| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2008; 107:452-458 © 2008 International Anesthesia Research Society doi: 10.1213/ane.0b013e31817b842c
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
BACKGROUND: In this prospective, multicenter, observational study, we evaluated the incidence and time course of postoperative nausea and vomiting (PONV), assessed prophylactic and rescue antiemetic use in high-risk patients, and determined population-based effectiveness of antiemetics, including the impact of American Society of Anesthesiologists (ASA) and American Society of Perianesthesia Nurses (ASPAN) guideline compliance.
METHODS: Eligible patients undergoing elective laparoscopic or major plastic surgery possessed two or more of the following Apfel PONV risk factors: female gender, history of PONV or motion sickness, and nonsmoking status. Antiemetic use, emetic episodes, severity of nausea, and functional interference due to PONV were documented during the first 72 h after surgery. Complete response (CR) was defined as no emesis or rescue medication use, and complete control was defined as CR and no moderate-severe nausea. The effect of compliance (versus noncompliance) with ASA and ASPAN guidelines on PONV outcomes was also analyzed.
RESULTS: The proportion of patients experiencing postoperative emesis ranged from 18% to 40% depending on the number of antiemetics administered. The rate of rescue medication (45%) was similar to the reported incidences of moderate-to-severe nausea (47%) and functional interference due to emetic symptoms (44%). The administration of three or more antiemetics produced better patient outcomes overall compared to <1 prophylactic antiemetic. CR rates were <70% despite adherence to current organizational PONV management guidelines (ASA: 69%; ASPAN: 63%). The complete control rates were 10% lower than CR rates over the 3 day study period.
CONCLUSIONS: Administration of three or more prophylactic antiemetics had the most positive impact on emetic outcomes over 72 hrs in patients at risk of developing PONV. Although compliance with organizational PONV management guidelines improved patient outcomes, postoperative emetic symptoms and interference with patient functioning still occurred in more than 30% of these high-risk patients.
|
Introduction |
|---|
|
TopAbstractIntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
Despite widespread use of prophylactic antiemetics for preventing postoperative nausea and vomiting (PONV), many surgical patients undergoing general anesthesia still experience PONV in the postanesthesia care unit (PACU), the hospital, and at home after discharge.1,2 In a study of patient attitudes regarding surgery, vomiting, nausea, and pain were ranked as three of the primary outcomes that patients found least desirable.3 PONV can contribute to delays in the time to hospital discharge and prolong the time to return to work and resumption of other activities of daily living.
Previously published studies suggested that 25%–30% of patients undergoing elective surgery experience PONV at some point during their recovery after surgery, and rates can approach 60%–80% for patients with multiple preexisting risk factors.4,5 The risk factors for PONV in adults include patient-related factors, surgical and anesthesia-related factors, as well as postoperative factors.6 The most important risk factors include female gender, nonsmoking status, history of PONV or motion sickness and perioperative use of opioid analgesics.5 Laparoscopic and major plastic surgery have been associated with moderate-to-high risk of PONV despite the routine use of prophylactic antiemetics.7–10
Current evidence on the treatment effect of prophylactic antiemetics is primarily derived from prospective, randomized, controlled, clinical trials, which typically include or exclude patients with attributes that influence the outcome. These randomized, clinical trials are designed and powered to determine efficacy, a measure of the ability of the treatment to reduce the incidence, duration or severity of nausea and vomiting. Although practice guidelines influence local institutional policies (and can be used by payors to influence reimbursement policies), the controlled clinical trials upon which practice guidelines are based have inherent limitations and, therefore, may not reflect the population-based effectiveness of the recommended antiemetic interventions. Effectiveness, as opposed to efficacy, refers to an evaluation of the benefits of interventions to the broader patient population treated in routine clinical practice. No studies have been published in the peer-reviewed literature in which effectiveness, rather than efficacy, of antiemetic prophylaxis for the prevention of PONV was evaluated.
