| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
© 2000 International Anesthesia Research Society
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Because no completely effective antiemetic exists for the prevention of postoperative nausea and vomiting (PONV), we hypothesize that a multimodal approach to management of PONV may reduce both vomiting and the need for rescue antiemetics in high-risk patients. After IRB approval, women undergoing outpatient laparoscopy were randomized to one of three groups. Group I (n = 60) was managed by using a predefined multimodal clinical care algorithm. Patients undergoing the same surgical procedure who received a standard balanced outpatient anesthetic with ondansetron 4 mg (Group II, n = 42) or placebo (Group III, n = 37) prophylaxis were chosen to establish baseline incidence of nausea and vomiting. None of the Group I patients vomited before discharge, compared with 7% in Group II (P = 0.07) and 22% in Group III (P = 0.0003). However, one patient (2%) in Group I required treatment for symptoms in the postanesthesia care unit, compared with 24% in Group II (P < 0.0001) and 41% in Group III (P < 0.0001). Time to discharge-ready was significantly shorter in Group I (128, 118–139 min; mean, 95% confidence interval) versus Group II (162, 145–181 min; P = 0.0015) and Group III (192, 166–222 min; P = 0.0001). Patient satisfaction with control of PONV was not different between Group I and Group II. Return to normal daily activity and overall satisfaction were not different among groups. Multimodal management resulted in a 98% complete response rate and a 0% incidence of vomiting before discharge; however, this improvement did not result in an increased level of patient satisfaction when compared with routine monotherapy prophylaxis. We conclude that both multimodal management and routine monotherapy antiemetic prophylaxis resulted in an increased level of patient satisfaction than symptomatic treatment in this high-risk population.
Implications: Use of a multimodal clinical care algorithm eliminates predischarge vomiting and improves satisfaction in patients undergoing outpatient laparoscopy.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Despite the advances made in anesthesia care, postoperative nausea and vomiting (PONV) is a common complication after ambulatory anesthesia (1–3). In addition to the acute discomfort associated with emetic symptoms, nausea, and vomiting can delay the patient’s discharge and may result in a prolonged stay in the recovery room or an unexpected hospital admission (1,4). A variety of factors have been implicated in PONV, including the patient’s gender, weight, age, presurgical anxiety state, surgical procedure, type and duration of anesthesia, degree of postoperative pain, and time to ambulation. Despite the introduction of new antiemetics over the past decade, no completely effective antiemetic exists for the prevention or treatment of PONV.
In women undergoing gynecologic surgery, the reported incidence of PONV ranges from 25% to 60% (5–7). Although a variety of drugs, including droperidol, dexamethasone, metoclopramide, ondansetron, and dolasetron decrease the incidence of PONV, none of these medications, alone or in combination, reduce the incidence to 0% (8–11). In addition to pharmacologic interventions designed to limit the incidence of PONV, other modalities, such as aggressive IV rehydration of the patient during and after surgery (12), aggressive control of postoperative pain (13), and choice of anesthetic technique (14) have all impacted on the incidence of PONV. However, few, if any, data exist to determine whether a multimodality approach to the prevention of emesis is effective in improving outcome after ambulatory surgery.
The primary aim of this study was to test the hypothesis that a multimodal approach to management would result in no vomiting and no need for rescue antiemetics, which has been defined as a complete response (10), in the immediate postoperative period even in a high-risk population such as women undergoing gynecologic laparoscopy. A secondary aim of the study was to compare the results of multimodal management with more conventional management techniques to determine if efficacy and outcome endpoints such as time to discharge from PACU, patient satisfaction, and return to normal daily activity were improved.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
One hundred thirty-nine female patients, ages 18–50 yr, ASA physical status I, II, or III, undergoing outpatient gynecologic laparoscopy under general anesthesia, were enrolled in this study, which was performed in the Outpatient Surgery Center of Wake Forest University Baptist Medical Center. The protocol was approved by the IRB of Wake Forest University School of Medicine. Patients with or without prior history of PONV or prior history of motion sickness were included. Enrollment was limited to patients who were
150% of ideal body weight. Patients were randomized to one of three groups. Group I (n = 60) was managed, in a single-blinded fashion, by using a predefined multimodal clinical care algorithm consisting of a total IV anesthesia (propofol and remifentanil), no N2O, no neuromuscular blockade, aggressive IV hydration (25 mL/kg), triple prophylactic antiemetics (ondansetron 1 mg, droperidol 0.625 mg, and dexamethasone 10 mg), and ketorolac 30 mg (Table 1).
