II
II
AANA
Research
in Action
Use of fentanyl markedly increases
nausea and vomiting in
gynecological short stay patients
NANCY J. GASKEY, CRNA, PhD
Pittsburgh,Pennsylvania
LOI RI FERRIERO, CRNA, BS
LYNN POURNARAS, CRNA, BS
JOHINETTE SEECOF, CRNA
The anesthetic technique used in ambulatory surgery should provide a rapid, smooth induction and recovery. Sequelae that might delay
recovery or be the cause of postoperative hospitalization of the patient should be absent.
Nausea and vomiting frequently follow ambulatory surgery for gynecological problems and
may be a side effect of the anesthetic agent used. In
this study a comparison was made of the incidence
of postoperative nausea and vomiting and the
incidence of hospital admission in ambulatory gynecological surgical patients given nitrous oxide
plus fentanyl-isoflurane (Group A), isoflurane
(Group B), or fentanyl (Group C).
Methods. After approval by the hospital Institutional Review Board on Human Research and
the hospital department of anesthesiology, 90 English-speaking female patients (ASA classification I
and II) between 18 to 50 years of age undergoing
elective ambulatory gynecological surgery were divided into three groups. All patients were assessed
by an anesthesiologist, and those with a history of
motion sickness, psychological disorders, or mental
August-1986/Vol. 54/No. 4
handicaps were excluded from the study. A table
of random numbers was used to assign the patients
to one of the three groups. No patient was premedicated. After pre-oxygenation and intravenous
administration of 3 mg of tubocurarine, anesthesia
was induced with intermittent doses of sodium
thiopental (6 mg/kg). Supplemental doses of thiopental were given as needed. Induction was defined
by loss of response to verbal commands, loss of
eyelid reflex, and loss of voluntary movement. If
these criteria were not met, additional boluses of
thiopental 50 mg were injected. Succinylcholine
was administered intravenously to facilitate tracheal intubation. After intubation, the lungs were
mechanically ventilated with 67% nitrous oxide33% oxygen (4:2 L/minute). Tidal volume and
rate of ventilation were adjusted to maintain normocarbia (Perkin-ElmerTM mass spectrometer).
Group A thereafter received fentanyl (1
g/kg) and isoflurane (0.1-1.0% inspired concentration); Group B received isoflurane (0.5-1.5%);
and Group C received intermittent boluses of fentanyl (3 g/kg). The average dose of fentanyl was
65 g (SD 17) in Group A and 330 pg (SD 38) in
Group C. An intravenous infusion of succinylcholine (0.2%) was administered as needed for surgical relaxation. All anesthetics were administered
by one of three student nurse anesthetists assigned
by clinical rotation and supervised by a staff anesthesiologist. Eighty to 90 percent of surgical diagnoses were infertility or intolerance to standard
methods of birth control. All patients had either a
laparoscopy or laparotoiny for tubal ligation.
At the end of surgery, the patients were transported to the recovery room and monitored for a
minimum of 60 minutes. The Aldrete Recovery
Room Score 1 was applied to every patient upon
admission and discharge. Patients were discharged
to the short stay unit when they were normotensive
(blood pressure within 20% of the preoperative
value), and appropriately responded to verbal commands.
After patients could stand and walk without
disequilibrium, retain liquids, and demonstrate
adequate motor coordination (evidenced by completion of the Trieger dot test), 2 they were released from the surgical short stay unit in the care
of a responsible companion. Patients unable to
retain fluids or walk without assistance were admitted to the hospital for further observation and
treatment. The frequency of nausea and vomiting,
abdominal pain, and need for analgesics were
noted by the recovery room and surgical short
stay unit nursing staffs. Nausea was recorded only
when the patient volunteered the information or
demonstrated signs of retching without emesis.
Data were compared using analysis of variance or
Fisher's exact test. Differences at a probability level
of less than 5% (P < 0.05) were considered significant.
Results. The groups did not differ in weight
or height. The ages were similar (Group A 31.6
+ 5.6 years-mean ± SD; Group B 31.3 ± 4.4
years; Group C 28.6 ±: 4.8 years). Patients given
fentanyl were more likely to experience nausea
and vomiting, regardless of the background anesthetic (Table I). Further, a higher dose of narcotic was associated with a higher incidence of
nausea (P = 0.025 for a comparison of Groups A
and C). Seven patients (7.9%) were admitted to
the hospital after surgery. Three of these in the
fentanyl-isoflurane group and one in the fentanyl
group were admitted for nausea and vomiting. The
other three were admitted because of surgical complications. Durations of anesthesia and recovery
were not significantly different among the three
groups. The importance of this finding may be
limited because all patients were required to remain in the recovery room for a minimum of 60
minutes, and discharge from the surgical short stay
unit was dependent on the availability of the surgical staff. The Aldrete score did not demonstrate
any difference among the three groups upon admission to or discharge from the recovery room.
Discussion. Although nausea and vomiting
are considered minor complications of anesthesia,
they can be disabling and stressful. As noted by
Rising et al., 4 nausea and vomiting may delay discharge or considerably increase the incidence of
hospitalization, and hence the cost of ambulatory
surgery. Results of the study discussed in this
article indicate that the use of fentanyl is associated with a higher incidence of nausea and vomiting in ambulatory gynecological surgical patients,
and that a higher frequency of nausea and vomiting occurs in patients given a larger dose of fentanyl.
