|Year : 2021 | Volume
| Issue : 11 | Page : 1633-1640
Prevalence study for postoperative nausea vomiting: A training hospital example
E Canakci, T Catak, HE Basar, Z Cebeci, I Coskun, AO Saltali, A Altinbas
Department of Anesthesiology and Reanimation, Ordu University School of Medicine, Ordu, Turkey
|Date of Submission||29-Jun-2020|
|Date of Acceptance||22-Mar-2021|
|Date of Web Publication||15-Nov-2021|
Dr. E Canakci
Department of Anesthesiology, Ordu University, School of Medicine, Training and Research Hospital and Reanimation, Bucak Town, Nefs-i Bucak Street, Ordu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Simplified risk models, such as the Apfel score, have been developed to calculate the risk of postoperative nausea-vomiting (PONV) for adult patients. In the absence of any risk factors, PONV risk is assumed to be 10%. While the presence of one of the four risk factors determined as female gender, non-smoking, PONV/car sickness history, and postoperative opioid use is associated with 20% risk for PONV, the risk increases by 20% with the addition of each risk factor, and reaches to 80% if four factors are present. Aim: Our aim in this study is to investigate the prevalence of PONV, and whether the scoring systems used for nausea-vomiting in the literature are still valid. Patients and Methods: Five groups of patients were included in the study with an Apfel score of 0, 1, 2, 3, 4. Each case was taken to the recovery room at the end of the operation. They were observed whether had nausea-vomiting was recorded according to the Abramowitz emesis score. Results: While the PONV risk for women is 24.637 times higher than men, the PONV risk of those who had gynecological surgery is 6.27 times higher than that of the other type of surgery. Those who had urological surgery are 0.345 times less than the other type of surgery. Those who had lower abdominal surgery had a risk of PONV of 4.56 times higher than the others. As the duration of the case increases, the risk of PONV increases 1.01 times (P values P < 0.001, P < 0.001, P < 0.001, P = 0.048, P < 0.001, respectively). Conclusion: As a result, our PONV prevalence is considerably lower than the frequency rates mentioned in the literature. PONV scoring systems need long-term studies with larger populations to be updated.
Keywords: Emesis score, postoperative nausea and vomiting, prevalence
|How to cite this article:|
Canakci E, Catak T, Basar H E, Cebeci Z, Coskun I, Saltali A O, Altinbas A. Prevalence study for postoperative nausea vomiting: A training hospital example. Niger J Clin Pract 2021;24:1633-40
|How to cite this URL:|
Canakci E, Catak T, Basar H E, Cebeci Z, Coskun I, Saltali A O, Altinbas A. Prevalence study for postoperative nausea vomiting: A training hospital example. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 28];24:1633-40. Available from: https://www.njcponline.com/text.asp?2021/24/11/1633/330462
| Introduction|| |
Postoperative nausea and vomiting (PONV) is one of the common complications associated with general anesthesia, which can be seen in some of the high-risk patients, even with a frequency of about 80%.
PONV is defined as a feeling of gagging or nausea-vomiting within the first 24 hours postoperatively.,,,
The prevalence of nausea and vomiting varies depending on the type of surgery performed. Its incidence is reported to be under general anesthesia and with an incidence between 30 and 80% generally.,,, Nausea and vomiting are among the major problems commonly seen in the postoperative period, and this reduces patient satisfaction. Certain medications given intravenously before extubation can eliminate the nausea-vomiting problem.
PONV, aspiration pneumonia, dehydration, electrolyte imbalance and patient dissatisfaction may result in a long stay in the hospital, late discharge and long-term nursing care. Therefore, it is important to prevent PONV. Prevention of PONV is not only for improving patient safety, but also to reduce medical costs. Several pharmacological agents such as serotonin 5-HT3 receptor antagonists, dexamethasone or droperidol administration are included in the PONV prophylactic strategy.
However, these approaches bring potential side effects and extra costs. For example, serotonin 5-HT3 receptor antagonists reduce the incidence of PONV,, but increase the incidence of arrhythmia, as well as complications such as headache or dizziness.,, In addition, serotonin 5-HT3 receptor antagonists are relatively expensive, thus, increasing the treatment costs of the patient.