|
Seventy-nine patients, undergoing the same surgical procedure, received a balanced outpatient anesthetic, also administered in a single-blinded fashion. This regimen consisted of midazolam 1–2 mg, fentanyl 1–2 mcg/kg, and propofol 2 mg/kg for induction of anesthesia. Intubation was facilitated with rocuronium 0.6 mg/kg. Anesthesia was maintained with sevoflurane, nitrous oxide, and oxygen. Neuromuscular blockade was antagonized at the end of the surgical procedure with neostigmine 70 µg/kg and glycopyrrolate 10 µg/kg. Fluid administration was left to the discretion of the attending anesthesiologist. Patients did not receive ketorolac. Patients receiving this anesthetic were randomized to receive, in a double-blinded fashion, either ondansetron 4 mg (Group II, n = 42) or a normal saline placebo (Group III, n = 37) before emergence from anesthesia.
Basic demographic information was collected from each patient after enrollment. All patients had a baseline nausea assessment 30 min before induction of the anesthesia. Nausea was scored by using an 11-point linear numerical scale from 0 to 10, with zero representing no nausea and 10 representing nausea "as bad as it can possibly be." On admission to the postanesthesia care unit (PACU) the patients were monitored by study personnel, blinded as to the anesthetic technique used, for both efficacy and outcomes. All patients were admitted to Stage I PACU for initial evaluation and management. Patients were discharged to a step-down unit called Stage II PACU when their Aldrete Score (15) was 10/10 (or the highest number possible for that patient) and any initial pain or PONV was controlled.
Nausea assessments were performed at 30-min intervals while patients were in PACU beginning on arrival and continuing until discharge ready. Nausea scores were also recorded whenever treatment for PONV was given while patients were in PACU. Each episode of emesis, defined as expulsion of gastric contents or an unsuccessful attempt to expel gastric contents (i.e., retching), was recorded during the patient’s recovery in PACU.
Patients received initial rescue treatment immediately in response to the first emetic episode or patient request as a result of nausea. Patients in Group I received dimenhydrinate 12.5 mg. Patients in Groups II and III received ondansetron 1 mg. Initial rescue medications were administered in a double-blinded fashion. Patients received additional treatment (i.e., rescue) if nausea or vomiting persisted >15 min after the initial rescue. Choice of medication was at the discretion of the attending anesthesiologist. Subsequent rescue medication was administered if symptoms persisted for an additional 15 min.
Pain after arrival in PACU was treated with fentanyl 25 µg up to 100 µg in all three groups. Additional pain therapy was at the discretion of the attending anesthesiologist.
Home readiness in Stage II PACU was evaluated at 10-min intervals by using a postanesthesia discharge scoring system (16), with a score of 9 (or the highest possible for the patient) being required for discharge ready. No minimum time to discharge was required in either Stage I or Stage II PACU. Time to discharge ready was recorded for all patients. All patients were initially scheduled as outpatients. Unexpected admissions to Day Hospital ("short stay" unit) were recorded for each group.
Patients were given questionnaires at the time of discharge from PACU (17). They were subsequently contacted by telephone to obtain the data recorded at 24 h and 5 days after discharge from PACU. Patients were asked to rate how satisfied they were with the management of their PONV first as a categorical "yes/no." They were then asked to rate their level of satisfaction on an 11-point (0–10) linear numerical scale. At 5 days, patients rated their level of satisfaction with their overall outpatient surgical experience by using the same 11-point linear numerical scale. Patients also answered a series of questions designed to identify the time necessary to return to normal daily activity after surgery (17).
