Prevention and treatment of postoperative nausea and vomiting

Abstracts

Náuseas e vômitos pós-operatórios são comuns e podem ser evitados. Complicações provenientes deste problema acarretam aumento de morbi-mortalidade. Foi realizada revisão de literatura no MEDLINE, com foco em estudos clínicos controlados. A fisiopatologia é complexa, com várias vias centrais aferentes e eferentes, e seu entendimento ajuda na escolha das medicações. Fatores de risco são apresentados, com escala de estratificação de chance para desenvolvimento de náuseas e vômitos pósoperatórios. Algoritmo para abordagem de pacientes com maior risco foi elaborado e estratifica nível de prevenção/tratamento a ser recebido, de modo a evitar uso excessivo de drogas e seus paraefeitos. Náuseas e vômitos pós-operatórios devem ser prevenidos, pois acarretam complicações e desconforto nos pacientes. Abordagem sistemática com análise de fatores de risco per-operatórios e prescrição de medicações podem ser eficazes para sua prevenção.

Náusea e Vômito pósoperatório; Complicações pós-operatórias

REVIEW ARTICLE

Prevention and treatment of postoperative nausea and vomiting

Carlos Roberto Naegeli Gondim^I; André Miguel Japiassú^II; Pedro Eder Portari Filho^III; Gustavo Ferreira de Almeida^IV; Marcelo Kalichsztein^V; Gustavo Freitas Nobre^VI

^IMedical student; Clerkship at the Intensive Care Unit of the Casa de Saúde São José, Rio de Janeiro (RJ), Brazil

^IIPhysician from the Intensive Care Unit of the Casa de Saúde São José, Rio de Janeiro (RJ), Brazil

^IIIAdjunct Professor from the General and Specialized Surgery Department of the Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro, (RJ), Brazil

^IVPhysician from the Intensive Care Unit of the Casa de Saúde São José, Rio de Janeiro (RJ), Brazil

^VPhysician from the Intensive Care Unit of the Casa de Saúde São José, Rio de Janeiro (RJ), Brazil

^VIPhysician from the Intensive Care Unit of the Casa de Saúde São José, Rio de Janeiro (RJ), Brazil

Author for correspondence

ABSTRACT

Postoperative nausea and vomiting are common and can be prevented. Complications of this condition cause higher rates of morbidity and mortality. A review of literature was carried out on MEDLINE, with focus on controlled clinical trials. Pathophysiology is complex, with many afferent and efferent pathways, and its comprehension facilitate the choice of medication. Risk factors are presented, with a stratified score of chance to develop postoperative nausea and vomiting. An algorithm for identification of higher risk patients was elaborated and classified the level of prevention/treatment recommended to avoid excessive use of drugs and their side effects. Postoperative nausea and vomiting must be prevented, because of the involved complications and discomfort for patients. A systematic approach with analysis of preoperative risk factors and prescription of medication can be effective for prevention.

Keywords: Postoperative nausea and vomiting/prevention & control; Postoperative Complications/prevention & control

INTRODUCTION

Side effects of surgical procedures are frequent at postoperative, pain, nausea and vomiting are common. Although there is a major concern with prevention of pain, vomiting at postoperative occurs in about 30% of patients.⁽¹⁾

Postoperative nausea and vomiting (PONV) are defined as development of episodes of nausea and emesis after a surgical act and before hospital discharge. Nausea is defined as subjective abdominal discomfort associated with an urge to vomit and may be caused by stimulation of mechanical receptors in the gastrointestinal tract and of the vestibular system. Also involved are the chemoreceptor trigger zone in the posterior area to the floor of the 4^th ventricle, stimulated by dopamine receptors D2 and 5-HT3 receptors and upper cortical centers. Vomiting consists of forced ejection of gastric content by the neuromuscular complex with voluntary and involuntary components.⁽²⁾ Center of vomiting is comprised by the solitary tract and by reticular formations of the bulbus, mediated by receptors H1 and M1 and parasympathetic activity.

Although PONV progresses in an auto-limited course, it may lead to dehydration, electrolytic disorders, dehiscence of the suture, bleeding, bronchoaspiration and rupture of the esophagus.⁽³⁾ The economic impact of this syndrome is underestimated, because costs associated to PONV may significantly increase with time of recovery after surgery.⁽⁴⁾

However the unrestrained use of antiemetic agents for universal prevention of PONV may be responsible for side effects and excessive cost. A better guidance of prophylaxis is required for those at higher risk of PONV and a stratified orientation for rescue treatment.

