International Journal of Surgery 15 (2015) 100e106
Contents lists available at ScienceDirect
International Journal of Surgery
journal homepage: www.journal-surgery.net
Review
Post-operative nausea and vomiting: Update on predicting the
probability and ways to minimize its occurrence, with focus on
ambulatory surgery
a, *
€
Emma Obrink
, Pether Jildenstål b, Eva Oddby a, Jan G. Jakobsson a
a
b
Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds Hospital, Stockholm, Sweden
€
Department of Anaesthesiology and Intensive Care, University Hospital of Orebro,
Sweden
h i g h l i g h t s
Postoperative nausea and vomiting (PONV) is still not uncommon after surgery and anaesthesia.
It is still not possible to guarantee that an individual patient will not experience PONV.
There are several factors contributing to the occurrence of PONV.
There is a need for proper risk assessment.
There is a need for further studies how to identify patients at risk.
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 15 November 2014
Received in revised form
6 January 2015
Accepted 26 January 2015
Available online 29 January 2015
Postoperative nausea and vomiting “the little big problem” after surgery/anaesthesia is still a common
side-effect compromising quality of care, delaying discharge and resumption of activities of daily living. A
huge number of studies have been conducted in order to identify risk factors, preventive and therapeutic
strategies. The Apfel risk score and a risk based multi-modal PONV prophylaxis is advocated by evidence
based guidelines as standards of care but is not always followed. Tailored anaesthesia and pain management avoiding too liberal dosing of anaesthetics and opioid analgesics is also essential in order to
reduce risk. Thus multi-modal opioid sparing analgesia and a risk based PONV prophylaxis should be
provided in order to minimise the occurrence. There is however still no way to guarantee an individual
patient that he or she should not experience any PONV. Further studies are needed trying to identify risk
factors and ways to tailor the individual patient prevention/therapy are warranted.
The present paper provides a review around prediction, factors influencing the occurrence and the
management of PONV with a focus on the ambulatory surgical patient.
© 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
Keywords:
Postoperative nausea and vomiting PONV
Ambulatory
Anaesthesia
Surgery
Prediction
Prophylaxis
1. Introduction
Postoperative nausea and vomiting (PONV) is one of most
frequent side effect after anaesthesia [1], occurring in 30% of unselected in patients and up to 70% of “high-risk” in patients during
the 24 h after emergence [2]. Its incidence following ambulatory
surgery is not uncommonly reported as lower than in inpatient
surgery, but PONV may be under-recognized in the outpatient
setting, where patients quickly leave direct medical oversight [3].
* Corresponding author. Department of Anaesthesia & Intensive Care, Dandryds
Hospital, 182 88 Danderyd, Sweden.
€
E-mail address: Emma.obrink@ds.se (E. Obrink).
http://dx.doi.org/10.1016/j.ijsu.2015.01.024
1743-9191/© 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
For the ambulatory patients Post Discharge Nausea and Vomiting
[4] (PDNV) must also be acknowledged. Even though predischarge
PONV predicts PDNV some patient do not experience emetic
sequelae until after discharge. Nausea and vomiting may start and
persist up to days after anaesthesia and thus strategies providing
long-lasting protections should be sought (Figs. 1 and 2).
The present paper aim at providing an overview around PONV
with a focus on prediction and factors that influence the risk for and
severity of PONV in the patient scheduled for ambulatory surgery
and anaesthesia.
Postoperative nausea and vomiting (PONV) is not only common
but is one of most distracting side effects after surgery/anaesthesia
[5]. Avoiding pain and PONV is highly prioritized [6]. PONV has
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et al. / International Journal of Surgery 15 (2015) 100e106
101
not be the same and thus complicating analysis of different study
results and comparing papers conclusion. Also clinical implication
should be acknowledged; a short episode of mild nausea should
possibly be weighed less than intense long-lasting/repeated episodes of vomiting. One episode of retching is likewise probably less
distressing than hours of nausea.
Vomiting may be objectively assessed during the hospital stay,
while nausea and retching are subjective experience, assessed by
questioning or recording of complaints. Relaying on personnel
observation only may underestimate the true incidence [12]. The
questioning may be conducted at several occasions or merely once,
obtaining possibly somewhat different responses. Apfel et al. [13]
provided a comprehensive review around methodology for
studies on PONV in 2002.
It seems obvious that method for assessing postoperative
emesis and the observation period is of huge importance. One may
argue that free of PONV is the ultimate outcome and any signs or
symptom is a merely to be seen as a failure.
