POSTANAESTHETIC VOMITING IN THE RECOVERY ROOM

Transcription

1 Brit. J. Anaesth. (199), 41, 143 POSTANAESTHETIC VOMITING IN THE RECOVERY ROOM BY MARTIN I. GOLD SUMMARY During a 21-month period, gynaecological were studied consecutively during 3 hours in the recovery room. Three primary anaesthetics were randomly utilized: (a) cyclopropane, with or without thiopentone; (b) halothane, with or without thiopentone; and (c) thiopentone-nitrous oxide-oxygen. Ten per cent of the received miscellaneous agents. The overall incidence of emesis was approximately 29 per cent. Cyclopropane was associated with a significantly higher incidence of emesis than were halothane and thiopentone-nitrous oxide-oxygen. Thiopentone induction followed by a primary inhalation agent was associated with a lower incidence of emesis than was induction with the primary agent alone. The duration of anaesthesia, the lithotomy in contrast to the supine position, the type of premedication and the specific type of gynaecological surgery were not significantly influential nor were many miscellaneous physical or pharmacological factors. The chief conclusion to be drawn from this study is that the primary anaesthetic agent and the presence or absence of a thiopentone induction remained the most vital influences on the incidence of postanaesthetic emesis in the recovery room. Although its aetiology and pathogenesis are unknown and apparently its incidence low in recent times, postanaesthetic vomiting may be troublesome and frightening to the patient, the anaesthetist and surgeon. It is somehow related to the surgical-anaesthetic event and has been the subject of many clinical investigations towards which criticism has been levied because of difficulty controlling variables. These difficulties include : (1) The fact that nausea in addition to vomiting is considered in the investigation as the endpoint. Nausea is a subjective phenomenon difficult to measure and grade with the more objective sign, vomiting. (2) Criteria for vomiting are rarely fully described in an investigation. Thus, saliva and mucus may be judged as vomitus. In addition, persons who diagnose vomiting are frequently registered nurses and licensed practical nurses who are often busy with other duties. (3) Most vomiting studies are truly surveys since control of the myriad influences of postanaesthetic vomiting such as sex, age, anaesthetic agent, duration of surgery and anaesthesia, and type of premedication was not attempted. (4) The significance of retching with or without emesis is not usually taken into consideration. A good example of this occurs with the post-cyclopropane retch. This results in a high percentage of in the immediate postanaesthetic period but a far smaller number of these will overtly vomit. (5) The duration of observation after anaesthesia may vary from study to study. It is clearly invalid to compare a 2 4 hour recovery-room investigation with one of 24 hours. Many leave the recovery room (where observations may be more accurately made) and proceed to vomit or retch in their hospital room. It is not practical to post an observer in the patient's room for 24 hours and, if it were, observations here would still be incomparable since his environment differs. () There are many variables which are impractical or impossible to control. These include the patient's mental status and nervousness, the effects of deep versus light anaesthesia, hypercarbia and hypoxaemia, hypotension, administration of drugs such as ergot derivatives, blood and MARTIN I. GOLD, M.D., University of Maryland Hospital and School of Medicine, Baltimore, Maryland, U.S.A.