Our objective is to review relevant studies on the occurrence of PONV in adults and draw up an algorithm for prevention and treatment of the syndrome. A reference survey was made in the database PubMed using the keywords "postoperative nausea and vomiting", as Mesh terms, producing 1680 references. Survey limits were used to focus search on the more relevant articles: studies in humans, English or Portuguese language, in adults (over 19 years of age) and clinical studies of any kind (case reports or series, stage I,II, III or IV studies, comparative studies, controlled clinical studies with or without randomization). The search disclosed 741 articles (6 reviews) classified as: etiology (203), physiopathology (12), epidemiology (178), diagnosis (13), therapy (487) prevention and control (405) and economy (13).

WHICH ARE THE RISK FACTORS?

Risks may be ranked in three categories: associated to the patient, to the surgical procedure and to the anesthesia performed.

Factors associated to the patient

The main risk factor associated to PONV is the female gender.⁽⁴⁾ Women before puberty may not present an increased risk for PONV, which suggests association with hormone factors.^(5,6)

Other risk factors are former history of kinetosis and PONV.^(7,8) Tobacco smoking seems to reduce the risk.⁽⁹⁾ Evidence proves that age would also be an independent risk factor, because the highest incidence is in children and risk after each decade of life is reduced by 10%.⁽⁷⁾ Other possible risk factors are: poorer evaluation in the American Society of Anesthesiology (ASA) score, migraine and postoperative anxiety.^(8-10)

Factors associated to surgical procedure

Surgery time is an independent risk factor for PONV (risk increases by 60% for each additional 30 minutes of surgery time.^(7,8) Type of surgery is considered as an important risk factor.^(9,11) It is known that intra-abdominal, laparoscopic, orthopedic, gynecological, plastic, otorhinolaryngologic surgeries, thyroid surgeries and breast surgeries have an increased risk in relation to other procedures.

Factors associated to anesthesia

Multiple variables related to anesthesia were associated to higher risk of PONV incidence. Use of volatile anesthetics and nitrous oxide particularly increase the risk.^(3,12,13) Use of high doses (above 2.5 mg) of neostigmine is also considered a risk factor.⁽¹⁴⁾

It is proven that opioids in the intra and preoperative periods increase risk of developing PONV. Venous, subcutaneous or spinal administration, is associated to occurrence of the syndrome.⁽¹⁵⁾ There is a dose-response relation between opioids and risk of PONV. ⁽¹⁶⁾ Tramadol shows relative higher risk of PONV than other opioids, remifentanil was temporarily associated to less risk, however there was no difference among use of remifentanil, fentanyl and PONV in controlled studies.⁽¹²⁾ Nevertheless, analgesic adjuvant drugs must be tried, aiming to reduce frequency of opioid use. General anesthesia is another risk factor if used in detriment to other forms of sedation and regional block.^(7,9)

HOW TO PREVENT AND/OR MANAGE PONV?

The identification of risk factors for PONV leads to the development of scores to quantify its probability. These scores are relevant in adults,⁽³⁾ and use as parameters only risk factors associated to the patient and some have already been validated.⁽¹⁷⁾ Accuracy was shown to be relatively low, improving prediction by 12% to 57%. Interventions oriented by scores significantly reduce PONV (23 to 71%) especially in high risk patients, while they avoid high costs and potential side effects in low risk patients.⁽¹⁸⁾ Simplified risk scores (only preoperative risk factors) do not have a reduced accuracy and easy to use, accuracy is equivalent or superior in relation to other more complex systems.