Fig. 1. Major factors with impact on the risk for PONV.
Fig. 2. The PONV prophylaxis/prevention escalating pyramid.
major impact on quality of care [7] but it has also impact on patients
transfer along the ambulatory pathway; delaying discharge [8] and
may cause unanticipated admission [9,10]. PONV may also on rare
occasions lead to dehydration; hypovolemia compromising safety.
Numerous studies have been conducted aiming at increasing the
understanding of the ethiology, trying to identify risk factors; patient related risks, surgery associated to high risk and anaesthesia/
analgesia related factors. There are also huge numbers of studies
evaluating different preventive and therapeutic strategies. All of
these are aiming at reducing the occurrence, severity and duration
of emetic symptoms throughout the perioperative period [11].
PONV is usually “self-limiting” but may last for up to 2e3 days and
thus interfere with resumption of activities of daily living [4].
1.1. Method for assessment, how PONV should be followed and
presented
Postoperative nausea and vomiting - PONV - include a variety of
symptoms; all from mild nausea up to severe repeated vomiting.
When assessing studies around PONV study design and way of
defining and recording the “outcome” is of importance. PONV may
1.2. Patient factors, likelihood of becoming nauseated
The exact pathophysiology for emesis is not well understood.
Vomiting e getting rid of potentially dangerous intake e is a
defence mechanism. The emetic centre is most certainly scanning,
reacting on, possibly irritating, dangerous triggers starting the
emetic event [14]. There are a number of endogenous triggering
substances. Multiple receptors in the chemo-trigger zone are
involved and multiple substances have anti-emetic potentials
[15,16] e.g. acetylcholine, dopamine, and serotonin. The exact
triggering sequence for the individual patient is however not
known. From populations studies we know that female, nonesmoking and younger age are known patient factors.
Prediction of the risk for PONV has been suggested since long
[17]. The best scoring system has been argued. The Apfel score; age
<50 years of age, female, non-smoking, and history of PONV, has
become highly accepted [18]. The Sinclair score include also length
and type of surgery [19]. The risk factors for post discharge nausea
and vomiting (PDNV) also been assessed by Apfel group. These
include female gender, age less than 50 yr, history of nausea and/or
vomiting after previous anaesthesia, opioid administration in the
post-anaesthesia care unit and nausea in the post-anaesthesia care
unit [20]. Female gender is associated to more PONV than men also
among elderly patients [21]. Both the Apfel and Sinclair scores are
not only feasible but most adequate tools for preoperative prediction and it may be worth doing a pre-discharge assessment
providing patients information/advise and possibly rescue antiemetics if having a high risk score for PDNV.
Emesis may from an evolutional perspective be seen as a protective measure, getting rid of inappropriate intakes. There are
without doubt several patient factors having huge impact on risk
that should be assessed and current risks scores should be implemented and adhered to.
1.3. Trigger factors, anaesthesia
The impact of the composition of the fresh gas flow the FiO2 and
whether nitrous oxide is mixed or not has been debated since long.
Oxygen, high oxygen fraction, perioperative use of FiO2 0.8, has
been studied in several studies. The meta-analysis from 2008 could
not find clear evidence for any PONV preventive effect of a high
FiO2 during surgery [22]. A more recent meta-analysis by Hovaguimian et al. published in 2013 concluded that an intra-operative
high FIO2 decreases the risk of surgical site infections (SSI) in surgical patients receiving prophylactic antibiotics, has a weak beneficial effect on nausea, and does not increase the risk of
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postoperative atelectasis [23]. It seems reasonable to conclude that
we cannot explicitly state whether high oxygen fraction has an
anti-emetic or merely a zero effect; not worsening the risk for
PONV. The oxygen studies eliminate the potential impact of nitrous
oxide. Nitrous oxide has a weak emetic potential, but whether it use
as part of the fresh gas flow and thus reducing the need for more
potent anaesthetics have any clinical relevant impact on the risk for
PONV is less obvious. The ENIGMA-I trial showed “as expected
according to Apfel risk score that age <55 yr, female sex were
predictors but also that abdominal surgery, nitrous oxide administration, absence of BIS monitoring, and longer duration of
anaesthesia were predictors of severe PONV [24]. The duration of
nitrous oxide exposure seems to have an impact, less than 1 h use
as part of the fresh gas has not been shown to increase the risk [25].
It may be similar to the other inhaled anaesthetics a matter of
duration and concentration, thus nitrous oxide may be an option
for the shorter ambulatory procedures [26].