The primary aim of the study was to demonstrate a 100% complete response rate, defined as no vomiting and no need for rescue antiemetics. A sample size of 60 patients in the multimodal clinical care algorithm group (Group I) provides a 95% upper confidence interval that the failure rate (i.e., patients failing to have a complete response during PACU stay) would be 5%. Comparison data for the secondary aims of the study were collected from Group II (ondansetron prophylaxis) or Group III (placebo prophylaxis). These secondary aims included individual comparisons of the incidence of postoperative vomiting, need for rescue antiemetic while in PACU, time to discharge ready, vomiting after discharge, patient satisfaction, and time needed to return to normal daily activity. Based on findings from a similar group of patients (17), 42 patients in Group II would provide a 90% power (
= 0.05, one-sided, Fisher’s exact test) to detect a difference in complete response compared with Group I. This assumes an incidence of rescue treatment in Group II of 30% and an incidence of rescue treatment in Group I of 5%. Similarly, 37 patients in Group II would provide a 90% power ( = 0.05, one-sided, Fisher’s exact test) to detect a difference in complete response compared with Group I, assuming an incidence of rescue treatment in Group III of 40% vs 5% in Group I. No correction for multiple comparisons was made in these power analyses.
Statistical analyses were performed by using SAS, version 6.12 (SAS Institute Inc, Cary, NC). Analysis of variance was used to compare continuous variables (e.g., age, weight, IV fluids). Duration of anesthesia and times to PACU discharge ready were not normally distributed. Log transformation normalized the data for the analysis of variance, and geometric means were reported. Intergroup comparisons were made by using analysis of variance with pairwise contrasts. Exact 
2 was used to analyze frequency data (e.g., number of patients with emetic episodes). A survival analysis was performed by using Wilcoxon’s test to compare the time needed to return to normal activity after surgery by using data obtained from the 24-h and 5-day surveys. Bonferroni corrections were made for two multiple comparisons whenever pairwise intergroup comparisons were made.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patient characteristics for the three study groups are shown in Table 2. There were no statistically significant differences except patient weight and total dose of fentanyl received. Patients in Group I tended to weigh less than those in Group II. Patients in Group I also received less fentanyl when compared with Groups II and III. No patients in Group I experienced vomiting before discharge. However, few patients in either Group II (7%) or Group III (3%) required treatment for vomiting either. In fact, most patients who received treatment for symptomatic PONV did so for complaints of nausea. Most of these patients were in Groups II and III. This was also reflected by the nausea scores at the time of treatment. There was a statistically significant difference among groups in need for treatment of symptomatic PONV, with 1 (2%) patient in Group I requiring treatment while in PACU, compared with 10 (24%) patients in Group II (P < 0.0001) and 15 (41%) in Group III (P < 0.0001) (Table 3). The only patient in Group I who requested treatment has a nausea score of 5 at the time of treatment. However, 5 patients in Group I had nausea scores >0 before surgery (range 2–9), compared with 1 patient in Group II and 1 patient in Group III.
|
|
The efficacy of the multimodal management (Group I) algorithm persisted throughout the patients’ PACU stay. No patients in Group I experienced vomiting while in PACU (Table 4), which was different than Group III (22%, P = 0.0003); however, the incidence of PACU vomiting was not statistically different than that observed for Group II (7%, P = 0.067). Most patients had their nausea controlled by time of discharge with no statistically significant differences shown between groups; however, patients in Groups II and III frequently required two or more rescue antiemetics to achieve this result. Although the antiemetic efficacy of multimodal management did persist into the postdischarge period (12% incidence of postdischarge vomiting in Group I) and was statistically superior to that seen in Group III (32%, P = 0.0003), it was not statistically different from that seen in Group II (21%, P = 0.268).