Preoperative strategies

Even at preoperative stages, there are strategies for prevention of PONV. Patient hypovolemia may increase incidence of PONV and generous hydration or more liberal conduct regarding zero diet may ease these effects. ⁽¹⁹⁾ Inhalation anesthetics increase risk of PONV, mainly nitrous oxide. In studies with animals, this agent may alter the pressure of the middle ear and cause intestinal distension, besides activating the dopamine system.^(20-22) Effects of inhalation agents further depend on duration of anesthesia, and are greater in procedures of more than 3 hours duration. Regard-ing anesthesia, propofol was associated to decreased risk, although its antiemetic mechanism has not been proven.⁽²³⁾ Maintenance of anesthesia with propofol, when compared to inhalation anesthetic agents, significantly reduces incidence of PONV, regardless of other risk factors, mainly if used in continuous infusion.⁽²⁴⁾ At the end of surgery, anticolinesterasic drugs are administered to antagonize the residual effect of neuromuscular blocking agents, however they increase gastrointestinal motility and gastric secretion, that are balanced by means of anticolinergic agents.⁽¹⁴⁾ Administration of supplemental oxygen at high fractions is not beneficial when, compared to use of oxygen at 30% as previously suggested. ^(25,26) Gastric aspiration may reduce risk of PONV in surgeries with large blood accumulation in the stomach (oropharyngeal surgeries), because blood is a potent emetogenic in addition to the nauseating effect of gastric distension.⁽²⁷⁾

Pharmacological prophylaxis

Chart 1 shows the main drugs used for PONV prophylaxis. Several studies were carried out with antagonists of the 5-HT3 receptors. Ondansetron is effective for treatment of PONV, more so against vomiting than nausea.⁽²⁸⁾ It was proven that 8mg of ondansetron at the end of surgery is not more efficient than 4 mg. ⁽²⁹⁾ Dolasetron also proved efficient to prevent PONV, in a dose of 12.5 mg at the end of surgery.⁽³⁰⁾ Comparing ondansetron with dolasetron, no difference was found in the efficacy of PONV prophylaxis.⁽³¹⁾ Granisetron is new antiemitic agent, however with no ideal dose defined.⁽³²⁾ The more common para-effects of these drugs are headaches, constipation and elevation of hepatic enzymes. Furthermore, electrocardiographic alterations may be found, although seldom and dosedependent.⁽³³⁾

Butyrophenones have an antiemetic effect due to blockade of dopamine receptors D2 of the chemoreceptor trigger zone of the posterior area. They are more effective against nausea than vomiting. Studies show that there is no statistical difference in prophylaxis of PONV and occurrence of para-effects with droperidol (0.625mg or 1.25 mg) or ondansetron (4 mg).⁽³⁴⁾ In 2001, the Food and Drug Administration (FDA) ruled that droperidol should be restricted to patients who did not respond to or tolerate other treatments. |Due to the risk of triggering a prolonged QT interval and arrhythmias, patients must be submitted to cardiac monitoring before and after use of this drug.

Anticolinergic agents are antagonists of M1 receptors in the brain cortex and of H1 receptors in the hypothalamus and in the center of vomiting, in addition to suppressing the noradrenergic system, improving adjustment to vestibular stimulation and are often used in kinetosis management.⁽³⁷⁾ Transdermal scopolamine is efficient in PONV prophylaxis,^(35,36) disclosing better results in patients with a history of kinetosis and nausea induced by opioids.⁽³⁷⁾ Its application is recommended on the night before surgery or up to four hours prior to end of anesthesia. More common side effects are visual disturbances and dry mouth.

Antihistamines have antiemetic qualities because of their ability to suppress the vestibular stimulus and due to anticolinergic and sedative effects. Dymenhydrinate is effective in prophylaxis of PONV, especially in patients of moderate or high risk although benefit has not been proven when compared to ondansetron.⁽³⁸⁾ The more common side effects are headache, sleepiness and vertigo.

Phenothiazines have antiemetic effects by blocking dopamine receptors D2 of the chemoreceptor trigger zone and the cortical centers of the central nervous system. Promethazine further presents antihistaminic and anticolinergic activity, and is more efficient than ondansetron in PONV prophylaxis in middle ear surgeries.⁽³⁹⁾ Prochlorperazine has a more rapid action than promethazine and has also sedative effect. Its administration was even more effective in reducing PONV when compared to ondanestron in hip and knee surgeries.⁽⁴⁰⁾ The more common side effects of phenothiazines are extrapyramidal symptoms.