There is also still sparse data showing clear evidence for any
therapeutic effect from oxygen therapy in patients experiencing
PONV, it is still not uncommonly part of the general manoeuvres
made in patients retching or vomiting in the recovery area.
Whether oxygen has any explicit effect on established PONV or is
merely a part of a tradition and general care needs further studies.
The major multi-factorial study by Apfel et al. showed that there
is, regardless of anaesthetic technique and multi-modal triple
prophylaxis, a residual group experiencing PONV [27]. It seems fair
to state that inhaled anaesthetics have an emetic potential. In
contrast to propofol that has been suggested to have a small but
anti-emetic effect as long there is a low blood level. The debate
around choice of anaesthetic for ambulatory surgery is continuing.
Kumar et al. [28] published in 2014 October issue of Anaesthesia a
meta-analysis concluding that based on the published evidence to
date, maintenance of anaesthesia using propofol appeared to have
no major impact on the incidence of unplanned admission to
hospital. Propofol base anaesthesia was found to be associated with
a decreased incidence of early postoperative nausea and vomiting
compared with sevoflurane or desflurane in patients undergoing
ambulatory surgery but the impact on discharge seems minor. It
seems also as the effects are short-lasting, follow-up after ambulatory surgery at 24-h show commonly no difference [29e31]. Voigt
et al. [32] found dual preventive anti-emetic therapy to provide
similar and even numerically better PONV prevention when given
prior to inhaled anaesthesia as compared to TIVA in females undergoing breast surgery. The choice of main anaesthetic inhaled or
intravenous, propofol, seems further not to have major impact on
oral intake day 1e2 after anaesthesia [33]. Avoiding early PONV is
of value but propofol based anaesthesia is not sufficient to eliminate the occurrence on PONV.
A more precise titration of depth of anaesthesia could have
protective effects reducing the risk for PONV. The ENIGMA I study
suggested that BIS monitoring had a significant impact reducing the
incidence [34,35]. Whether this is a direct effect by reducing the
amount of anaesthetic, decreasing the area under the curve delivered amount anaesthetic/analgesic or an indirect effect, lesser
swings in circulation, stress, hypo/hypertension etc cannot from
available information.
The above data on fresh gas composition, anaesthetic technique,
technique to titrate, and dose main anaesthetic is compiled from
both in-patient and ambulatory surgery. The potential pharmacological impact is reasonably applicable for out as well as in-patient
care. The duration, “area under the curve”, amount of exposure is of
importance. Both the Sincalair score and the studies with depth-ofanaesthesia monitoring support this assumption.
Anaesthetic technique has an impact both drugs used and how
they are administered, how depth of anaesthesia is titrated.
Propofol exhibit no emetic potential, inhaled anaesthetics, the
potent halogenated as well as nitrous oxide has emetic effects, and
all opioid substances do carry risk for nausea and vomiting. Minimising the dose and duration, fin-tuning administration is of value.
1.4. The airway, ventilation and gastric emptying
There is sparse data around the independent effects of the
airway; Larygeal mask airway vs. tube [36,37]. It seems more
important to secure safety appropriate ventilation and avoidance of
risk for regurgitation/aspiration. Likewise, whether assisted,
controlled ventilation is associated to any different risk for PONV as
compared to spontaneous breathing during surgery and anaesthesia has not been studied in prospective randomised studies
having PONV as primary outcome. The potential impact of
emptying the stomach by the use of a naso-gastric tube has not
been shown to have major impact. Kerger et al. [38] published the
results from the IMPACT study including more than 4000 patients
with a special reference to the use of naso-gastric tube and these
results provide evidence that routine use of an NG tube does not
reduce the incidence of PONV.
The explicit choice of airway, airway management seems not to
have major impact on the occurrence of PONV.
1.5. Surgery aspects
An outpatient study found that each 30-min increase in surgery
duration increased baseline PONV risk by 60% and that plastic and
orthopaedic shoulder surgery had a six-fold increase in the risk for
PONV and duration of anaesthesia/surgery is included as risk factors in the Sinclair score [17]. Other studies have suggested that
orthopaedic surgery is less emetogenic. Grabowska-Gaweł et al.