Simplified risk models, such as the Apfel score, have been developed to calculate the risk of PONV for adult patients. In the absence of any risk factors, PONV risk is assumed to be 10%. While the presence of one of the four risk factors determined as female gender, non-smoking, PONV/car sickness history and postoperative opioid use is associated with 20% risk for PONV, the risk increases by 20% with the addition of each risk factor, and reaches 80% if four factors are present.
In our hospital, we observed that the number of patients developing nausea and vomiting postoperatively was very low. The purpose of this study is to investigate the prevalence of postoperative nausea-vomiting and validity of the scoring systems used for nausea-vomiting in the literature.
| Material and Method|| |
Ethical approval for our study was obtained from Ordu University Clinical Research Ethics Committee (Date 30.01.2020, Decision no: 2020/12). Patients between 18 and 65 years of age who received general anesthesia in the operating rooms of Ordu University Training and Research Hospital between 01.01.2020 and 30.04.2020 were included in the study. The exclusion criteria were pre-medication and prophylactic antiemetic, anesthesia methods other than general anesthesia was given, patients who had total intravenous anesthesia (TIVA), and patients with malignancies receiving chemotherapy.
In order to estimate the prevalence of 40% with the accuracy of 5 and 95% confidence level required for our study, it was determined that 319 patients should be studied.
The formula used in sample calculation for prevalence is as follows:
Here, the Z value is taken as a fixed table value of 1.96. P value is the prevalence value and is taken differently for each class. D value expresses the precision value and is taken as 0.05 in the study. We included 321 cases in our study.
Patients who came to the operating room were monitored by routine monitoring methods. All the cases were fitted with ECG palettes, non-invasive blood pressure cuff and saturation probe. Age, weight, height, gender, ASA risk class, duration of surgery and type of surgery to be performed were recorded for each case. The type of surgeries were grouped as gynecological surgery, urological surgery, lower abdominal surgery, upper abdominal surgery, laparoscopic surgery, otolaryngology (ENT) surgery and orthopedic surgery.
Following the standard monitoring procedures, vascular access was opened with 20G intracath from the right or left back of the hand of the patients according to the localization of the surgery. Their weights and the perioperative fluid to be given during the operation were calculated. Fluid replacement was started with 0.9% NaCl. Patients were preoxygenated for 5 min. No patient was premedicated, no prophylactic antiemetic or dexamethasone or steroid medicines like methylprednisolone were applied to the patients. The same anesthesia induction protocol was applied for each case. For induction, 2% lidocaine was used at a dose of 40 mg, 2 mg/kg propofol, and 0.6 mg/kg rocuronium bromide was used. A 2% concentration of sevoflurane and 45% oxygen and 55% fresh air was used for the maintenance of anesthesia. Nitrogen protoxide was not used. Instead, 0.25 mcg/kg/min remifentanil infusion was used for surgical analgesia.
Demographic characteristics (age, weight, height, gender), ASA risk class and Apfel score were recorded for each case. Apfel score is presented in [Table 1].,,, Again, the duration and type of surgery (gynecological/urological, lower/upper abdominal, laparoscopic, orthopedic, ENT and other) were recorded for each case.
|Table 1: Postoperative nausea and vomiting risk scoring system in adults (Apfel score)|
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Meperidine was administered 20 min prior to the end of the surgery at a dose of 1 mg/kg for patients who used opioids for postoperative analgesia. In cases where opioid was not used for postoperative analgesia, 15 mg/kg intravenous (IV) was given as paracetamol intravenous form 20 min before the end of the operation.
Five groups with the Apfel score of 0, 1, 2, 3, 4 were included in the study.
Each patient was taken to the recovery room (PACU: Post Anesthesia Care Unit) at the end of the operation. They were observed for 30 min and whether there was nausea and vomiting was recorded according to the Abramowitz Emesis score. In the PACU, the Abramowitz Emesis scores were recorded as 1 min, 5 min, 15 min and 30 min. The Abramowitz Emesis Scoring system is presented in [Table 2].
