Ketorolac and propofol administration for prevention of nausea and vomiting in patients undergoing minor gynecologic surgery

This clinical review explores the efficacy of the nonsteroidal antiinflammatory agent, ketorolac tromethamine, added to an anesthetic regimen utilizing intravenous propofol. Both agents have been shown to reduce the incidence of nausea and vomiting postoperatively when administered to patients undergoing minor gynecologic surgery. Because the incidence of nausea and vomiting is significantly reduced when ketorolac is used in place of opioids to attenuate postoperative pain, it would appear to be an appropriate choice of agent to use following propofol anesthesia. The use of this combination of drugs may not only reduce the incidence of postoperative nausea and vomiting in patients undergoing minor gynecologic surgery, but could reduce the duration of hospitalization and enhance recovery from anesthesia.     

Intravenous dolasetron mesilate in the prevention of postoperative nausea and vomiting in females undergoing gynecological surgery

STUDY OBJECTIVE: To evaluate a range of doses of intravenous (i.v.) dolasetron mesilate, in preventing postoperative nausea and vomiting (PONV). DESIGN: Double-blind, placebo-controlled, randomized, multicenter trial. SETTING: Ten hospitals and/or surgical centers. PATIENTS: 281 women undergoing gynecologic surgery with general anesthesia. INTERVENTIONS: Patients received one of four single, i.v. doses of dolasetron mesilate (12.5 mg, 25 mg, 50 mg, and 100 mg) or placebo administered following cessation of anesthesia. MEASUREMENTS AND MAIN RESULTS: Patients were monitored for 24 hours following study drug administration. The antiemetic efficacy of each dolasetron mesilate dose was evaluated by recording the number and timing of emetic episodes, and the effects on nausea were assessed by use of visual analog scales (VAS). Safety was assessed by adverse event reports, clinical laboratory tests, electrocardiographic (ECG) measurements, and monitoring vital signs. Complete responses (patients with no emetic episodes and no escape antiemetic medication requirements in 24 hours) were achieved by 54% in the 12.5-mg, 67% in the 25-mg, and 59% in both the 50-mg and 100-mg dolasetron mesilate dose groups, and by 43% in the placebo group. Nausea VAS assessments demonstrated that dolasetron-treated patients were significantly (p = 0.048) more likely to report no nausea (VAS score < 5 mm) than those in the placebo group. Adverse events reported generally were mild in intensity, and there were no clinically significant changes in laboratory tests, vital signs, or ECG parameters. CONCLUSIONS: Dolasetron was effective and well tolerated for the prevention of PONV in female patients undergoing gynecologic surgery with general anesthesia.     

Management of nausea and vomiting in children

When children experience nausea and vomiting (N/V) as side effects of anesthesia or chemotherapy, a major role for nurses is to promote comfort. In addition to the discomfort of N/V in children, other detrimental effects include dehydration, weight loss, fluid and electrolyte imbalance, and emotional distress. This article describes the physiological pathways through which the vomiting center is stimulated to cause nausea and vomiting and identifies appropriate interventions for blocking these pathways using both pharmacological and nonpharmacological means. Medications used to control nausea and vomiting, including phenothiazines, substituted benzamide, corticosteroids, benzodiazepines, antihistamines, and serotonin antagonists, are discussed. Nonpharmacological interventions that are described include reducing anxiety, music therapy, hypnosis, progressive muscle relaxation, dietary modifications, and acupressure.     

Postoperative vomiting. A score for prediction of vomiting risk following inhalation anesthesia

Despite numerous factors are thought to affect postoperative vomiting (PV) recent studies demonstrated that the risk of PV can be predicted by considering just the most important ones. Therefore, the aim of this study was to present the clinically most relevant factors, a risk score based upon those factors and its clinical applicability for other types of surgery. METHODS: In a prospective study 2220 adult inpatients scheduled for elective surgery were monitored for PV after inhalational anaesthesia over 24 hours. None of the patients received prophylactic antiemetic treatment. Multivariate analyses were performed with data of patients who underwent otolaryngological procedures to identify the major risk factors and to derive a risk score. The applicability of the score in surgical and ophthalmological procedures was tested by linear regression analysis of expected and observed incidences. RESULTS: In the multivariate model, clinically most important risk factors for PV were female gender, young age, a positive history of postoperative nausea and vomiting or motion sickness, non-smoking and a long duration of anaesthesia, whereas the relative impact of the "type of operation itself" was small. Expected and observed incidences in patients undergoing other types of surgery were strongly correlated (R2 = 0.99, P < 0.001). CONCLUSION: The risk for PV after inhalational anaesthesia in adults can be predicted using a score which is based on individual risk factors and the duration of anaesthesia only.     