[39] found a clear relation between the frequency of postoperative
nausea and vomiting occurrence and the type of operative procedure. The relation appeared to be the strongest in case of the sick
who underwent abdominal and laryngological procedures, as well
as ophthalmologic procedures. However, the relation was the
weakest in case of the sick who underwent orthopaedic procedures. Breast surgery has been shown to be associated to high
incident, whether this is an effect of female gender and age or if the
surgery as such has an independent effect cannot be explicitly
stated [40]. It is however not easy to fully assess the independent
effect, comparing the various studies as patient age, gender,
smoking habits, anaesthetic technique, pain management and
assessment of PONV commonly differ between studies [41].
Type of surgery have an influence on risk for PONV, abdominal
surgery, breast surgery and ear nose and throat carry a high risk for
PONV. Surgery associated to sever postoperative pain and need for
higher doses of postoperative opioid, e.g. major orthopaedic surgery is also at risk. Preventive strategies should take surgical procedure into account, including an effective postoperative pain
management plan possibly minimising need for opioids e.g. by
nerve block and perineural catheter techniques.
1.6. Trigger agents
Balanced analgesia, or multi-modal pain management,
combining analgesics with different mode of action aiming at
minimising the need for opioid analgesics was introduced in the
mid 1990s [42,43]. Local anaesthesia in order to reduce pain and
thus lower the need for opioids have become standard of care [44].
The optimal technique, central blocks, spinal or epidural, regional
techniques or merely wound infiltration and catheters should be
adopted on a procedural basis [45]. The implementation of laparoscopic techniques and Enhanced Recovery Program has made
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more extensive central block less appropriate [46].
Paracetamol, NSAIDs and Coxibs are commonly used for pain
management for ambulatory surgery reducing the need for opioid
and subsequently morphine related side effects [47,48]. Coxibs may
have a benefit by less effect on platelets and thus risk for bleeding
[49].
Complete opioid free anaesthesia has been shown to have
favourable effect reducing PONV [50,51]. Reducing intraoperative
opioid in combination with multi-modal analgesia has been shown
to reduce PONV, postoperative nausea (68% vs. 27%) and vomiting
(32% vs. 8%) in the first 24 postoperative hours, in females undergoing major breast [52]. Choice of intraoperative opioid seems not
to have major impact, good evidence, however, exists to show that
fentanyl and alfentanil do not cause more nausea and vomiting
than the ultra fast-acting remifentanil [53,54].
Reversal agents, the use of standard 2.5 mg neostigmin and
0.5 mg glucopyrrolate for reversal of neuromuscular block seems
not to increase the risk for PONV [55,56]. Postoperative use of
opioids provides additional risk for PONV. Claxton et al. found
fentanyl and morphine to be associated with similar risk for PONV
but morphine caused more PDNV [57].
Multimodal opioid sparing analgesia, combining analgesics;
paracetamol, NSAIDs/Coxibs and local anaesthesia has become
standard of care in ambulatory surgery. Single shot local anaesthesia has a limited duration. Catheter techniques in order to prolong the duration may be used also in ambulatory surgery. Studies
are ongoing with different slow release formulation of local
anaesthesia.
1.7. Ethnicity
A meta-analysis of PONV after gynaecological surgery [58] and a
study in the laboratory-induced motion sickness setting [59] suggest that ethnicity (Dutch or English versus Scandinavian and
Chinese or Asian-American versus Caucasian- or African-American,
respectively) could be a PONV risk factor. Black South African
ethnicity has also been shown as an independent risk factor for
decreasing the incidence of PONV. The reason for this observation
remains speculative and further investigation is warranted. The
inclusion of ethnicity as a risk factor into PONV scoring systems has
been suggested [60].
1.8. Homeostasis
Time without food and drink should follow revised, updated
guidelines 6 h for food and 2 h for clear liquor. Whether preoperative “nutritional drinks” exhibits explicit benefits, e.g. reduced
PONV needs further studies [61]. Fluids during anaesthesia volume
and content has recently been reviewed in a meta-analysis suggest
that a liberal crystalloid regime is favourable reducing PONV risk
[62]. Hypotension may indeed as well as bradycardia trigger emesis
and ephedrine has been shown to provide beneficial effects
reducing PONV and hypotension [63], it provides similar effects as
droperidol but less sedation [64]. Postoperative oral intake may
delay discharge but seems not to have explicit effects on risk for
PONV. Jin et al. found no significant difference in the frequency of
PONV between the drinking and the nondrinking groups either in
the hospital or after discharge [65].
Adherence to updated modern guidelines avoiding prolong
fasting should be adopted, maintaining homeostasis and avoiding
dehydration with the risk for drop in blood pressure during early
ambulation is of huge importance.