Dexamethasone is an antiemetic routinely used for patients submitted to chemotherapy. Although its mechanism and ideal dose remain unknown^(41,42) it is believed that dexamethasone may antagonize prostalgandins and release endorphins. In studies on prophylaxis for PONV, there was efficacy and there were no reports of adverse effects by administering a single dose.⁽⁴³⁾ Its effects on PONV prophylaxis are comparable to those of other classes of antiemetics, such as antagonists of the 5-HT3 and D2 receptors. A dexamethasone dose of 8 mg before induction of anesthesia may reduce fatigue, pain and need of opioids as well as reduce the level of protein C reactive at postoperative.⁽⁴⁴⁾

Metoclopramide (group of benzamides) is prokinetic and antagonist of central dopamine D2 receptors. When administered in the habitual 10 mg dose, metoclopramide is not efficient in prevention of PONV. In a review of 66 randomized studies (626 patients) it was proven that use of metoclopramide does not prevent nausea at postoperative.⁽⁴⁵⁾ Its use for prophylaxis of postoperative vomiting, is efficient when compared to placebo, although there is no consensus about use.⁽¹⁾ However, metoclopramide manages nausea and vomiting efficiently when induced by paralytic ileum, due to high morphine does for control of postoperative pain.⁽⁴⁶⁾

Rescue treatment

For rescue treatment, blockers of the 5-HT3 receptors have been the most studied drugs. This class presents better results when treating vomiting than nausea episodes.⁽⁴⁷⁾ Scarce information is available on use of other classes of drugs for treatment of PONV, Rescue treatment of PONV must be begun with drugs of a different class than that used for prophylaxis.⁽⁴⁸⁾

Alternative and nonpharmacologic therapy

Studies disclose that nonpharmacological or alternative therapies may be beneficial for prophylaxis and treatment of PONV, such as acupuncture, transcutaneous nerve stimulation, hypnosis and aromatherapy.⁽⁴⁹⁾ Noteworthy is stimulus of the acupoint P6 (Nei-Guan), located on the median nerve, between the tendons of the flexor carpi radialis and palmaris longus muscles, that has proven efficient in comparison to antiemetics.⁽⁵⁰⁾

FINAL CONSIDERATIONS

Analysis of risk factors may be useful in the approach of postoperative PONV (Figure 1). Some types of surgery (plastic, orthopedic, ophthalmic, gastrointestinal and gynecological) predispose to PONV, as well as a longer surgery time, use of inhalation anesthetics and opioids, while continuous infusion of propofol is protective. When arriving at the intensive care unit, a risk score is calculated (female gender, tobacco smoking, history of kinetosis or PONV and use of opioids) and if there are two or more of these, prophylactic drugs should be administered. This approach may reduce discomfort and postoperative complications.

CONCLUSIONS

PONV are easily recognized and may be prevented. They entail complications and discomfort to patients, mainly after some specific types of surgery. Systematic approaches with analysis of preoperative risk factors as well as drug prescription may be efficient to prevent the undesirable PONV.

