
30. Henzi I,Walder B,Tramer MR. Dexamethasone for the
prevention of postoperative nausea and vomiting: a
quantitative systematic review. Anesth Analg.2000;
90:186-194.
10. Wu CL, Berenholtz SM, Pronovost PJ, Fleisher LA.
Systematic review and analysis of postdischarge
symptoms after outpatient surgery. Anesthesiology.
2002;96:994-1003.
11. Apfel CC, Greim CA, Haubitz I, et al.A risk score to
predict the probability of postoperative vomiting in
adults. Acta Anaesthesiol Scand. 1998;42:495-501.
12. Apfel CC, Greim CA, Haubitz I, et al.The discriminating
power of a risk score for postoperative vomiting in
adults undergoing various types of surgery. Acta
Anaesthesiol Scand. 1998;42:502-509.
13. Visser K, Hassink EA, Bonsel GJ, Moen J, Kalkman CJ.
Randomized controlled trial of total intravenous anesthesia
with propofol versus inhalation anesthesia with isoflurane-
nitrous oxide: postoperative nausea with vomiting and
economic analysis. Anesthesiology. 2001;95:616-626.
14. Sinclair DR, Chung F, Mezei G. Can postoperative
nausea and vomiting be predicted? Anesthesiology.
1999;91:109-118.
15. Hough M, Sweeney B.The influence of smoking on
postoperative nausea and vomiting. Anaesthesia.
1998;53:932-933.
16. Chimbira W, Sweeney BP.The effect of smoking on
postoperative nausea and vomiting. Anaesthesia.
2000;55:540-544.
17. Palazzo M, Evans R. Logistic regression analysis of fixed
patient factors for postoperative sickness: a model for
risk assessment. Br J Anaesth. 1993;70:135-140.
18. Apfel CC, Kranke P, Eberhart LH. Comparison of surgical
site and patient’s history with a simplified risk score for
the prediction of postoperative nausea and vomiting.
Anaesthesia. 2004;59:1078-1082.
19. Sneyd JR, Carr A, Byrom WD, Bilski AJ.A meta-analysis of
nausea and vomiting following maintenance of anaesthesia
with propofol or inhalational agents. Eur J Anaesthesiol.
1998;15:433-445.
20. Gan TJ, Glass PS, Howell ST, Canada AT, Grant AP,
Ginsberg B. Determination of plasma concentrations of
propofol associated with 50% reduction in postoperative
22
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13. 25
41. Shah AK, Hunt TL, Gallagher SC, Cullen MT, Jr.
Pharmacokinetics of palonosetron in combination with
aprepitant in healthy volunteers. Curr Med Res Opin.
2005;21:595-601.
42. Gesztesi Z, Scuderi PE,White PF, et al. Substance P
(Neurokinin-1) antagonist prevents postoperative
vomiting after abdominal hysterectomy procedures.
Anesthesiology. 2000;93:931-937.
43. Watcha MF.The cost-effective management of postoperative
nausea and vomiting [editorial; comment].
Anesthesiology. 2000;92:931-933.
44. Apfel CC, Roewer N. Risk assessment of postoperative
nausea and vomiting. Int Anesthesiol Clin. 2003;41:13-32.
45. Gan TJ. Postoperative nausea and vomiting—can it be
eliminated? JAMA. 2002;287:1233-1236.
46. Pierre S, Corno G, Benais H,Apfel CC.A risk score-
dependent antiemetic approach effectively reduces
postoperative nausea and vomiting—a continuous quality
improvement initiative. Can J Anaesth. 2004;51:320-325.
47. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects of non-
steroidal antiinflammatory drugs on patient-controlled
analgesia morphine side effects: meta-analysis of
randomized controlled trials. Anesthesiology.
2005;102:1249-1260.
48. Gan TJ, Franiak R, Reeves J. Ondansetron orally disintegrating
tablet versus placebo for the prevention of postdischarge
nausea and vomiting after ambulatory surgery. Anesth
Analg. 2002;94:1199-1200.
49. Lee A, Done ML.The use of nonpharmacologic tech-
niques to prevent postoperative nausea and vomiting:
a meta-analysis. Anesth Analg. 1999;88:1362-1369.
50. White PF, Issioui T, Hu J, et al. Comparative efficacy of
acustimulation (ReliefBand) versus ondansetron (Zofran)
in combination with droperidol for preventing nausea
and vomiting. Anesthesiology. 2002;97:1075-1081.
51. Coloma M,White PF, Ogunnaike BO, et al. Comparison of
acustimulation and ondansetron for the treatment of
established postoperative nausea and vomiting.
Anesthesiology. 2002;97:1387-1392.
31. Kranke P, Morin AM, Roewer N,Wulf H, Eberhart LH.
The efficacy and safety of transdermal scopolamine for
the prevention of postoperative nausea and vomiting: a
quantitative systematic review. Anesth Analg.
2002;95:133-143.
32. Habib AS, Gan TJ. Evidence-based management of
postoperative nausea and vomiting: a review. Can J
Anaesth. 2004;51:326-341.
33. Scuderi PE, James RL, Harris L, Mims GR, III. Multimodal
antiemetic management prevents early postoperative
vomiting after outpatient laparoscopy. Anesth Analg.
2000;91:1408-1414.
34. Apfel CC, Korttila K,Abdalla M, et al.An international
multicenter protocol to assess the single and combined
benefits of antiemetic interventions in a controlled
clinical trial of a 2×2×2×2×2×2 factorial design (IMPACT).
Control Clin Trials. 2003;24:736-751.
35. Charbit B,Albaladejo P, Funck-Brentano C, Legrand M,
Samain E, Marty J. Prolongation of QTc interval after post-
operative nausea and vomiting treatment by droperidol
or ondansetron. Anesthesiology. 2005;102:1094-1100.
36. White PF, Song D,Abrao J, Klein KW, Navarette B. Effect of
low-dose droperidol on the QT interval during and after
general anesthesia: a placebo-controlled study.
Anesthesiology. 2005;102:1101-1105.
37. Wilson AJ, Diemunsch P, Lindeque BG, et al. Single-dose
i.v. granisetron in the prevention of postoperative nausea
and vomiting. Br J Anaesth. 1996;76:515-518.
38. Mikawa K,Takao Y, Nishina K, Shiga M, Maekawa N,
Obara H. Optimal dose of granisetron for prophylaxis
against postoperative emesis after gynecological surgery.
Anesth Analg. 1997;85:652-656.
39. Kranke P,Apfel CC, Eberhart LH, Georgieff M, Roewer N.
The influence of a dominating centre on a quantitative
systematic review of granisetron for preventing post-
operative nausea and vomiting. Acta Anaesthesiol Scand.
2001;45:659-670.
40. Siddiqui MA, Scott LJ. Palonosetron. Drugs.
2004;64:1125-1132.
24
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14. 27
NotesNotes
26
Copyright
©
2006
M
cM
ahon
Publishing
G
roup
unless
otherw
ise
noted.
A
llrights
reserved.Reproduction
in
w
hole
or
in
part
w
ithout
perm
ission
is
prohibited.