Therefore, this multicenter, prospective, observational study was designed to estimate the effectiveness of common antiemetic therapies for the prevention and treatment of PONV through an assessment of practice patterns in patients at risk for PONV. We determined the incidence and time course of PONV symptoms and the extent to which these emetic sequelae interfere with patients' postoperative functioning. Due to the increased focus on quality improvement and pay for performance initiatives in health care, this observational study also provided a unique opportunity to evaluate the impact of compliance with the American Society of Anesthesiologists (ASA) and the American Society of PeriAnesthesia Nurses (ASPAN) antiemetic prophylaxis guidelines on outcomes related to PONV.11,12
|
METHODS |
|---|
|
TopAbstractIntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
After IRB approval at 11 sites in different geographical locations within the United States, 391 patients were screened for study eligibility, and 376 of the eligible patients consented to participate in the study from March, 2005 through March, 2006. Patients eligible to participate in this study included male and female adults
18-yrs-of-age who were scheduled to undergo either elective abdominal laparoscopic surgery, gynecological laparoscopic surgery, or major plastic surgery with an expected surgical duration of 1 h. At least two major risk factors for PONV (i.e., female gender, nonsmoking status, history of PONV or motion sickness)5 were required, as well as an anticipated discharge from the facility within 24 hrs after surgery. Patients were excluded from participation in the study if they had received chemotherapy, radiotherapy, or investigational drugs within 30 days before surgery, had prior use of palonosetron, received any drug with a potential antiemetic effect within 24 hrs before surgery, or were treated with remifentanil or atropine during surgery.
The standard practice for general anesthesia included use of IV (propofol) for induction, inhaled (volatile) anesthetics for maintenance, and antiemetic prophylaxis was left to the discretion of the anesthesiologist. The rescue antiemetic therapy at each site was not specified. Typically, patients were not discharged with a prescription; however, they were instructed to contact the study site if rescue medication was needed.
Before surgery, demographic data were collected for all eligible patients. Preoperative medications and anesthetic medications (e.g., induction drug, muscle relaxant, volatile drug, highest and lowest concentration of nitrous oxide, opioid analgesics, reversal drugs, and use of local anesthetics at incision sites) were also documented. Prophylactic and rescue antiemetic medications administered during the perioperative period, including dosages and the times of administration were recorded. Rescue medications were defined as any antiemetic drugs used for treating nausea and/or vomiting by the patient during the postoperative time period.
A stratified sample of eligible patients (defined as patients scheduled to undergo elective abdominal laparoscopic surgery, gynecological laparoscopic surgery, or major plastic surgery) was identified by the participating investigators. Within one month before surgery, the investigators were told to ask each patient to complete a pretreatment demographic questionnaire and other pretreatment assessments. After surgery, the investigators and patients were asked to capture PONV-related outcome data (i.e., time to first emesis, total number of emetic episodes, nausea severity, and interference using daily activities due to nausea and vomiting) with an interactive voice recording system (JestaRx, Laguna Beach, CA) over the entire 72 h postoperative observation period. The investigators and patients were responsible for assessing PONV at 2, 6, 24, 48, and 72 h after the patient awakened from surgery (i.e., was able to postoperatively respond to vocal commands).
Nausea was assessed using a four-point Likert scale with 0 = none, 1 = mild, 2 = moderate, and 3 = severe. The ability of nausea and/or vomiting to interfere with activities of daily living (i.e., appetite, sleep, physical activity, social life, enjoyment of life) was measured using a modified Osoba nausea and emesis module.13 Complete response (CR) was defined as no emesis and no use of rescue antiemetic medications. Complete control (CC) was defined as CR with no more than mild nausea (i.e., no moderate-to-severe nausea).
Statistical Analysis
The primary objective of the study was to estimate the effectiveness of current antiemetic prophylaxis for up to 72 hrs after laparoscopic or plastic surgery in patients at risk for PONV. A sample size of 375 provided adequate precision to estimate the overall percent of patients with a CR to within four percentage points, with 95% confidence at the specific assessment intervals. The secondary objective was to assess the impact of compliance with organization guidelines for the management of PONV on emetic outcomes. In addition, we described the patterns of antiemetic interventions and established the outcomes associated with their use during the continuum of perioperative care up to 3 days after surgery.