The data were analyzed using IBM SPSS program v23. Normal distribution was analyzed with Kolmogorov Smirnov and Shapiro-Wilk tests. A Chi-square test was completed for the comparison of categorical data by groups. In the comparison of scores by binary groups, an independent two-sample t-test was used for normally distributed data, and a Mann-Whitney U test was used for data that did not distribute normally. A one-way analysis of variance (ANOVA) was used for the normally distributed data and a Kruskal Wallis test was used for the non-normally distributed data in comparing the scores according to groups of three and above. A Friedman test was used for the data that did not distribute normally in comparing the scores according to three or more times. According to the Apfel score, a Binary Logistic Regression analysis was used to analyze the risk factors affecting PONV risk, and a logistic regression analysis was performed with the univariate and multivariate model. Spearman's Rho correlation coefficient was used to examine the relationships between normally distributed data. The result of the analysis was presented as mean ± standard deviation and median (minimum-maximum) for the quantitative data, and was presented as frequency (percentage) for categorical data. The level of significance was considered as P < 0.050.
| Results|| |
Between 01.01.2020 and 30.04.2020, 321 cases who underwent general anesthesia in the main building and annex operating rooms of Ordu University were included in the study.
According to Apfel scores, there is a statistically significant difference between the distribution of ASA risk scores (P = 0.010). Of those with an Apfel score of 0, 83.3% were ASA 2, 11.1% were ASA 3, 5.6% were ASA 1. Of those with an Apfel score of 1, 50% are ASA 2, 4.2% are ASA 3, 45.8% are ASA 1. Of those with an Apfel score of 2, 70.7% are ASA 2, 6.1% are ASA 3, 23.2% are ASA 1. Of those with an Apfel score of 3, 61.8% are ASA 2, 9.6% are ASA 3, 26.9% are ASA 1. Of those with an Apfel score of 4, 61.8% were ASA 2, 8.1% were ASA 3, 11.8% were ASA 1. As the ASA score increases, we can say that the Apfel score increases, or vice versa, in patients with high Apfel score,, patients with high ASA score (ASA 3) also increased slightly.
There is a statistically significant difference between gender distributions according to Apfel scores (P < 0.001). Hundred percent of those with an Apfel score of 0 are males, 83.3% of those with an Apfel score of 1 are males, 71.7% of those with an Apfel score of 2 are females, 93.3% of those with Apfel score of 3 are females and 100% of those with an Apfel score of 4 are females.
According to the Apfel scores, there is a statistically significant difference between the distributions of the surgical type (P < 0.001). About 41.7% of those with an Apfel score of 0 had urological surgery, 35.4% of those with an Apfel score of 1 had other operations, 31.3% of those with an Apfel score of 2 had other surgeries, 33.7% of those with an Apfel score of 3 had gynecological surgeries and 26.5% of those with operation and Apfel score of 4 had gynecological surgeries.
Comparison of age, weight, height and case duration according to Apfel score is presented in [Table 3].
There is a statistically significant difference between the means of height according to Apfel scores (P < 0.001). The mean height of those with an Apfel score of 0 was 171.67 cm, the mean height of those with an Apfel score of 1 was 172.46 cm, the mean height of those with an Apfel score of 2 was 162.27 cm, the mean height of those with an Apfel score of 3 was 160.42 and the mean height of those with an Apfel score of 4 was 162.09 cm. This difference is due to the mean height of those with an Apfel score of 0 and 1 being higher than the average of other Apfel scores. According to Apfel scores, there is no statistically significant difference between the distributions of other parameters (P > 0.050).
There is a statistically significant difference between the means of the Apfel score by gender (P < 0.001). The mean score of women was 2.75 and the average score of men was 1.05. The mean Apfel score of women was higher than the men. There is no statistically significant difference between the gender groups and the distribution of Abramowitz scores within the groups (P > 0.050).
Correlation analysis results for the Abramowitz scores are presented in [Table 4].