REFERENCES

• 1. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramèr MR, Watcha M; Department of Anesthesiology, Duke University Medical Center. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg. 2003;97(1):62-71, table of contents. Review.
• 2. Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001;120(1):263-86.
• 3. Apfel C, Kranke P, Katz MH, Goepfert C, Papenfuss T, Rauch S, 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(5):659-68.
• 4. Carroll NV, Miederhoff PA, Cox FM, Hirsch JD. Costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting. J Clin Anesth. 1994;6(5):364-9.
• 5. Rowley MP, Brown TC. Postoperative vomiting in children. Anaesth Intensive Care. 1982;10(4):309-13.
• 6. Honkavaara P, Lehtinen AM, Hovorka J, Korttila K. Nausea and vomiting after gynaecological laparoscopy depends upon the phase of the menstrual cycle. Can J Anaesth. 1991;38(7):876-9.
• 7. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology. 1999;91(1):109-18.
• 8. Koivuranta M, Läärä E, Snare L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia. 1997;52(5):443-9.
• 9. Cohen MM, Duncan PG, DeBoer DP, Tweed WA. The postoperative interview: assessing risk factors for nausea and vomiting. Anesth Analg. 1994;78(1):7-16. Comment in: Anesth Analg. 1994;78(1):5-6.
• 10. Van den Bosch JE, Moons KG, Bonsel GJ, Kalkman CJ. Does measurement of preoperative anxiety have added value for predicting postoperative nausea and vomiting? Anesth Analg. 2005;100(5):1525-32, table of contents.
• 11. Lerman J. Surgical and patient factors involved in postoperative nausea and vomiting. Br J Anaesth. 1992;69(7 Suppl 1):24S-32S.
• 12. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, Zernak C, Danner K, Jokela R, Pocock SJ, Trenkler S, Kredel M, Biedler A, Sessler DI, Roewer N; IMPACT Investigators. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350(24):2441-51.
• 13. Tramèr M, Moore A, McQuay H. Omitting nitrous oxide in general anaesthesia: meta-analysis of intraoperative awareness and postoperative emesis in randomized controlled trials. Br J Anaesth. 1996;76(2):186-93.
• 14. Tramèr MR, Fuchs-Buder T. Omitting antagonism of neuromuscular block: effect on postoperative nausea and vomiting and risk of residual paralysis. A systematic review. Br J Anaesth. 1999;82(3):379-86.
• 15. Toner CC, Broomhead CJ, Littlejohn IH, Samra GS, Powney JG, Palazzo MG, et al. Prediction of postoperative nausea and vomiting using a logistic regression model. Br J Anaesth. 1996;76(3):347-51.
• 16. Roberts GW, Bekker TB, Carlsen HH, Moffatt CH, Slattery PJ, McClure AF. Postoperative nausea and vomiting are strongly influenced by postoperative opioid use in a dose-related manner. Anesth Analg. 2005;101(5):1343-8. Comment in: Anesth Analg. 2005;101(5):1341-2.
• 17. Apfel CC, Läärä 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(3):693-700.
• 18. 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(4):320-5.
• 19. Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg. 2003;90(4):400-6.
• 20. Perreault L, Normandin N, Plamondon L, Blain R, Rousseau P, Girard M, Forget G. Middle ear pressure variations during nitrous oxide and oxygen anaesthesia. Can Anaesth Soc J. 1982;29(5):428-34.
• 21. Eger EI 2nd, Saidman LJ. Hazards of nitrous oxide anesthesia in bowel obstruction and pneumothorax. Anesthesiology. 1965;26:61-6.
• 22. Murakawa M, Adachi T, Nakao S, Seo N, Shingu K, Mori K. Activation of the cortical and medullary dopaminergic systems by nitrous oxide in rats: a possible neurochemical basis for psychotropic effects and postanesthetic nausea and vomiting. Anesth Analg. 1994;78(2):376-81. Comment in: Anesth Analg. 1995;80(4):855-6.
• 23. Borgeat A, Wilder-Smith OH, Suter PM. The nonhypnotic therapeutic applications of propofol. Anesthesiology. 1994; 80(3):642-56.
• 24. 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 Anaesth. 1998;15(4):433-45.
• 25. Joris JL, Poth NJ, Djamadar AM, Sessler DI, Hamoir EE, Defêchereux TR, et al. Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidectomy. Br J Anaesth. 2003;91(6):857-61.
• 26. Greif R, Laciny S, Rapf B, Hickle RS, Sessler DI. Supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Anesthesiology. 1999;91(5):1246-52.
• 27. Golembiewski J, Chernin E, Chopra T. Prevention and treatment of postoperative nausea and vomiting. Am J Health Syst Pharm. 2005;62(12):1247-60; quiz 1261-2. Comment in: Am J Health Syst Pharm. 2005;62(22):2350; author reply 2350, 2352.
• 28. Tramèr MR, Reynolds JM, Moore RA, McQuay HJ. Efficacy, dose-response, and safety of ondansetron in prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized placebo-controlled trials. Anesthesiology. 1997;87(6):1277-89. Comment in: Anesthesiology. 1997;87(6):1271-3. Anesthesiology. 1999;90(2):355-6.