Personality factors associated with anticipatory nausea/vomiting in patients receiving cancer chemotherapy.

100 cancer chemotherapy patients were interviewed, rated the severity of pre- and posttreatment nausea and emesis, and completed the State-Trait Anxiety Inventory. In addition, scores on the Millon Behavioral Health Inventory were obtained for 59 Ss. 33% of the Ss reported having experienced anticipatory nausea, and 11% reported having experienced anticipatory vomiting. Ss who experienced anticipatory nausea had more posttreatment nausea and vomiting, were more depressed, and were characteristically more anxious than other Ss. Future despair, social alienation, inhibited personality style, gastrointestinal susceptibility, chronic tension, and confident personality style were variables that best distinguished Ss who experienced anticipatory nausea. (29 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevention of nausea and vomiting in female patients undergoing breast surgery: a comparison with granisetron, droperidol, metoclopramide and placebo

Centromerically located alphoid satellite DNAs are present in all primates. They typically consist of arrays of a 340-bp monomeric unit that is composed of related, but diverged, 170-bp subunits. A unique monomeric unit has recently been described: the alphoid satellite monomers of the neotropical primate Chiropotes satanas (bearded saki) are typically 539 bp in length. In addition, a number of smaller satellite sequences are present in this species. Analysis of two primates closely related to Chiropotes, Pithecia irrorata (saki) and Cacajao melanocephalus (uakari), show that they also contain unique alphoid satellites that are different from those of Chiropotes and different from one another. Southern blot and sequence analyses suggest that an alphoid satellite rearrangement(s) occurred early in the history of the tribe Pitheciini (Chiropotes, Pithecia, Cacajao) and that rearrangements are continuing to occur in this group of primates.     

Tricyclic antidepressants for functional nausea and vomiting: clinical outcome in 37 patients

Tricyclic antidepressants (TCAs) have been used successfully in the treatment of irritable bowel syndrome and unexplained chest pain. Little information is available regarding their use in other functional gastrointestinal disorders. Clinical charts were analyzed from 37 outpatients (mean age 45 +/- 2 years, 25 females/12 males) with chronic nausea and vomiting that could not be explained by any conventional organic disorder (mean duration of symptoms 28 +/- 8 months). Twenty-one (57%) had chronic persistent symptoms; 16 (43%) had intermittent relapsing symptoms; 13 (35%) also had pain as a dominant complaint. Each patient had been treated with TCAs specifically for the gastrointestinal symptoms (amitriptyline, desipramine, nortriptyline, doxepin, or imipramine), and the subject group was followed for 5.4 +/- 1.1 months. Response (at least moderate symptom reduction using a priori chart rating criteria) occurred in 31 patients (84%), and complete symptom remission occurred in 19 (51%)--in 41% with the first TCA trial. Dose at response averaged 50 mg/day, and outcome was unrelated to TCA used. Logistic regression analysis revealed that pain dominance interfered with remission (P = 0.03), but other clinical characteristics were not predictive of outcome. This uncontrolled clinical experience indicates that the open-label response rate of functional nausea and vomiting to low dosages of TCAs resembles that noted in irritable bowel syndrome. TCAs should be studied in controlled fashion for this and related dyspeptic syndromes, as the success of other treatments is limited.     

Behavioral treatment of chemotherapy-induced nausea and vomiting

Nausea and vomiting associated with chemotherapy most commonly occur after administration of the drug regimen, but a substantial proportion of patients also develop these symptoms in anticipation of treatment, after one or more courses of chemotherapy have been given. Currently available pharmacologic agents are unable to provide complete protection from either anticipatory or post-treatment nausea and emesis associated with cancer chemotherapy. Since anticipatory nausea and vomiting are believed to become conditioned responses through the learning process of classical conditioning, behavioral treatments may be particularly appropriate. Progressive muscle relaxation training is effective in preventing as well as decreasing the frequency of postchemotherapy nausea and vomiting, whereas systematic desensitization has been found to be more effective against anticipatory nausea and emesis. Hypnosis and cognitive distraction have been used mainly in children and adolescents.     

Appropriateness of taped versus live relaxation in the systematic densensitization of anticipatory nausea and vomiting in cancer patients.