2 144 BRITISH JOURNAL OF ANAESTHESIA vasopressors and, finally, metabolic imbalances involving electrolyte and acid-base disturbances, endocrine dysfunction and the presence of cancer. Recently a decline in postanaesthetic vomiting has been reported (Riding, 193). The incidence is certainly lower today than the 75 per cent reported in 1899 (Blumfeld, 1899). Such a decline in the incidence of this complication may reflect better anaesthetic techniques including adequate oxygenation and carbon dioxide removal. Virtual banishment of deep planes of anaesthesia, widespread use of intravenous barbiturates for anaesthetic induction, use of halogenated hydrocarbons, including halothane (as contrasted with diethylether and cyclopropane), and attention to metabolic disturbances before and during anaesthesia may all contribute to this decline in vomiting postanaesthetically. The prophylactic use of antiemetics prior to anaesthesia has been criticized, primarily because it is of little therapeutic value and may be potentially dangerous (Keats, 191). PROCEDURE During a 21-month period, female were studied in a consecutive fashion. All were listed for short gynaecological surgery. These included 753 dilatation and curettages (D and C's), 241 vaginal radium implantations, 138 breast biopsies, and 91 miscellaneous procedures in the lithotomy position. These females were observed for vomiting and retching (but not nausea) in the immediate postanaesthetic period in the recovery room. The majority (887) were premedicated with quinalbarbitone and atropine (quinalbarbitone 1 mg/lb. body weight and atropine 0.5 mg) given intramuscularly 1 hour prior to induction of anaesthesia. Three primary anaesthetic routines were randomly utilized: (a) cyclopropane, with or without thiopentone induction; (b) halothane, with or without thiopentone induction; and (c) thiopentone-nitrous oxideoxygen. About 10 per cent of the total number of received miscellaneous agents including diethyl ether and conduction anaesthesia. Tracheal intubation was not performed although insertion of an oral airway was noted. Spontaneous respiration only was utilized through a semiclosed or closed freshly charged circle carbon dioxide absorption system in the gynaecological operating room. Each female was observed for vomiting by a physician from the time the face mask was lifted in the operating room until she was transferred to the stretcher and removed to the recovery room, where further close observation was performed for 180 minutes. In the recovery room, all were observed by staff anaesthetists and registered nurses trained specifically in recovery-room duties. These nurses were periodically lectured on the subject of postoperative emesis and were both familiar with and interested in the investigation. They were able to discriminate accurately between true emesis versus saliva, mucus, and retching. They were specifically trained to ignore voluntary complaints of nausea (there were a few). If retching persisted beyond a 3-5 minute period without visible emesis this was included as a positive endpoint; however, this occurred only 5-10 times alone and the great majority of positive results were actual vomiting occurrences. Each patient in the study who entered the recovery room had a red flag placed on her recovery-room stretcher and a standard form completed by the observing nurse at the termination of the 180-minute observation period. These forms served as the first step in the data processing. From here each patient's data were transferred to a McBee keysort card by punching the positive variable. From this, the statistical analysis and results were obtained. RESULTS Influence of procedure. Four primary types of surgery were performed (table I; fig. 1): (a) dilatation and curettage, (b) radium implantation, (c) miscellaneous gynaecological procedures including anterior and posterior repair, vaginal tubal ligation, etc., and (d) breast biopsy. The average incidence of vomiting was per cent. The only procedure with a significantly lower incidence of emesis was radium implantation (P<0.05). Influence of anaesthetic agent or technique (table II; fig. 2). The great majority of had three general types of anaesthetics: (a) cyclopropane (with or without thiopentone), (b) halothane (with or without thiopentone), and (c) thiopentone-nitrous oxide. Three other types of agents or techniques were also utilized including diethyl ether, conduction anaesthesia and miscellaneous

3 POSTANAESTHETIC VOMITING IN THE RECOVERY ROOM 145 TABLE I after four surgical procedures. Procedure 1. Dilatation curettage* 2. Radium implantation 3. Misc. gynaecology! 4. Breast biopsy * * Also D and E, pelvic examination, cervical biopsy, t Includes longer procedures: anterior and posterior repair, Rubin's test, vaginal tubal ligation and other vaginal surgery. % P<0.05. TABLE II after six primary anaesthetic agents or techniques. Primary agent 1. cyclopropane A. Thiopentone B. No thiopentone 2. halothane A. Thiopentone B. No thiopentone 3. Thiopentone-N 2 O-O 2 4. Diethyl ether 5. Miscellaneous*. Conduction f 13.f % 23.0f 51.8f t f 11.f 14.3t * Includes: N 2 O, trichloroethylene, narcotics, and thiopentone alone, t P<0.05. TABLE III and pre-anaesthetic medication. Premedication 1. Oxybarbiturate and anticholinergic 2. Anticholinergic only 3. Narcotic and anticholinergic 4. None 5. Miscellaneous* % f * Antihistamines, phenothiazines or oxybarbiturate alone. t P<0.05. x O o z 10- BADIUM IMPLANT OTHER GVN BREAST BIOPSY FIG. 1 Postanaesthetic vomiting and operative procedure. H-VOMITEIf FIG. 2 Number of vomiters and non-vomiters among postanaesthetic in recovery room. Six primary agents. Cyclopropane and halothane are subdivided into: (a) no thiopentone (b) thiopentone induction. Miscellaneous includes: nitrous oxide, trichloroethylene, narcotics and thiopentone alone. Conduction includes: spinal, epidural or nerve block anaesthesia.