Patient demographics and risk factors were compared between prophylactic antiemetic treatment groups using analysis of variance for continuous variables and appropriate 
2 testing for categorical parameters. The CR and CC rates, with 95% confidence intervals, were calculated for each postoperative time interval using logistic regression and/or Cochran-Mantel Haenszel tests. Incidences of mild, moderate or severe nausea and interference with activities of daily living were analyzed using 95% confidence intervals, and comparisons of antiemetic treatment groups were considered statistically significant if the confidence intervals did not overlap. Time to first emesis was analyzed using Kaplan-Meier methods and the resulting curves were compared using the log-rank test. These curves were generated based on the number of prophylactic antiemetics administered, and accounted for appropriate censoring over the entire study period, as well as for the time period before and after discharge from the PACU.
The impact of guideline compliance on effectiveness was evaluated as part of a post hoc analysis. Guideline compliance was determined using two published PONV guidelines (Appendix), namely 2002 ASA guidelines and 2006 ASPAN guidelines.11,12 Compliance with the selected guidelines was based on the type and frequency of the antiemetic 5-HT3 receptor antagonist medications, appropriate use of the rescue medications and other recommended therapies (e.g., IV hydration). Rates and 95% confidence intervals for the previously defined end-points were then determined based on compliance status for each guideline and assessment interval.
|
RESULTS |
|---|
|
TopAbstractIntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
Three hundred seventy-six patients had complete information available for evaluation (i.e., surgical, medication, and patient-reported outcomes for the first 72 h after surgery). The patient populations from all study sites were comparable with respect to demographic data, risk factors, and types of surgery procedures. The majority of the patients were women who underwent laparoscopic surgery procedures (Table 1), 97% received propofol for induction of anesthesia, 95% of patients were discharged within 6 hrs, 100% received an opioid analgesic in the PACU and postdischarge.
|
Although all 376 patients were considered to be at risk for developing PONV symptoms, only 92% of the patients received a prophylactic antiemetic (Table 1). A single antiemetic drug, most often a 5-HT3 receptor antagonist, was used as prophylaxis in 34% of these patients (Table 2). A similar proportion of patients received a two-drug prophylactic regimen, most often a 5-HT3 receptor antagonist and dexamethasone. Finally, 23% of the patients received three or more drugs for prophylaxis, with the most common combination being a 5-HT3 receptor antagonist, dexamethasone, and droperidol. The patient demographic characteristics including the number and type of risk factors were similar for the one, two and three or more antiemetic subgroups.
|
Composite End-Points of PONV
The CR rates were 54% for the 0–24 h interval and 64% for the 24–72 h interval. As expected, CC rates were lower at 45% for the 0–24 h interval and 54% for the 24–72 h interval. Similarly, over the entire course of the 3-day study period, a larger percent of patients met the criteria for CR (49%) than for CC (39%) (Fig. 1).
|
Postoperative Emesis
Emesis rates were nonsignificantly lower in the 24–72 h time interval compared with the 0–24 h time interval (Fig. 2). Over the entire 3-day study period, emesis rates were lower (18%) when three or more prophylactic antiemetics were administered compared with only one antiemetic medication (40%). The mean length of time emetic episodes persisted was reduced for patients who received three or more antiemetics (3.8 h) compared with patients who received only one or two prophylactic antiemetics (6.7 and 8.6 h, respectively).
|
Time to Occurrence of Postoperative Emesis
Time to first emesis curves for patients receiving prophylaxis demonstrate that emesis most commonly occurs in the PACU or within 24 h after discharge from the PACU. Emesis rarely occurs for the first time as late as the third day after surgery (Fig. 3a). Of the 12% of patients who experienced their first episode of vomiting in the PACU, the majority received fewer than three prophylactic antiemetics. Although little clinical benefit was apparent in the PACU setting when three or more antiemetics were administered, the value of multimodal prophylaxis was clearly apparent after discharge from the PACU (Fig. 3b). The proportion of patients experiencing emesis after they were discharged from the PACU (9%) was significantly lower in the 3+ antiemetic group compared to patients receiving only one or two antiemetics (18% and 22%, respectively). However, the postdischarge data demonstrated that there were patients who experienced their first episode of emesis at time points up to 60 hrs after discharge (Fig. 3b).
|
Use of Rescue Medications After Surgery
Overall, 41% of patients received a rescue antiemetic within the first 24 h and 45% within 72 h after surgery. However, 33% of the patients received a rescue antiemetic within the first 6 h after surgery. The most common medications used for rescue in the PACU were ondansetron and promethazine. After discharge, promethazine was the most commonly prescribed antiemetic.