Investigated the suggestion that the relaxation part of systematic desensitization—an effective treatment for the nausea and vomiting experienced by approximately 25% of cancer patients in anticipation of chemotherapeutic treatments—could be learned from a prerecorded audiotape prior to meeting a psychologist for treatment. 10 cancer patients who had developed anticipatory nausea or vomiting were assigned to either a live-relaxation or a tape-relaxation group. Results show that 4 of 5 Ss assigned to the tape-relaxation group experienced nausea while listening to the prerecorded audiotape, while none of the patients in the live-relaxation group reported nausea when subsequently listening to an audiotape made during the live presentation of relaxation. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sensitizing effects of pretreatment measures on cancer chemotherapy nausea and vomiting.

This study explored the sensitizing effects of pretreatment assessment on posttreatment chemotherapy nausea and vomiting and the interactive effects of personal dispositions for information seeking. Seventy oncology outpatients were recruited from oncology waiting rooms prior to receiving scheduled chemotherapy. Half of the patients were asked to complete an inventory about the severity of side effects that they had experienced following their most recent treatment session (experimental condition) and half were asked to complete an inventory concerning parking conditions at the treatment facility (control condition). All patients were also asked to complete the Miller Behavioral Style Scale (MBSS) and to later rate the severity of their side effects (between 36–48 hr following treatment). Based on the MBSS scores, patients were then divided into information seekers (monitors) and information avoiders (blunters). Overall, patients in the experimental condition rated the severity of their nausea as more severe than the control patients. In addition, patients who preferred a monitoring coping style experienced a significantly higher incidence rate and longer episodes of nausea than patients who preferred a blunting style. The methodological implications of these results for data collection and the assessment of side effects associated with aversive medical procedures are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Inconsistency of prognostic factors for post-chemotherapy nausea and vomiting

In this in vitro study the retentive strength of enamel, either conventionally etched with a phosphoric acid gel or conditioned with an oxalic acid containing etching agent, was investigated. Five experimental restorative resins with filler contents between 0 and 78% by weight were polymerized on the etched enamel surfaces. In spite of the pronounced micromorphological differences of the patterns generated with the two etching agents, the bond strengths mediated were very similar. Application of an intermediate low-viscous or adhesive resin had no influence on bond strength. Exponential relationships were found between the filler content of the resins on the one hand and their flexural moduli and flexural strengths on the other. Significant exponential relations were also demonstrated between filler content and bond strength to the etched enamel surface. The linear relationship between mechanical properties of the resins and their bond strengths to etched enamel indicates that debonding occurred by cohesive failure in resin.     

Role of echocardiography in patients undergoing elective cardioversion of atrial fibrillation

BACKGROUND: Performance of endomyocardial biopsy (EMB) to diagnose myocarditis in patients with dilated cardiomyopathy is controversial because of a lack of evidence favoring immunosuppressive therapy. In spite of advances in heart failure treatment, dilated cardiomyopathy carries a poor prognosis, and myocardial inflammation and viral infection are potential therapeutic targets. METHODS: We used decision analysis to determine the efficacy (5-year risk reduction in mortality or transplantation) that a treatment for myocarditis would require to favor a biopsy-guided approach over conventional therapy. Literature-based estimates included prevalence of myocarditis among patients with dilated cardiomyopathy with or without borderline myocarditis (16% and 11%, respectively); probability of 5-year transplantation-free survival (55%); sensitivity (50% and 63%, respectively), specificity (95.4%), and mortality rate (0.4%) of EMB; side effects resulting in withdrawal of immunosuppressive treatment (4%); and a 6-month mortality rate for immunosuppressive treatment (0.1%). All estimates were varied to determine impact on model results (sensitivity analysis). RESULTS: A therapy that decreased the rate of death or transplantation by 12.7% and 7.1% for patients without or with borderline myocarditis, respectively, favored EMB. Sensitivity analysis indicated that therapeutic efficacy was influenced by myocarditis prevalence and biopsy-related death, but not by accuracy of biopsy or probability of immunosuppressive therapy side effects. Randomized trials powered to detect 7% and 25% reductions in death and transplantation would require 5790 and 380 end points, respectively. CONCLUSION: Decreasing the rate of death or transplantation by 7.1% offsets therapy side effects, EMB-related death, and inaccuracies in histologic diagnosis. Prospective randomized trials of treatments for myocarditis may be more feasible during periods of high prevalence or with more sensitive diagnostic techniques.     

A longitudinal study of the development of anticipatory nausea and vomiting in cancer chemotherapy patients: The role of absorption and autonomic perception.