There is a statistically significant positive and very weak relationship between age and Abramowitz Emesis 5 min score (P = 0.017; r = 0.133). Abramowitz Emesis score increases moderately as age increases. There is a statistically significant positive and weak relationship between age and Abramowitz Emesis 15 min score (P = 0.001; r = 0.180). Abramowitz Emesis score increases moderately as age increases. This confirms our hypothesis for the second time. There is a negative and weak relationship between weight and Abramowitz 30 min score (P = 0.001 r = -0.178). Abramowitz Emesis score decreases with increasing weight. There is a negative correlation between weight and nausea. There is a statistically significant negative and very weak relationship between height and Abramowitz 15 min score (P = 0.036 r = - 0.117). Abramowitz Emesis score decreases with increasing height. We can say that there is a negative correlation between height and nausea. There is a statistically significant positive and very weak relationship between ASA and Abramowitz 5 min score (P = 0.009; r = 0.146). We can say that as the ASA increases, the Emesis score increases There is a statistically significant positive and weak relationship between ASA and Abromowitz 15 min score (P = 0.009; r = 0.146). We can say that as the ASA increases, the Emesis score increases. This confirms our hypothesis for the second time. There is a statistically significant positive and weak relationship between case duration and Abromowitz 30 min score (P = 0.035; r = 0.118). As the surgical time increases, the Emesis score increases. There is a statistically significant positive weak relationship between Apfel score and Abramowitz 1 min score (P = 0.005; r = 0.158). We can say that as the Apfel score increases, the Emesis score increases.
Frequency distribution of gender, ASA, surgery type, Apfel and Abramowitz scores are presented in [Table 5].
|Table 5: Frequency distribution of Gender, ASA, Surgical type, Apfel and Abromowitz scores|
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About 65.34% of the patients were female, 65.7% of them had an ASA risk score of 2, 18.7% of them had gynecological surgery, 32.4% of them had an Apfel score of 3, 95% of them had an Abramowitz score of 0 for 1 min, 5 min, 15 min and 96.6% had a score of 0 for the 30th min.
The analysis of risk factors affecting PONV risk according to Apfel score with Binary Logistic Regression analysis is presented in [Table 6].
|Table 6: Analysis of risk factors affecting PONV risk according to Apfel score with Binary Logistic Regression analysis|
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Independent risk factors affecting PONV were investigated by logistic regression. Logistic regression analysis was performed as univariate and multivariate models. According to the univariate model, height, gender and type of surgery were obtained as independent risk factors on PONV risk. As height increases, the risk of PONV decreases by 0.91 times. While the PONV risk for women is 24.637 times higher than men, the PONV risk of those who had gynecological surgery is 6.27 times higher than that of the other types of surgery. Those who had urological surgery are 0.345 times less than the other type of surgery. Those who had lower abdominal surgery had a risk of PONV of 4.56 times higher than the other types of surgery. According to the results of multivariate analysis, women have 40.347 times higher risk of PONV compared to men, while those who had lower abdominal surgery had 4.853 times higher risk than the other types of surgery. As the duration of the case increases, the risk of PONV increases 1.01 times.
| Discussion|| |
The prevalence of PONV in this study does not exceed 5%. Even in the groups with high risk of PONV, a maximum incidence of 5%. Considering the frequency of PONV stated in the literature, our PONV prevalence was found to be quite low. As age increased, the incidence of PONV increased minimally, and as ASA risk class increased, incidence of PONV increased minimally. The PONV frequency increased minimally with the increase in case duration. The PONV frequency in women was higher than in men. The PONV frequency showed minimal increase in gynecological and lower abdomen surgery. As the height increased, the frequency of PONV decreased. Even in those with high Apfel scores, Abromowitz scores were found to be low as their height increased. As the height increases, the frequency of PONV decreases. A second contribution to the literature is the determination of the relationship between the frequency of PONV and height. As the height increases, the frequency of PONV decreases. We identified this both in correlation analysis and the univariate logistic regression analysis. In summary, the validity of Apfel scores should be re-evaluated and the height factor should also be added because the PONV prevalence does not increase linearly as the Apfel score increases.
In the study of Eklund I. et al., the relationship between PONV prevalence and pain in elective knee arthroplasties was evaluated. They stated that the frequency of PONV was higher in females, and that it was not related to age and postoperative pain. This study did not investigate the frequency of postoperative pain and the frequency of PONV. However, we found that it was more in females and there was no relationship between PONV and age. Our results are partially in line with the results of Eklund I. et al.