Table I
Postoperative morbidity
Group A
Fentan yl-lsoflurane
No.
Percent
Nausea
Vomiting
Hospital admission
Surgical
complication
Anesthesia
complication
Group B
Insoflurane
No.
Percent
30* +
30*
Group C
Fentanyl
No.
Percent
0
3.3
17
11
57*
37*
1
3.3
2
6.7
0
0
3
10.0
0
0
1
3.3
* Significantly different from Group B.
+Significantly different from Group C.
310
Journal of the Association of Nurse Anesthetists
These results confirm hbservations from other
investigations that the addition of fentanyl to an
inhaled anesthetic increases the incidence of nausea
and vomiting. 3 -5 Few studies have assessed this relationship when the potent inhaled anesthetic was
isoflurane. Rising et al. found that the combination
of fentanyl, nitrous oxide, and isoflurane for ]aparoscopy demonstrated an incidence of nausea of
60%, whereas if fentanyl were omitted, the incidence was
16%/,.
These results are similar to the
findings in this study. (Table I). However, unlike
Rising et al., this study also found that administration of fentanyl increased the incidence of vomiting. L ess well controlled studies have failed to
reveal an effect of the addition of narcotic to anesthesia with isoflurane and nitrous oxide. In the
multicenter clinical evaluation of 6800 patients, no
correlation was found between either nausea or
vomiting and narcotic administration."' The results shown in this study also (liffer from those of
previous investigations in that data suggest that
the dose of fentanyl may be important to the incidence of nautsea (compare the incidence for
post-
Groups A and C, Table I) . If avoidance of
nausea is needed in ambulatory gyne-
operative
cologic patients. it may be necessary to decrease or
eliminate the use of narcotics.
The results shown here have several limitations. They may not apply to all ambulatory patients. Young women having intra-abdominal procedures were studied, and these factors may increase the incidence of nausea and vomiting, eslpecially in women in the latter part of their
menstrual (cycle.Nor can there be speculation about
the propensity of any of the three anesthetic techniqutes to cause prolonged or delayed nausea and
vomiting since the postoperative evaluation did
not include the recovery period following discharge from the surgical short stay unit. Rising et
al. found that 24°% of their patients who were
given fentanyl vomited four or more hours after
anesthesia.' The albsence of nautsea and vomiting in
the isoflurane group may indicate that nitrous
oxide is less of a factor in postoperative nausea and
August-1986/ Vol. 5//No.
4
fentanyl to produce nausea and vomiting. However, in a similar group of patients given an average of
1tg fentanyl with nitrous oxide, Melnick
et al. found that nausea and vomiting occurred in
36 {, of patients despite the intravenous injection
of 0.6 mg of dIroperidol with induction of anesthesia. 5 This incidence is comparable to the incidence
(30%) for the lpatients in Group A in this study
(who received 65 ptg of fentanyl). It should be
noted that in addition to its antiemetic effect,
droperidol may increase drowsiness and postoperative dizziness 8 and thus may not be best for
short-stay patients.
89
REFERENCES
(1) Aldrete JA and Kroulik D. 1983. A postanesthetic recovery
score. A nest/s Analg. 49:924.
(2) Newman MG, Trieger N, and Miller JC. 1969. Measuring
recovery from anesthesia-a simple test. Anesth Analg. 48:136.
(3) Hackett GH, Harris MNE, Plantevin
Pringle DBi, and
Avery
1982. Anaesthesia for outpatient termination of pregnancy. Br J Anaesth. 54:865-879.
(4)
Rising .S, Dodgson MS, andl Stcen PA. 1985.
v
fentanyl for outpatient laparoscopy. Arta A nae.sfiesiol .Stand.
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(5) Melnick BM, Chalasani J, and t~y NTI.. 1984. Comparison
of enflurane, isoflurane, andlcout inuous fentanyl infusion for
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(6)
iluflington (:\V. 1982. Reflex actions (luring isoflurane an-
HM,
AjI.
Isoflurane
(Suippl)
aesthesia. Cant Annesti S o,- 129
:S35-43.
(7)
Eger
1985. Nitrous Oxide. New York:
El.
Elsevier,
pp.
58-59.
(8) Cohten SE, Woods WA, and Wyner J. 19844. Antiemnetic
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60:67.
AUTHORS
Nancy J. (;askey, CRNA, Phi), is a gradttate of the Mercy
Hospital School of Anesthesia, Pittshurgh. Pennsylvania. She
has a tmaster's degree in ct rictit lun and supervision and a
dloctorate
in
educational
comnuuticat
ions andl technology from
the U nivetsity of Pittshturgh. She was previously D~irector of the
School of Nurse Anesthesia at the Western Pennsylvania Hospital, Pittsburgh, atnd is now D~irector of the School for Nurse
Aniesthetists at University Health Center of Pittsburgh. Dr.
G;askey was awardled the 2tid Annutal Research in Action award
sponisoredl by
Critikon
for this research project, which she pre-
sented at the 1985 AANA Annual Meeting in Anaheim.
Ionri
r0r, CR NA, 11S, is a gradutate of Carlow College,
Pittsburgh and of the Western Pennsylvania Hospital School of
Ntorse Anesthesia in Pittsburgh. She is cturrently employed as a
staff nurse anesthetist at Mercy H-ospital in Pittsburgh.
lyn
..ot. rnras, CR'UNA, BS. gaduated from... Mc1ill Ilni-
311l