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1.9. None-pharmacological aspects
Non-pharmacological techniques for alleviation of postoperative pain and distress are not extensively used. The potential
benefit and low risk should however be acknowledged. Nonepharmacological manoeuvres with impact on PONV, anxiety/information/preparation, and acupuncture [66] should not be
neglected. There is reassuring evidence for acupressor being
effective in reducing the risk for PONV. The last Cochrane review
was published in 2009 [67] and showed clear evidence for its efficacy, P6 acupoint stimulation prevented PONV. There was no
reliable evidence for differences in risks of postoperative nausea or
vomiting after P6 acupoint stimulation compared to antiemetic
drugs. There is one more meta-analysis by Cheong et al. [68] published in 2013 supporting beneficial effects from acupressure. PC6
acupressure significantly reduced the number of cases of nausea
and vomiting during the first 24 postoperative hours. The effects of
“therapeutic suggestion” have also been studied but the results are
fragile show only limited benefit [69,70].
It's surprising that simple non-pharmacological techniques such
as the acupressure wrist band are not more commonly used.
1.10. The traditional anti-emetics recent meta-analysis and
guidelines
There are recent reviews around trigger substances and pharmacological interventions. There are several classical receptor antagonists apart from the 5-HT-3 blockers that have effect on PONV
and systematic review around antiemetics and drug combination
have recently been published [71e73]. A meta-analysis by DeOliviera et al. published late 2012 [74] showed that the old and wellestablished metoclopramide 10 is effective for prevention of PONV.
Likewise the antiemetic effects of low <1 mg droperidol has been
documented in a meta analysis by Shaub et al. [75]. Because adverse
drug reactions are likely to be dose-dependent, there is an argument to stop using doses of more than 1 mg. Trans-dermal
scopolamine (TDS) has also been evaluated in a meta-analysis by
Apfel et al. [76]. TDS was associated with significant reductions in
PONV with both early and late patch application during the first
24 h after the start of anaesthesia. TDS was associated with a higher
prevalence of visual disturbances at 24e48 h after surgery, but no
other AEs, compared with placebo. Steroids have received
increasing attention having potential impact on pain, PONV but also
possibly on the risk for neurocognitive side effects. The beneficial
effects of single preoperative intravenous dexamethasone seem
reassuringly proven [77,78]. The increase in blood glucose must be
acknowledged.
1.11. New pharmacological options
There is ongoing research looking for further improvement.
Palonosetron is the most recently US Food and Drug Administration (FDA)-approved 5-HT3 receptor antagonist for use in the
management of PONV. It is interesting because of its long half life
[79]. It is however not well proven whether the longer half-life
translate in to clear clinical superiority. Park and Cho [80] found
palonosetron more effective as compared to ondansetron. The
incidence of PONV was significantly lower in the palonosetron
group compared with the ondansetron group (42.2% vs 66.7%,
respectively). Laha et al. [81] evaluated the efficacy of intravenous
palonosetron (0.075 mg) versus ondansetron (4 mg) in preventing
PONV during the first 24 h following laparoscopic cholecystectomy.
They found not significantly different between the palonosetron
and ondansetron groups, suggesting that the antiemetic efficacy of
palonosetron is similar to that of ondansetron for preventing PONV,
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despite the difference in pharmaco kinetics. Kang et al. [82] studied
continuous palonosetron infusion, following single injection, reduces the incidence of PONV compared with single injection only in
female patients undergo gynecologic laparoscopic surgery. However there were still about one third of patients that experienced
PONV; the 24 h postoperatively was 31.8 vs. 56.1%, P ¼ 0.009 for the
continuous palonosetron infusion group than the single-injection
palonosetron group respectively. Candiotti et al. [83] studied
intravenous palonosetron 0.075 mg and intravenous ondansetron
4 mg for the treatment in patients experiencing PONV following
laparoscopic abdominal or gynaecological surgery despite prophylactic ondansetron. Palonosetron and ondansetron did not
show differences in the primary efficacy endpoint during the 72 h
after study drug administration.
Neurokinin-1(NK1) receptor antagonists are today approved
for the treatment and prevention of chemotherapy induced nausea
and vomiting. There are also studied evaluating apretenin for the
prevention of PONV. The effect seems more pronounced for the
reduction of vomiting while the effects on nausea and over all
occurrence or PONV seem to be about the same as for 5-HT-3
blockers. Gan et al. [84] found aprepitant superior to ondansetron
for prevention of vomiting in the first 24 and 48 h, but no significant differences were observed between aprepitant and ondansetron for nausea control, use of rescue, or complete response. Habib
et al. [85] found the combination of aprepitant and dexamethasone
more effective than was the combination of ondansetron and
dexamethasone for prophylaxis against postoperative vomiting in
adult patients undergoing craniotomy under general anaesthesia.
