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Query: UMLS:C0042963 (vomiting)
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In a recent editorial, Kapur described perioperative nausea and vomiting as "the big 'little problem' following ambulatory surgery."257 Although the actual morbidity associated with nausea is relatively low in health outpatients, it should not be considered an unavoidable part of the perioperative experience. The availability of an emesis basin for every patient in the postanesthesia recovery unit is a reflection of the limited success with the available therapeutic techniques.257 There had been little change in the incidence of postoperative emesis since the introduction of halothane into clinical practice in 1956. However, newer anesthetic drugs (e.g. propofol) appear to have contributed to a recent decline in the incidence of emesis. Factors associated with an increased risk of postoperative emesis include age, gender (menses), obesity, previous history of motion sickness or postoperative vomiting, anxiety, gastroparesis, and type and duration of the surgical procedure (e.g., laparoscopy, strabismus, middle ear procedures). Anesthesiologists have little, if any, control over these surgical factors. However, they do have control over many other factors that influence postoperative emesis (e.g., preanesthetic medication, anesthetic drugs and techniques, and postoperative pain management). Although routine antiemetic prophylaxis is clearly unjustified, patients at high risk for postoperative emesis should receive special considerations with respect to the prophylactic use of antiemetic drugs. Minimally effective doses of antiemetic drugs can be administered to reduce the incidence of sedation and other deleterious side effects. Potent nonopioid analgesics (e.g., ketorolac) can be used to control pain while avoiding some of the opioid-related side effects. Gentle handling in the immediate postoperative period is also essential. If emesis does occur, aggressive intravenous hydration and pain management are important components of the therapeutic regimen, along with antiemetic drugs. If one antiemetic does not appear to be effective, another drug with a different site of action should be considered. With the availability of new antiserotonin drugs, the incidence of recurrent (intractable) emesis could be further decreased. Research into the mechanisms of this common postoperative complication may help in improving the management of emetic sequelae in the future. As suggested in a recent editorial, improvement in antiemetic therapy could have a major impact for surgical patients, particularly after ambulatory surgery. Patients as well as those involved in their postoperative care look forward to a time when the routine offering of an emesis basin after surgery becomes a historical practice.
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PMID:Postoperative nausea and vomiting. Its etiology, treatment, and prevention. 843 45

Vomiting after strabismus surgery is a major problem that remains as yet unsolved, especially in children. Droperidol and metoclopramide, both known as powerful antiemetic drugs, were compared in this study. METHODS. One hundred ASA class I and II children ranging from 3 to 10 years of age were studied in a double-blind, randomised fashion. They were assigned to three groups: group D (n = 33) received 0.075 mg/kg droperidol, group M (n = 33) 0.15 mg/kg metoclopramide, and group N (n = 34) 0.1 ml/kg NaCl i.v. upon arrival in the post-anaesthesia recovery room (PARR). After oral premedication with 0.4 mg/kg midazolam, anaesthesia was induced via a face mask by inhalation of halothane, nitrous oxide, and oxygen. Barbiturates, atropine, and succinylcholine were not used; 0.05 mg/kg vecuronium was given to facilitate intubation. Gastric contents were aspirated by a gastric tube at the end of the operation. Vomiting and retching were recorded for 24 h; recovery from anaesthesia was assessed by a modified Steward score. RESULTS. The three groups were comparable regarding age, body weight, duration of anaesthesia, number of repaired eye muscles, and occurrence of the oculocardiac reflex (OCR). During the first 24 h postoperatively 21/33 (64%) patients of group D vomited, 24/33 (73%) of group M, and 33/34 (97%) of group N. The differences between groups D and N and between M and N were significant (P less than 0.01); comparison of groups D and M showed no statistical significance. Droperidol was more effective in reducing severe vomiting. Of the group N children, 47% vomited more than 6 times in 24 h compared to 18% of group M and 0% of group D. Age, sex, duration of anaesthesia, number of repaired eye muscles, and occurrence of the OCR had no influence on postoperative vomiting. Despite being administered at the end of the operation, droperidol did not prolong the patients' stay in the PARR. The post-anaesthetic scores for group D children were only slightly lower compared to groups M and N. CONCLUSIONS. Droperidol (0.075 mg/kg) and metoclopramide (0.15 mg/kg) both reduce postoperative vomiting after strabismus surgery. Droperidol seems to be more effective in reducing severe vomiting. Postoperative sedation after droperidol was not a major problem in our experience.
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PMID:[Droperidol versus metoclopramide. Prevention of emesis following strabismus surgery in children]. 161 15