Postoperative Nausea
The proportion of patients who experienced moderate- to-severe nausea closely corresponded to the proportion of patients who received rescue antiemetic therapy. Overall, 32% experienced moderate-to-severe nausea within the first 6 h, 41% experienced moderate-to-severe nausea within the first 24 h, and 47% of patients experienced moderate-to-severe nausea during the 3 day study period. The percentage of patients with any nausea (mild, moderate and severe) was lower when three or more antiemetics were administered (51%) compared with only one or two antiemetics (67% and 64%, respectively) (Fig. 2).
Interference of PONV Symptoms with Patient Functioning
Similar to the incidences of rescue medication administration and moderate-to-severe nausea, 44% of all patients reported that nausea and/or vomiting interfered with their overall postoperative functioning over the 3-day study period. The incidence was highest for patients who received only one or two antiemetics (46% and 50%, respectively) (Fig. 2). This interference with functioning was consistently seen for the specific domains of functioning including appetite, sleep, physical activity, social interactions, and general ability to enjoy of life. Over the 3-day period, the proportion of patients who experienced interference with these specific activities ranged from 49% (for interference with social interactions) to 65% (for interference with appetite).
Influence of ASA and ASPAN Guideline Compliance on PONV Outcomes
Based on cumulative data obtained over the 3-day study period, 61% and 52% of patients were given prophylaxis and rescue medication in accordance with the ASA and ASPAN clinical practice guidelines for the management of PONV, respectively. As expected, compliance with practice guidelines resulted in increased effectiveness (Fig. 4). Over the 3-day period, 69% and 63% of patients had a CR when the ASA and ASPAN guidelines were followed. In contrast, when clinical practice patterns failed to comply with the ASA or ASPAN guidelines, only 17% and 34% of patients, respectively, achieved the CR criteria.
|
|
DISCUSSION |
|---|
|
TopAbstractIntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
High-risk patients frequently receive antiemetic drugs for the prevention and treatment of PONV. However, the choice of antiemetic drugs, the appropriate number of antiemetics to administer, and even the timing of their administration (i.e., before induction, before skin closure or after symptoms develop) are subject to variations in practice patterns within a single institution and across centers as demonstrated in this and other recently reported observational studies.14,15 In contrast to most published PONV studies, patients in the current prospective observational study were carefully monitored for up to 72 h after hospital discharge.
In order to foster greater standardization of antiemetic use for prevention of PONV, an expert panel of anesthesiologists developed consensus clinical practice guidelines based upon evidence from the peer-reviewed medical literature, and these guidelines were published by the ASA in 2002.11 As is typical for guideline development committees, this process included an evidence-based review of published PONV studies (e.g., prospective, randomized, controlled clinical trials) and analyses of standard end-points (e.g., incidences of vomiting, nausea, rescue therapy, and CR) to determine the efficacy of antiemetic drug regimens. However, reports of the population-based effectiveness of commonly used antiemetic drugs alone or in combination in high-risk surgical populations were not available for incorporation into these clinical practice guidelines.
The design of this multicenter, prospective, observational study allowed us to assess the clinical effectiveness of prophylactic and rescue antiemetics in high-risk patients by determining the occurrence of emetic symptoms, as well as developing a better understanding of the time course of PONV. The design of this prospective clinical trial allowed us to not only analyze traditional PONV efficacy measures, but to also estimate population-based effectiveness measures over time in the postoperative period (i.e., how well PONV was controlled in a high-risk population during routine clinical care). These data allow the practitioner to better understand answers to questions, such as 1) the incidence of PONV in high-risk patients receiving different prophylactic antiemetic drug regimens, 2) the relationship between moderate-to-severe nausea and the use of rescue antiemetics, and 3) how the development of evidence-based PONV management guidelines may improve population-based outcomes.