• 29. Figueredo ED, Canosa LG. Ondansetron in the prophylaxis of postoperative vomiting: a meta-analysis. J Clin Anesth. 1998;10(3):211-21.
• 30. Philip BK, McLeskey CH, Chelly JE, McKenzie R, Kovac AL, Diemunsch P, DuBois DM. Pooled analysis of three large clinical trials to determine the optimal dose of dolasetron mesylate needed to prevent postoperative nausea and vomiting. The Dolasetron Prophylaxis Study Group. J Clin Anesth. 2000;12(1):1-8.
• 31. Zarate E, Watcha MF, White PF, Klein KW, Sa Rego M, Stewart DG. A comparison of the costs and efficacy of ondansetron versus dolasetron for antiemetic prophylaxis. Anesth Analg. 2000;90(6):1352-8. Comment in: Anesth Analg. 2001;92(3):797.
• 32. Wilson AJ, Diemunsch P, Lindeque BG, Scheinin H, Helbo-Hansen HS, Kroeks MV, Kong KL. Single-dose i.v. granisetron in the prevention of postoperative nausea and vomiting. Br J Anaesth. 1996;76(4):515-8.
• 33. Navari RM, Koeller JM. Electrocardiographic and cardiovascular effects of the 5-hydroxytryptamine3 receptor antagonists. Ann Pharmacother. 2003;37(9):1276-86. Comment in: Ann Pharmacother. 2003;37(12):1918; reply 1918-9.
• 34. Fortney JT, Gan TJ, Graczyk S, Wetchler B, Melson T, Khalil S, et al. A comparison of the efficacy, safety, and patient satisfaction of ondansetron versus droperidol as antiemetics for elective outpatient surgical procedures. S3A-409 and S3A-410 Study Groups. Anesth Analg. 1998;86(4):731-8. Comment in: Anesth Analg. 1999;88(2):465-6.
• 35. Parrott AC.Transdermal scopolamine: are view of its effects upon motion sickness, psychological performance, and physiological functioning. Aviat Space Environ Med. 1989;60(1):1-9.
• 36. 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(1):133-43, table of contents.
• 37. Ferris FD, Kerr IG, Sone M, Marcuzzi M. Transdermal scopolamine use in the control of narcotic-induced nausea. J Pain Symptom Manag. 1991;6(6):389-93.
• 38. Kranke P, Morin AM, Roewer N, Eberhart LH. Dimenhydrinate for prophylaxis of postoperative nausea and vomiting: a meta-analysis of randomized controlled trials. Acta Anaesthesiol Scand. 2002;46(3):238-44. Comment in: Can J Anaesth. 2003;50(1):11-2. Can J Anaesth. 2003;50(1):12-3.
• 39. Khalil S, Philbrook L, Rabb M, Wells L, Aves T, Villanueva G, et al. Ondansetron/promethazine combination or promethazine alone reduces nausea and vomiting after middle ear surgery. J Clin Anesth. 1999;11(7):596-600.
• 40. Chen JJ, Frame DG, White TJ. Efficacy of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting after total hip replacement or total knee replacement procedures: a randomized, double-blind, comparative trial. Arch Intern Med. 1998;158(19):2124-8. Erratum in: Arch Intern Med. 1999;159(6):615.
• 41. Liu K, Hsu CC, Chia YY. The effect of dose of dexamethasone for antiemesis after major gynecological surgery. Anesth Analg. 1999;89(5):1316-8.
• 42. Ho ST, Wang JJ, Tzeng JI, Liu HS, Ger LP, Liaw WJ. Dexamethasone for preventing nausea and vomiting associated with epidural morphine: a dose-ranging study. Anesth Analg. 2001;92(3):745-8.
• 43. Henzi I, Walder B, Tramèr MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg. 2000;90(1):186-94.
• 44. Wang JJ, Ho ST, Tzeng JJ, Tang CS. The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting. Anesth Analg. 2000; 91(1):136-9.
• 45. Henzi I, Walder B, Tramèr MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. Br J Anaesth. 1999;83(5):761-71.
• 46. Assaf RA, Clarke RS, Dundee JW, Samuel IO. Studies of drugs given before anaesthesia. XXIV: Metocloramide with morphine and pethidine. Br J Anaesth. 1974;46(7):514-9.
• 47. Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. Efficacy, dose-response, and safety of ondansetron in prevention of postoperative nausea and vomiting. Anesthesiology. 1997; 87(6):1277-89. Comment in: Anesthesiology. 1997;87(6):1271-3. Anesthesiology. 1999;90(2):355-6.
• 48. Kovac AL, O'Connor TA, Pearman MH, Kekoler LJ, Edmondson D, Baughman VL, 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(6):453- 9.
• 49. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg. 1999;88(6):1362-9. Comment in: Anesth Analg. 1999;88(6):1200-2.
• 50. Carneiro NM. Acupuntura na prevenção e tratamento de náusea e vômitos. In: Associação Médica Brasileira, Conselho Federal de Medicina. Projeto Diretrizes. São Paulo: AMB/CFM; 2002.

Publication Dates

• Publication in this collection
  04 May 2009
• Date of issue
  Mar 2009

History

• Accepted
  15 Jan 2009
• Received
  13 Oct 2008