Vomiting is a common problem after strabismus surgery in pediatric outpatients. We compared the effects of propofol with and without N2O and droperidol to the effects of a conventional regimen consisting of halothane-N2O-droperidol on the recovery characteristics and the incidence of postoperative emesis after strabismus surgery in 120 ASA physical status 1 or 2 children. After induction of anesthesia with halothane-N2O, patients were randomly assigned to one of four groups. Group A (control) received halothane, 66% N2O, and droperidol 75 micrograms.kg-1; group B, propofol 2 mg.kg-1 bolus followed by infusion of 160 microgram.kg-1.min-1; group C, propofol (as in group B) and 66% N2O; and group D, propofol (as in group B), 66% N2O (as in group C), and droperidol 75 micrograms.kg-1. Patients in group B had more episodes of intraoperative oculocardiac reflex responses than patients in group A, but had shorter times to extubation, oral intake, ambulation, and discharge, as well as a lower incidence of postoperative emesis (P less than 0.05). The addition of N2O to the propofol anesthetic regimen (group C) was associated with an increased incidence of emesis (P less than 0.05), whereas the addition of droperidol to the propofol-N2O regimen (group D) did not affect the incidence of emesis compared to the other three groups. We conclude that maintenance of anesthesia with a total intravenous regimen using propofol results in a more rapid recovery and less postoperative emesis than with a halothane-N2O-droperidol regimen.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients. 185 8

A prospective, double-blind study was conducted to compare the effect of pressure at the P6 (Neikuan) point with placebo as an antiemetic in children. Sixty-six patients, ages 3-12 yr, undergoing outpatient surgery for correction of strabismus, were allocated randomly to receive either bilateral P6 acupressure or placebo during the perioperative period. The study was designed to detect a 50% difference in the incidence of postoperative vomiting between the two groups, with a 90% power of achieving a statistically significant result at the 5% level (two-tailed). The incidence of postoperative vomiting for the placebo group was 58% before discharge from hospital, 73% at home and 82% in the first 24 h after surgery. The corresponding results for the acupressure group were 58% before discharge, 71% at home and 94% in the first 24 h. These differences were not significant; P6 acupressure did not reduce the incidence of postoperative vomiting in children undergoing strabismus surgery.
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PMID:Effect of P6 acupressure on postoperative vomiting in children undergoing outpatient strabismus correction. 161 Jun 42

The incidence of emetic episodes during the first 24 h after anaesthesia was studied prospectively in 485 children aged 0-16 years in relation to age, premedication, type of induction, type and duration of anaesthesia, type of surgery and use of postoperative analgesics. The incidence of emetic episodes was 25% in the whole material. The majority of the emetic episodes were recorded after the immediate recovery period. In children under 2 years of age, vomiting was only recorded in 5%. Nausea and vomiting was most common after squint surgery (75%) and least common after endoscopies (17%). Neither premedication with diazepam nor the method of induction (thiopentone, i.v., thiopentone rectally, inhalation with halothane) influenced the incidence of nausea. For the same type of surgery, maintenance of anaesthesia with halothane resulted in a lower incidence of nausea than anaesthesia with fentanyl-pancuronium.
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PMID:Postanaesthetic nausea in children. 197 65

The purpose of this study was to determine whether serum gastrin levels are increased by reflexogenic stimuli applied to the extrinsic muscles of the eye. Serum gastrin and blood glucose concentrations were measured in ten normal children aged between 5 and 12 yr during general anaesthesia with halothane and nitrous oxide and during strabismus surgery. Fasting basal concentrations of gastrin (33.6 +/- 14.8 pg.ml-1) and of glucose (4.43 +/- 0.72 mmol.L-1) were in the normal range of values for children. Intravenous atropine (0.01 mg.kg-1), general anaesthesia with halothane in nitrous oxide and oxygen by mask for three minutes, tracheal intubation, extraocular muscle stimulation and surgical stress did not cause any variation in the mean serum gastrin concentration. On the contrary, tracheal intubation and surgical stress increased blood glucose concentrations (P less than 0.05). There was no difference in the serum gastrin levels after extraocular muscle stimulation between children with positive or negative oculocardiac reflexes (44.5 +/- 16.7 pg.ml-1 vs 38 +/- 14.7 pg.ml-1, respectively). The incidence of vomiting predischarge was 60 per cent. Serum gastrin levels did not differ between children who vomited and children who did not (44.3 +/- 18.5 pg.ml-1 vs 47.1 +/- 16.9 pg.ml-1, respectively). Vomiting after strabismus surgery cannot be attributed to high gastrin serum levels. Consequently, it is unlikely that vomiting after strabismus surgery is linked to an "oculogastric reflex" with the vagus nerve as the efferent pathway.
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PMID:Serum gastrin and blood glucose levels during halothane-nitrous oxide anaesthesia and strabismus surgery in children. 198 38