The individual symptom and composite end-point data from this study clearly illustrate that PONV remains an all-to-common clinical problem. Although many practitioners may believe that emesis is adequately controlled with current prophylactic techniques, it is important to note that 42% of these high-risk patients received either no or only one antiemetic. Of these patients, more than one in three experienced emesis after surgery. Importantly, the emesis did not necessarily occur during the time anesthesia providers were responsible for patient care (i.e., before discharge from the PACU or the ambulatory surgery facility). The time course data clearly illustrate that patients are as likely to develop emetic symptoms following discharge (i.e., in the car, walking into the door of their house) as they are in the PACU or day-surgery unit. The period of time during which these patients are at risk of developing emetic symptoms appears to be up to at least 60 hrs after discharge from the PACU.
As expected, the patients who were best protected from PONV symptoms were those who had received three or more antiemetic drugs. Considering the relatively low cost of the commonly used antiemetics (e.g., droperidol, dexamethasone, ondansetron), and the clear difference in effectiveness of combination versus single drug prophylactic therapy, health care providers should obviously offer patients at increased risk of developing PONV the benefits provided by multimodal antiemetic prophylaxis regimens.1
Interestingly, the use of rescue medications appeared to correlate with moderate-to-severe nausea. While the early administration of rescue medication (33% received rescue within the first 6 h after surgery) may have reduced the incidence of nausea, 40%–56% of these patients experienced nausea during the 24–72 h postoperative period (Fig. 2). These data suggest that, even though clinicians are frequently administering rescue antiemetic medication to treat nausea, these drugs may be unable to effectively control this common postoperative symptom.
Importantly, these data suggest that moderate-to-severe nausea and/or vomiting negatively affected a patient's ability to regain normal functioning after surgery. Given growing attention to quality initiatives for patient care and "pay for performance" proposals, it is important to recognize that nausea and vomiting are preventing patients from performing activities after surgery. Health care providers need to assess whether their antiemetic prophylaxis strategy is effective in improving the quality of patient care after surgery.
Although adherence to organizational-based PONV clinical practice guidelines results in an improvement in the prevention and treatment of PONV (Fig. 4), there are still patients who suffer unnecessarily because of the suboptimal use of prophylactic antiemetic therapy. Less than two-thirds of the patients received antiemetic interventions that were consistent with standard PONV treatment guidelines (61% for ASA and 52% for ASPAN). Importantly, the CR rate for patients treated with the newer ASPAN guidelines was similar (63%) to the rate for patients treated with the older ASA guidelines (69%).
We conclude that despite the use of antiemetic prophylaxis and compliance with current clinical practice guidelines for PONV management, emetic symptoms still occur in high-risk patients undergoing laparoscopic or major plastic surgery procedures. Persistent emetic symptoms require the time and attention of the perioperative health care team, and lead to the administration of rescue antiemetic therapy for one in every three high-risk patients during their PACU stay. Finally, PONV can interfere with postoperative patient functioning despite the use of multimodal antiemetic therapy in high-risk surgical populations. In order to achieve an optimal fast-track recovery after elective surgery,16 improved techniques for preventing common side effects like PONV are needed.
|
ACKNOWLEDGMENTS |
|---|
The authors would like to recognize the efforts of the other investigators who were members of the POST-OP Study Group and enrolled patients for this study, specifically Drs. Christian Apfel, Michael Berrigan, Michael Howie, Julia Pollock, Suzanne Trupin, and Everett Tucker. In addition, the assistance of Rebecca Gerber, Susan Weidner, Jennifer Vanden Burgt, Tim DeGroot, and Laura Bean Warner from MGI PHARMA, INC. in the analysis of these data and the careful review of this manuscript was greatly appreciated.
|
Appendix. |
|---|
|
TopAbstractIntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
|
|
Footnotes |
|---|
Accepted for publication April 9, 2008.
Dr. Paul F. White is editor of Special Projects for the Journal. This manuscript was handled by Peter S.A. Glass, Section Editor for Ambulatory Anesthesiology. Dr. White was not involved in any way with the editorial process or decision.