In a 10-year retrospective study by Ghosh S. et al., patients who underwent orthognathic surgery were included in the study. They found that 59.4% of the patients who underwent orthognathic surgery suffered from PONV unlike this study where PONV was very low. In a study by Taniguchi H. et al., 84 patients who had laparoscopic gynecological surgery were studied; 34 of the cases were given tramadol for postoperative analgesia, and 50 cases were given IV paracetamol, as in our study. Those with an Apfel score of 0-2 were considered as PONV low risk, and 3-4 were considered high risk. In the paracetamol group, there was reduced incidence of the PONV whereas in the tramadol group they found that the PONV incidence was high, although the Apfel scores were low. The authors claimed that IV paracetamol may decrease the frequency of PONV. In this study, our PONV prevalence did not exceed 5% regardless of the Apfel score both in the opioid and IV paracetamol groups. Taniguchi H. et al. encountered PONV with a frequency of over 50% in the opioid-treated group. In our study, although the frequency of PONV increased minimally in laparoscopic gynecological surgeries, it was still much lower than the ones mentioned in the literature. No prophylactic antiemetic or steroid was administered in our study. The difference between the literature and our study in terms of incidence may be due to the fact that we used remifentanil infusion for maintaining anesthesia. In our study, the same induction agents were used in all cases and remifentanil infusion was given at the same time. Thus, homogenization of the cases was maintained.
Kim GH. et al., in their study of 99 women who underwent elective endoscopic thyroidectomy, investigated the effects of propofol-remifentanil with TIVA and sevoflurane anesthesia on PONV. In the group where TIVA was applied at intervals of 0-2 h, 2-6 h, the rate of PONV was found to be significantly lower compared to the sevoflurane group, and there was no significant difference between the two groups in the 6-24-h interval In the postoperative early period (postoperative first 6 h), comparing both groups, nausea and vomiting were significantly less in the TIVA group. However, in the next 6-24-h period, there was no significant difference in terms of nausea and vomiting scores between the group undergoing TIVA and the group receiving inhalation anesthesia. The authors advocated the superiority of TIVA in terms of PONV. In our study, TIVA was not performed but inhalation anesthesia was used. However, remifentanil was used for intraoperative analgesia. We think that using remifentanil has an important contribution to our PONV prevalence being very low.
In the study conducted by Yoo C. et al. on 62 patients who had laparoscopic radical prostatectomy, the effects of Desfluran and TIVA on PONV were compared. As a result of the study in which both groups were applied Ramosetron as a 5-HT3 antagonist at the end of surgery, the rate of PONV was found to be significantly lower in the group administered TIVA-Ramosetron in the first postoperative 6 h, and there was no significant difference between 6 and 48 h.
Ionescu D., Prathep S et al., in their study with patients who underwent laparoscopic cholecystectomy, compared Propofol-TIVA and Isofluran anesthesia in terms of PONV and found that the incidence of PONV was significantly lower in the group treated with TIVA., In our study, TIVA was not performed, instead, the combination of sevoflurane-remifentanil was used. Our results align perfectly with the studies of Kim, Yoo, Ionescu, Prathep et al. We can say that remifentanil infusion significantly reduces the frequency of PONV.
There are limitations of our study. First, the study investigated the frequency of PONV in all types of operations, not in a specific surgical group. Second, the PONV observation was limited only to the recovery unit, and only early-period PONV frequency was observed. Late-period PONV was not observed. Nitrogen protoxide use was eliminated from general anesthesia practice completely. The third limitation was not to use nitroproxide. However, we believe that this should not be considered as a limitation.
As a result, our PONV prevalence is considerably lower than the frequency rates mentioned in the literature. Since nitrogen protoxide can increase the frequency of PONV in general anesthesia in operating rooms, it should not be used and instead remifentanil infusion should be used. The Apfel scoring system should be reconsidered. As the Apfel score increases, the PONV incidence does not increase in direct proportion. As the height increases, the frequency of PONV decreases. PONV scoring systems need long-term studies with larger populations to be updated. We believe that our study will shed light on future research conducted with large populations.
Ethics Committee Approval
Clinical Studies Ethics Committee of Ordu University, Faculty of Medicine, (Date 30.01.2020 Decision no: 2020/12).
Written informed consent was obtained from patients who participated in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]