Interviewed 70 cancer patients (aged 20–74 yrs) receiving chemotherapy at home before their 2nd treatment session to obtain baseline measures of absorption, autonomic perception, depression, state–trait anxiety, and basic demographic information. Ss were then interviewed before each of their next 6 treatment sessions, at which time measures of depression, state anxiety, severity and duration of postchemotherapy nausea and/or vomiting (PCNV), and experience of anticipatory nausea and/or vomiting (ANV) were obtained. Ss with ANV scored significantly higher on measures of absorption and autonomic perception than Ss who did not develop ANV. Those variables hypothesized to mediate conditioning (i.e., toxicity of treatment drugs, severity of PCNV, levels of state anxiety) accurately predicted which patients developed ANV. Absorption and autonomic perception added significantly to the prediction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postoperative lung injury and oxidative damage in patients undergoing pulmonary resection

Postpneumonectomy pulmonary oedema (PPO) complicates a significant number of thoracic surgical procedures involving lung resection and in its extreme form is indistinguishable from the acute respiratory distress syndrome. This study investigated the possibility that ischaemia-reperfusion (I-R) injury contributes to PPO via the production of damaging reactive oxygen species. In a prospective, observational, comparative study, patients undergoing pneumonectomy, lobectomy, or wedge resection or open lung biopsy were investigated for perioperative changes in lung function indicative of lung injury and changes in plasma indices of oxidative damage. Significant percentage perioperative falls in plasma protein thiol levels (-17.9+/-7.0% for pneumonectomy, -24.3+/-5.5% for two-lobe lobectomy and -10.2+/-2.2% for one-lobe lobectomy, p<0.05) and rises in plasma protein carbonyl levels (26.2+/-10.5% for pneumonectomy, p<0.05, 9.8+/-7.0% for two-lobe lobectomy and 5.0+/-2.7% for one-lobe lobectomy) were identified, but not in patients undergoing biopsy or wedge resection. Plasma myeloperoxidase levels rose in all groups, but not significantly. The carbon monoxide transfer coefficient (K(CO)) fell significantly in patients undergoing lobectomy (p<0.05) but not in those undergoing wedge resection, lung biopsy or pneumonectomy. Changes in markers of oxidative protein damage occurred in patients undergoing lung resection, although the gas transfer coefficient fell significantly only following lobectomy. Oxidative damage occurs during pulmonary resection, although associated effects on gas exchange are seen only after lobectomy.     

A randomized trial of tropisetron in the prophylaxis of nausea and vomiting induced by chemotherapy

Thirty patients receiving cisplation or non-cisplatin (containing cyclophosphamide and adriamycin) chemotherapy were enrolled in a randomized, crossover study comparing the efficacy of single dose of Navoban (tropisetron, 5 mg) and Kytril (granisetron, 3 mg). The effective control of acute vomiting induced by cisplatin was achieved in 95.2% (20/21) of patients receiving Navoban and 90.5% (19/21) in those receiving Kytril. Complele control rate was 71.4% (15/21) in Navoban arm, and 81.0% (17/21) in Kytril arm. Total control of delayed vomiting (day 2-5) was 71.4%-90.4% in Navoban arm, while it was 66.7%-4% in Kytril arm. The effective control of vomiting induced by non-cisplatin drugs was achieved in 9/9 in both arms. It is concluded that both agents are effective in the control of vomiting induced by chemotherapy. They have identical adverse effects and are well tolerated by the patients.     

Postoperative nausea and emesis: mechanisms and treatment

The incidence of postoperative emetic symptoms in patients varies between 3 and 91%. Nausea and emesis remain the most common as well as unpleasant side-effects experienced by patients following general anaesthesia, both in the ambulatory and non-ambulatory care setting. Furthermore, emesis carries the risk of severe postoperative complications and is associated with additional costs. Multiple factors are associated with an increased risk of developing postoperative nausea and emesis including age, gender, weight, preexisting disease, as well as anaesthetic and surgical procedures. Routine antiemetic prophylaxis is not currently advisable in patients with a low Emesis Risk, due to undesirable side-effects of antiemetics and additional costs. However, anti-emetic prophylaxis is recommended for patients with an increased risk. Besides administration of antiemetics, other factors that may provoke postoperative emesis need to be considered such as gastric distension, early mobilisation, insufficient analgesia, choice of anaesthetic drugs. High-risk patients may be anaesthetized with propofol, if possible. If symptoms do develop in the recovery room, tight fitting oxygen masks should be avoided and adequate hydration and analgesia ensured. To avoid side effects, antiemetics should be administered in minimally effective dosages. If emesis persists, combination of antiemetic drugs with different profiles of receptor action may be particularly useful.