|
Multimodal management did result in a significantly shorter time to patient discharge ready (128 min; 95% confidence interval 118–139) when compared with Group II (162 min; 95% confidence interval 145–181; P = 0.0015) and Group III (192 min; 95% confidence interval 166–222; P = 0.0001) (Table 5). The number of unscheduled Day Hospital admissions was not reduced. None of the patients in any of the three groups were admitted because of intractable nausea and/or vomiting; rather, these admissions occurred as a result of changes in the planned surgical procedure. Multimodal management did not result in improved patient satisfaction with control of PONV when compared with Group II. However, Group I and Group II were both superior to Group III in patient satisfaction with control of nausea and vomiting. This improvement in satisfaction did not result in an improvement in overall satisfaction with the outpatient surgical experience assessed at 5 days post-PACU discharge. With the exception of the ability to prepare meals, there was no significant group effect on patient outcomes at 5 days after discharge (Table 6). There was also no overall improvement in the percentage of patients not able to perform one or more of the activities that could be performed before surgery (see Figure 1).
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The multimodal management algorithm made it impossible to perform the study in a conventional double-blinded fashion. The anesthesia care team could not be blinded to the anesthetic technique; however, study personnel collecting data postoperatively were blinded as to the anesthetic technique used, as were the patients themselves. The hypothesis that multimodal management of PONV would result in a 100% complete response in the immediate postoperative period (i.e., PACU stay) also did not allow for a conventional between-group comparison design. Although the results did show that none of the subjects treated with the multimodal management algorithm experienced vomiting or retching while in PACU, these findings should be interpreted with caution. It is of course impossible to demonstrate with certainty that an event will not occur (18). Regardless of the number of observations (i.e., the denominator of the study) it is always possible that the next observation may result in a nonzero numerator.
One patient did require treatment for nausea, resulting in a complete response rate of 98%. We chose to include 60 patients in our multimodal management group, which provides an upper 95% confidence limit of 5% for failure to achieve a complete response in the multimodal management group (i.e., Group I). Relatively little additional "power" would have been gained by increasing the study size. For instance, increasing the study size to 120 patients would only have decreased the upper 95% confidence limit to 2.5%. Consequently we have not "proven" that patients treated with the multimodal management algorithm will never vomit while in PACU, and we failed to prove that multimodal management can achieve a 100% complete response rate. We have shown that it is possible to decrease the incidence of this undesirable side effect of anesthesia and surgery to an extremely small level, even in a high-risk population. Although one patient in Group I did request treatment for nausea while in PACU, the nausea score at the time of treatment was 5. Nausea is a symptom subject to considerable individual variation in perception and tolerance; consequently, complete control of nausea leading to a complete response rate of 100% in PACU may be difficult or even impossible to achieve.
The two additional groups were studied to establish the incidence of symptomatic PONV in our patient population when managed in a more conventional manner. We chose to use 4 mg of ondansetron as prophylaxis in Group II because it is the currently approved dose. However, 1 mg of ondansetron was chosen in Group I because our preliminary data suggested that this was sufficient when combined with the other prophylactic medicines administered. Group III received no prophylaxis and served as placebo control. These two groups (II and III) allowed comparison with multimodal management (Group I) to satisfy the secondary aim of the study. There was a striking difference in the need for treatment of symptomatic treatment of PONV while patients were in PACU. As noted, only 1 patient (2%) in Group I required any treatment, compared with 24% of those in Group II and 41% of those in Group III (Table 3). Interestingly, this difference was attributable primarily to treatment for nausea, not vomiting. In fact, patients receiving ondansetron prophylaxis (Group II) required treatment for vomiting 7% of the time compared with 5% of those receiving placebo prophylaxis (Group III), a difference not statistically significant.
Although those patients managed by the multimodal clinical care algorithm (Group I) did exhibit improved efficacy relative to PONV, differences in outcome were less pronounced. Time to discharge ready was shortened in Group I compared with both Groups II and III; however, there was no difference in the incidence of unplanned admissions to Day Hospital among the three groups, suggesting that PONV was not a significant cause of unexpected admission. No patient subsequently required admission after his or her Day Hospital stay. Given the historically infrequent incidence of unplanned admission resulting solely from postoperative vomiting (19) (approximately 0.2%), this is not surprising. Assuming that the incidence of unplanned admission resulting solely from PONV is <1%, this study did not have sufficient statistical power to detect a difference in admission rates among groups.