Supported by MGI PHARMA, INC. Additional support for Dr. Paul F. White was provided by the Margaret Milam McDermott Distinguished Chair in Anesthesiology and the White Mountain Institute, a not-for-profit private foundation.
|
REFERENCES |
|---|
|
TopAbstractIntroductionMETHODSRESULTSDISCUSSIONAppendix.REFERENCES |
|---|
- White PF. Prevention of postoperative nausea and vomiting – a multimodal solution to a persistent problem. N Engl J Med 2004;350:2511–2
[Free Full Text] - Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg 1995;80:903–9[Abstract]
- Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? Anesth Analg 1999;89:652–8
[Abstract/Free Full Text] - Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs 2000;59:213–43[Web of Science][Medline]
- Apfel CC, Laara 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;91:693–700[Web of Science][Medline]
- Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992;77:162–84[Web of Science][Medline]
- White PF, Issioui T, Hu J, Jones SB, Coleman JE, Waddle JP, Markowitz SD, Coloma M, Macaluso AR, Ing CH. Comparative efficacy of acustimulation (ReliefBandTM) versus ondansetron (ZofranTM) in combination with droperidol for preventing nausea and vomiting. Anesthesiology 2002;97:1075–81[Web of Science][Medline]
- White PF, Hamza MA, Recart A, Coleman JE, Macaluso AR, Cox L, Jaffer O, Song D, Rohrich R. Optimal timing of acustimulation for antiemetic prophylaxis as an adjunct to ondansetron in patients undergoing plastic surgery. Anesth Analg 2005;100:367–72
[Abstract/Free Full Text] - White PF, Tang J, Hamza MA, Ogunnaike B, Lo M, Wender RH, Naruse R, Sloninsky A, Kariger R, Cunneen S, Khalili T. The use of oral granisetron versus intravenous ondansetron for antiemetic prophylaxis in patients undergoing laparoscopic surgery: the effect on emetic symptoms and quality of recovery. Anesth Analg 2006;102:1387–93
[Abstract/Free Full Text] - White PF, Tang J, Song D, Coleman JE, Wender RH, Ogunnaike B, Sloninsky A, Kapu R, Shah M, Webb T. Transdermal scopolamine: an alternative to ondansetron and droperidol for the prevention of postoperative and postdischarge emetic symptoms. Anesth Analg 2007;104:92–6
[Abstract/Free Full Text] - American Society of Anesthesiologists Task Force on Postanesthetic Care. Practice guidelines for postanesthetic care. Anesthesiology 2002;96:742–52[Web of Science][Medline]
- American Society of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team. ASPAN's evidence-based clinical practice guideline for the prevention and/or management of PONV. J Perianesth Nurs 2006;21;230–50[Medline]
- Osoba D, Zee B, Warr D, Kaizer L, Latreille J, Pater J. Quality of life studies in chemotherapy-induced emesis. Oncology 1996;53:92–5[Web of Science][Medline]
- Ruiz JR, Selvan M, Ross MI, Riedel BMD. Comparitive [sic] analysis of ponv risk within the oncology surgical population. Poster presented at: The 2007 Am Society of Anesthesiology (ASA) Annual Meeting; San Francisco, CA, 2007
- Philip BK, Chen, YT, Gan TJ, Ma L, Hu HX. Post-operative nausea/vomiting after high-risk ambulatory surgeries. Poster presented at: The 2007 Am Society of Anesthesiology (ASA) Annual Meeting; San Francisco, CA, 2007
- White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F, Fast-Track Surgery Study Group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007;104:1380–96
[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
 |
|
  R. H. Wender Do current antiemetic practices result in positive patient outcomes? Results of a new study Am. J. Health Syst. Pharm., January 1, 2009; 66(1_Supplement_1): S3 - S10. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Ignoffo Current research on PONV/PDNV: Practical implications for today's pharmacist Am. J. Health Syst. Pharm., January 1, 2009; 66(1_Supplement_1): S19 - S24. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. L. Lichtor and P. S. A. Glass We're Tired of Waiting Anesth. Analg., August 1, 2008; 107(2): 353 - 355. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