However, there was no difference between the groups in the incidence or severity of nausea, need for rescue antiemetics, or in
complete response between the groups. Thus the NK-1 receptor
inhibitors seem to be highly effective reducing the occurrence of
vomiting but with less of impact on the risk for any emetic
symptoms.
George et al. published in 2010 a review on new agents for the
prevention and treatment of PONV [86]. There is one study of new
dopamine receptor antagonistic effect. Kranke et al. [87] published
the results from a randomized prospective study of three different
doses (1, 5, or 20 mg) of investigational substance, amisulpride an
antagonist at D2 and D3 receptors, in moderate-risk to high-risk
adult surgical patients. The 5 mg dose was effective and superior
to both the 1 and 20 mg doses still 14 percent vomited once or more
and 24 needed rescue antiemetic therapy also in the 5 mg group of
patients. The incidences of adverse events were similar for all study
groups and no toxicities associated with D2-antagonists, such as
extrapyramidal symptoms and psychological disturbances, were
observed.
There is as of today still no drug available eliminating the risk for
PONV and the last addition of approved drugs as well as investigational substances are effective in reducing but seems not to
provide any possibility to guarantee PONV free recovery. There is
even far less of high quality research around treatment of established PONV. A general recommendation is to use drugs with a
different mode of action than what has been administered for
prevention/prophylaxis. The best effects may be gained with a 5HT-3-blocker in not used for prevention [88].
Multimodal risk score based prophylaxis should be adhered to,
risk scoring and subsequent escalating prophylaxis and plan for
rescue therapy should be part of each department standard internal
guidelines.
more or less impossible to cover all papers published. The present
review aim merely at showing the complexity and the various aspects that needs to be kept in mind when planning for the individual patient care. There are recent updated guidelines [71,89] for
risk assessment, risk based multi-modal PONV prophylaxis and the
handling of patient experiencing PONV for the ambulatory patients
both having received and for those who have not received preventive therapy. Still it is of importance to be aware of the fact that
we cannot guarantee an individual patient that there will be no
emetic side effects after anaesthesia. It is also of importance to have
in mind that emetic symptoms do not only occur during the early
phase during the hospital stay but may last and start also after
discharge, post-discharge nausea and vomiting indeed have a most
negative impact on quality of care [90]. The current guidelines are
helpful but needs to be adhered to and followed in a proactive
fashion [91,92]. There is still obvious room for further studies
around how to identify patients at risk and more effective techniques to handle the at risk patient. Kranke [93] addressed the
query about aggressive prevention or effective treatment in a
recent editorial. The search for more specific makers in order to
identify high risk patients and also the low risk individuals in order
to better fine tune prevention is indeed of interest. A simple preoperative test would be of value. The serotonin gene type has been
shown to impact the risk of post discharge PONV following breast
cancer surgery [94]. Oddby et al. [95] studied whether chemotherapy provoked emesis and PONV interrelated and found no
convincing overlap but they also found group of females relatively
emetic resistant to both chemotherapy and anaesthesia/surgery.
There seems room for further studies around association between
motion sickness as well as hyperemsis gravidarum and PONV.
Oddby et al. studied also blood markers and found that three
different platelet-associated factors and an altered epinephrine
pattern were found to be associated with the occurrence of PONV
after breast cancer surgery [96] thus platelet pattern would be one
potential that could be explored. Further studies looking for blood
markers e.g. platelet profile, and possibly genetic subtypes associated to PONV and response to anti-emetics are warranted [97,98].
Ethical approval
None required.
Sources of funding
None.
Author contribution
All authors have contributed equally to the writing of this “mini
review”.
Conflicts of interest
Jan Jakobsson has received research grants from Baxter, Abbott,
MSD, Phizer, MundiPharma, Maquet and PhaseIn, has been
lecturing and taken part in advice board for these companies and is
paid consultant, safety physician for Linde Healthcare.
No further conflicts of interest.
1.12. Summary and conclusion
Guarantor
The number of studies and papers addressing nausea and
vomiting in conjunction to surgery and anaesthesia is huge and it is
NA.
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et al. / International Journal of Surgery 15 (2015) 100e106
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