Patients in Group I were pleased with the management of their PONV as assessed by satisfaction score; however, the "standard" monotherapy used in Group II also appeared to result in a high level of satisfaction. Patients who received no antiemetic prophylaxis (Group III) reported less satisfaction with their PONV control. This is consistent with previous studies that suggested that high-risk patients benefit from routine antiemetic prophylaxis if patient satisfaction with control of PONV is considered (17,20). In fact, two recent editorials (21,22) have recommended routine antiemetic prophylaxis for outpatients at risk for developing PONV.
Patients frequently cite PONV as a significant concern when questioned preoperatively (23), yet when they are questioned postoperatively, the significance attached to PONV appears to diminish. The management of PONV, although undoubtedly important to outpatients, is not the most important determinant of overall satisfaction (24). The multimodal antiemetic management approach used in the current study did not have an effect on the patients’ return to normal daily activities, suggesting that return to normal functioning after surgery is multifactorial.
In conclusion, elimination of vomiting and a reduction in the incidence of nausea in high-risk outpatients is possible with a multimodal antiemetic regimen. The algorithm may be institution- or procedure-specific and may not require all of the elements included in this protocol. It remains to be seen if reductions in the incidence of PONV beyond that achieved with monodrug prophylactic antiemetic therapy would reduce the already small rate of unanticipated admission after outpatient surgery.
|
Footnotes |
|---|
Presented in part at the Annual Meeting of the American Society of Anesthesiologists, October 9–13, 1999, Dallas, TX.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Burns K. Postoperative care and review of complications. In: Woo SW, ed. Ambulatory anesthesia care. Boston: Little, Brown and Company, 1982: 27–34.
- Palazzo MG, Strunin L. Anaesthesia and emesis. I. Etiology. Can Anaesth Soc J 1984; 21: 178–87.
- Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992; 77: 162–84.[Web of Science][Medline]
- McKie BD. Postoperative nausea and vomiting: a review of incidence, causes and effects. Aust NZ J Surg 1970; 39: 311–4.[Medline]
-
Madej TH, Simpson KH. Comparison of the use of domperidone, droperidol and metoclopramide in the prevention of nausea and vomiting following major gynaecological surgery. Br J Anaesth 1986; 58: 884–7.
[Abstract/Free Full Text] - Cohen SE, Woods WA, Wyner J. Antiemetic efficacy of droperidol and metoclopramide. Anesthesiology 1984; 60: 67–9.[Web of Science][Medline]
- McKenzie R, Kovac A, O’Connor T, et al. Comparison of ondansetron versus placebo to prevent postoperative nausea and vomiting in women undergoing ambulatory gynecologic surgery. Anesthesiology 1993; 78: 21–8.[Web of Science][Medline]
- Graczyk SG, McKenzie R, Kallar S, et al. Intravenous dolasetron for the prevention of postoperative nausea and vomiting after outpatient laparoscopic gynecologic surgery. Anesth Analg 1997; 84: 325–30.[Abstract]
- Tang J, Watcha MF, White PF, et al. A comparison of costs and efficacy of ondansetron and droperidol as prophylactic antiemetic therapy for elective outpatient gynecologic procedures. Anesth Analg 1996; 83: 304–13.[Abstract]
- McKenzie R, Uy NT, Riley TJ, Hamilton DL. Droperidol/ondansetron combination controls nausea and vomiting after tubal banding. Anesth Analg 1996; 83: 1218–22.[Abstract]
- Pueyo FJ, Carrascosa F, Lopez L, et al. Combination of ondansetron and droperidol in the prophylaxis of postoperative nausea and vomiting. Anesth Analg 1996; 83: 117–22.[Abstract]
- Yogendran S, Asokumar B, Cheng DC, Chung F. A prospective randomized double-blinded study of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgery. Anesth Analg 1995; 80: 682–6.[Abstract]
- Andersen R, Krohg K. Pain as a major cause of postoperative nausea. Can Anaesth Soc J 1976; 23: 366–9.[Web of Science][Medline]
-
Tramer M, Moore A, McQuay H. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systematic review of randomized controlled studies. Br J Anaesth 1997; 78: 247–55.