This randomized, double-blind study evaluated the antiemetic efficacy and the side-effects of promethazine pretreatment (0.5 mg.kg-1 IV + 0.5 mg.kg-1 IM) versus droperidol + placebo pretreatment (droperidol, 0.075 mg.kg-1 IV + physiological saline, 0.02 ml.kg-1 IM). One hundred unpremedicated ASA physical status I children ranging from two to ten years, and undergoing outpatient strabismus surgery were studied. All children received inhalational anaesthesia with halothane, nitrous oxide and oxygen. Neither opioids nor muscle relaxants were used. The incidence of vomiting and/or retching and the incidence of side-effects were determined in the post-anaesthesia recovery room (PARR), in the short-stay surgical unit (SSSU), and after discharge from the hospital (including the journey and the stay at home during the first postoperative day). Promethazine and droperidol were equally effective in reducing the incidence of vomiting before discharge to two and eight per cent respectively. On the contrary, the incidence of vomiting after discharge and overall were significantly less with promethazine (ten and ten per cent) than with droperidol pretreatment (54 and 56 per cent) (P less than 0.0001). Promethazine permitted the time to discharge from the hospital to be reduced to an average of three hours, without increasing the incidence of vomiting postdischarge. Promethazine pretreatment is much less expensive than droperidol pretreatment. The incidence of restlessness was significantly less with droperidol (eight per cent) than with promethazine (36 per cent) (P less than 0.001). Promethazine pretreatment demands the use of an analgesic like acetaminophen in order to reduce the incidence of postoperative pain and restlessness.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Antiemetic prophylaxis with promethazine or droperidol in paediatric outpatient strabismus surgery. 198 40

Children recovering from anaesthesia for strabismus surgery are particularly prone to nausea and vomiting as a result of intraoperative vagus irritation. Besides being disturbing to the patient, vomiting can be dangerous during emergence from anesthesia and can result in delayed discharge. Droperidol is a powerful antiemetic drug that has been shown to reduce the incidence and severity of postoperative nausea and vomiting in pediatric strabismus patients, although the best timing for administration is not clear. MATERIAL AND METHODS. We compared three randomized groups totalling 61 patients. Droperidol 0.075 mg/kg i.v. was given either at induction of anesthesia after intubation (n = 20) or during the last muscle suture (n = 21). The third group received no antiemetic treatment. The patients' ages ranged from 3 to 14 years (mean 5.9 +/- 2.84 years). There was no difference in age or sex between the three groups. Anesthesia was standardized with rectal midazolam premedication, atropine, thiopental, succinylcholine, O2/N2O = 1:2, enflurane, intubation, and a gastric tube. RESULTS. Nausea, retching, or vomiting occurred in 2/20 children (10%) given droperidol preoperatively, 4/21 children (19%) with droperidol during the operation, and 9/20 children (45%) with no antiemetic treatment. The difference between groups I and III was significant (p less than 0.05). Comparison of groups II and III and groups I and II showed no statistical significance. Operation time was similar in each group and there was no delay in time of extubation. In each group 1 case of hypotension occurred. No child showed extrapyramidal symptoms. The lower incidence of vomiting in all study groups compared to the literature is thought to be due to three factors: (1) emptying the stomach at the end of the operation by a gastric tube, which is removed before extubation; (2) avoidance of opioids; (3) surgical procedure being done by a very experienced surgeon in 57/61 children (12 vomiting versus 45 not vomiting) in contrast to 3/4 children vomiting postoperatively after surgery by a less experienced surgeon. CONCLUSIONS. We recommend preoperative droperidol 75 micrograms/kg i.v. as the best prophylaxis of postoperative emesis without severe side effects in pediatric strabismus surgery.
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PMID:[The prevention of postoperative vomiting following strabismus surgery in children]. 204 9

Scopolamine patch was evaluated for the prevention of postoperative emesis in 50 children undergoing strabismus surgery. All subjects were premedicated, with none receiving narcotic premedicants. Anaesthesia included controlled ventilation with the use of muscle relaxants, atropine, and halothane. Before operation, the subjects were randomly assigned to one of two groups: a treatment group received a scopolamine patch at a dose of either 0.75 mg or 0.375 mg, and a control group received no patch. Both the incidence and frequency of vomiting in the scopolamine-treated group were significantly (P less than 0.05) lower than in the control group.
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PMID:Scopolamine patch reduces postoperative emesis in paediatric patients following strabismus surgery. 206 10

Although chloral hydrate sedation has been proposed as an alternative to evaluation under anesthesia for pediatric patients who are unable to cooperate with routine test procedures, a careful study of the drug's safety and effectiveness is lacking. This study reports the effectiveness and safety of high-dose chloral hydrate for ophthalmic examination in 302 patients between the ages of 1 month and 5 years. The patients had nothing to eat or drink for 4 hours prior to drug administration. The patients were monitored during sedation and until fully awake. Eighty-eight percent of the patients (266/302) were successfully sedated without a supplemental dose. There were no reports of any complications including emesis, respiratory distress or depression, behavioral problems, changes in vital signs, patient injury, or hospital admission. The high-dose chloral hydrate protocol described, results in safe and generally successful sedation of pediatric patients for ophthalmic examination.
J Pediatr Ophthalmol Strabismus
PMID:Use of high dose chloral hydrate for ophthalmic exams in children: a retrospective review of 302 cases. 224 36


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