[Abstract/Free Full Text] -
Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg 1970; 49: 924–34.
[Free Full Text] - Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 1995; 7: 500–6.[Web of Science][Medline]
- Scuderi PE, James RL, Harris L, Mims GR. Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999; 90: 360–71.[Web of Science][Medline]
-
Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA 1983; 249: 1743–5.
[Abstract/Free Full Text] - Gold BS, Katz DS, Leaky JD, Nyhus JM. Unanticipated admission to the hospital following ambulatory surgery. JAMA 262:1989:3008–10.
- Tang J, Wang B, White PF, et al. The effect of timing of ondansetron administration on its efficacy, cost effectiveness, and cost benefit as a prophylactic antiemetic in the ambulatory setting. Anesth Analg 1999; 88: 274–82.
-
White PF, Watcha MF. Postoperative nausea and vomiting: prophylaxis versus treatment. Anesth Analg 1999; 89: 1337–9.
[Free Full Text] - Watcha MF. The cost-effective management of postoperative nausea and vomiting. Anesthesiology 2000; 92: 931–3.[Web of Science][Medline]
-
Macario A, Weiner M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89: 652–8.
[Abstract/Free Full Text] - Therex EM, Philip BK. Friendliness of OR staff is top determinant of patient satisfaction with outpatient surgery. Am J Anesthesiol 1998; 25: 154–7.[Medline]
This article has been cited by other articles:
|
|
 |
|
  P. Kranke, N. Roewer, A. F. Smith, S. N. Piper, J. Wallenborn, and L. H. J. Eberhart Postoperative Nausea and Vomiting: What Are We Waiting For? Anesth. Analg., March 1, 2009; 108(3): 1049 - 1050. [Full Text] [PDF]
|
|
|
|
|
|
B. Mraovic, T. Simurina, Z. Sonicki, N. Skitarelic, and T. J. Gan The Dose-Response of Nitrous Oxide in Postoperative Nausea in Patients Undergoing Gynecologic Laparoscopic Surgery: A Preliminary Study Anesth. Analg., September 1, 2008; 107(3): 818 - 823. [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]
|
|
|
|
|
|
P. H. Pan, S. C. Lee, and L. C. Harris Antiemetic Prophylaxis for Postdischarge Nausea and Vomiting and Impact on Functional Quality of Living During Recovery in Patients with High Emetic Risks: A Prospective, Randomized, Double-Blind Comparison of Two Prophylactic Antiemetic Regimens Anesth. Analg., August 1, 2008; 107(2): 429 - 438. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. F. White, O. Sacan, N. Nuangchamnong, T. Sun, and M. R. Eng The Relationship Between Patient Risk Factors and Early Versus Late Postoperative Emetic Symptoms Anesth. Analg., August 1, 2008; 107(2): 459 - 463. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Gan, T. A. Meyer, C. C. Apfel, F. Chung, P. J. Davis, A. S. Habib, V. D. Hooper, A. L. Kovac, P. Kranke, P. Myles, et al. Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting Anesth. Analg., December 1, 2007; 105(6): 1615 - 1628. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. F. White, H. Kehlet, J. M. Neal, T. Schricker, D. B. Carr, F. Carli, and the Fast-Track Surgery Study Group The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care Anesth. Analg., June 1, 2007; 104(6): 1380 - 1396. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Paech, M. W.M. Rucklidge, J. Lain, P. H. Dodd, E.-J. Bennett, and D. A. Doherty Ondansetron and Dexamethasone Dose Combinations for Prophylaxis Against Postoperative Nausea and Vomiting Anesth. Analg., April 1, 2007; 104(4): 808 - 814. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Gan Risk factors for postoperative nausea and vomiting. Anesth. Analg., June 1, 2006; 102(6): 1884 - 1898. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. B Leslie and T. J Gan Meta-Analysis of the Safety of 5-HT3 Antagonists with Dexamethasone or Droperidol for Prevention of PONV Ann. Pharmacother., May 1, 2006; 40(5): 856 - 872. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. F. White, J. Tang, M. A. Hamza, B. Ogunnaike, M. Lo, R. H. Wender, R. Naruse, A. Sloninsky, R. Kariger, S. Cunneen, et al. 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., May 1, 2006; 102(5): 1387 - 1393. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Goldfaden and J. D. Birkmeyer Evidence-Based Practice in Laparoscopic Surgery: Perioperative Care Surgical Innovation, March 1, 2005; 12(1): 51 - 61. [Abstract] [PDF]
|
|
|
|
|
|
P. F. White, M. A. Hamza, A. Recart, J. E. Coleman, A. R. Macaluso, L. Cox, O. Jaffer, D. Song, and R. Rohrich Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery Anesth. Analg., February 1, 2005; 100(2): 367 - 372. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A.-M. Korhonen, J. V. Valanne, R. M. Jokela, P. Ravaska, and K. T. Korttila A Comparison of Selective Spinal Anesthesia with Hyperbaric Bupivacaine and General Anesthesia with Desflurane for Outpatient Knee Arthroscopy Anesth. Analg., December 1, 2004; 99(6): 1668 - 1673. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. S. Habib, W. D. White, S. Eubanks, T. N. Pappas, and T. J. Gan A Randomized Comparison of a Multimodal Management Strategy Versus Combination Antiemetics for the Prevention of Postoperative Nausea and Vomiting Anesth. Analg., July 1, 2004; 99(1): 77 - 81. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. C. Apfel, K. Korttila, M. Abdalla, H. Kerger, A. Turan, I. Vedder, C. Zernak, K. Danner, R. Jokela, S. J. Pocock, et al. A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting N. Engl. J. Med., June 10, 2004; 350(24): 2441 - 2451. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. E. Turner, J. L. Parlow, N. D. Avery, D. A. Tod, and A. G. Day Prophylaxis of Postoperative Nausea and Vomiting with Oral, Long-Acting Dimenhydrinate in Gynecologic Outpatient Laparoscopy Anesth. Analg., June 1, 2004; 98(6): 1660 - 1664. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Ma, J. Tang, P. F. White, A. Zaentz, R. H. Wender, A. Sloninsky, R. Naruse, R. Kariger, R. Quon, D. Wood, et al. Perioperative Rofecoxib Improves Early Recovery After Outpatient Herniorrhaphy Anesth. Analg., April 1, 2004; 98(4): 970 - 975. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Gan, T. Meyer, C. C. Apfel, F. Chung, P. J. Davis, S. Eubanks, A. Kovac, B. K. Philip, D. I. Sessler, J. Temo, et al. Consensus Guidelines for Managing Postoperative Nausea and Vomiting Anesth. Analg., July 1, 2003; 97(1): 62 - 71. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Budd and B. J. Collett III. Old dog--new (ma)trix{dagger} Br. J. Anaesth., June 1, 2003; 90(6): 722 - 724. [Full Text] [PDF]
|
|
|
|
 |
|
 T. J. Gan Postoperative Nausea and Vomiting--Can It Be Eliminated? JAMA, March 13, 2002; 287(10): 1233 - 1236. [Full Text] [PDF]
|
|
|
|
|
|
J. Moss, C.-S. Yuan, and R. A. Steinbrook Selective Postoperative Inhibition of Gastrointestinal Opioid Receptors N. Engl. J. Med., February 7, 2002; 346(6): 455 - 455. [Full Text] [PDF]
|
|
|
|
|
|
C. C. Apfel, P. Kranke, L. H. J. Eberhart, A. Roos, and N. Roewer Comparison of predictive models for postoperative nausea and vomiting Br. J. Anaesth., February 1, 2002; 88(2): 234 - 240. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