4 14 BRITISH JOURNAL OF ANAESTHESIA O 40- z S 30- ENTS ; 20-5 PEDCENT O : BARB. ANTI- + CHOLINERGIC ANTI- CHOIINERGIC FIG. 3 Postanaesthetic vomiting and premedication. agents such as trichloroethylene, narcotics, and thiopentone alone. Compared with average incidence in the total of, diethyl ether and cyclopropane were associated with a significantly higher incidence of emesis while halothane, thiopentone-nitrous oxide-oxygen and conduction anaesthesia were associated with significantly lower incidence. Figure 2 is a circle portraying the absolute numbers of within a whole circle. In this fashion, the ratios of those who vomited with all agents and techniques, including those with thiopentone induction, may be ascertained. Influence of pre-anaesthetic medication (table III; fig. 3). Eighty-six per cent of all received an oxybarbiturate and anticholinergic within 1 hour of induction of anaesthesia. Other forms of premedication included anticholinergic alone, a combination of anticholinergic and narcotic, no premedication, and miscellaneous agents such as antihistamines, phenothiazines, or oxybarbiturates. The only significant influence of premedication was observed when anticholinergics were used alone (P<0.05); in these the incidence was higher than the mean. Duration of anaesthesia (table IV; fig. 4). The majority of received anaesthesia lasting from 15 to 59 minutes. However, all were divided into five groups according to onehalf-hour increments. There were no significant differences in the incidence of emesis according to the duration of anaesthesia. Miscellaneous factors. Six miscellaneous physical or pharmacological factors were studied (table V; fig. 5). The presence of an oral airway, the use of muscle relaxants, oxytocics, pressor agents, blood, and antibiotics were not associated with a significant increase or decrease in the incidence of postanaesthetic vomiting. TABLE IV and duration of anaesthesia. Minutes of anaesthesia S All P> MINUTE S FIG. 4 Postanaesthetic vomiting and duration of anaesthesia. TABLE V after six miscellaneous physical or pharmacological factors. Factor* 1. Oral airway 2. Muscle relaxant 3. Oxytocic 4. Pressor agent 5. Blood. Antibiotic % * Factors 1 and 2 were administered only during anaesthesia, while 3 to were given during anaesthesia but, in some cases, continued in the recovery room. All P>0.05.

5 1 ' _ ; - ; - ; - ; - ;. ' ' _ \ - POSTANAESTHETIC VOMITING IN THE RECOVERY ROOM 147 > 30 FIG. 5 Postanaesthetic vomiting and influence of miscellaneous factors. O«Al OXY- RELAXANT PRESSOR BLOOD AIRWAY TOCIC DRUGS z 10- ANTI- BIOTICS TABLE VI with or without a thiopentone induction. Without thiopsntone With thiopentone Primary agent No. vomiting % vomiting No. vomiting % vomiting Cyclopropane lt Halothane Nitrous oxide * 23.0 Diethyl ether t t P< I I NO THIOPENTONE NG ~ 50- O -JT THIOPENTONE C 40- z t 30- o z 20- ; FIG. Influence of thiopentone induction on postanaesthetic recovery room vomiting. 10- [THER N ]0,O, CTCIO. HAIOTHANE PRIMARY ANAESTHETIC AGENT

6 148 BRITISH JOURNAL OF ANAESTHESIA Type of induction (table VI; fig. ). Patients who received cyclopropane, halothane, nitrous oxide, and diethyl ether as primary agents were divided into those receiving only the primary agents and those who received a thiopentone induction followed by the primary agent. In all instances a thiopentone induction was associated with a lower incidence of emesis in the recovery room. Of 303 receiving only cyclopropane 132 or 43. per cent vomited. Of 29 receiving a thiopentone induction before cyclopropane, only 73 or 27.1 per cent vomited (P<0.001). DISCUSSION This study emphasizes the use of control of variables in an attempt to clarify the influence of certain stimuli on postanaesthetic vomiting. The involved included females scheduled for relatively short gynaecological procedures performed in the lithotomy position (with the exception of 138 breast biopsies). The majority received three primary anaesthetic agents (cyclopropane, halothane, and thiopentone-nitrous oxide). Eighty-six per cent were premedicated with an oxybarbiturate and anticholinergic. In addition, an attempt was made to assess six miscellaneous physical or pharmacological influences, including oral airway, muscle relaxant, oxytocic, pressor agent, blood, and antibiotics. The following conclusions were drawn: (1) The incidence of emesis during a 3-hour observation in the recovery room in all groups approached 30 per cent. The type of surgical procedure made little difference nor did the use of the supine or lithotomy position. An exception was radium implantation, in which a somewhat lower incidence of emesis resulted. Site of surgery has been cited as a causative factor in postoperative emesis. Thus, Bonica and associates (1959) and Bellville, Bross and Howland (190) found intra-abdominal surgery to be associated with an increased incidence of emesis, while Smessaert, Schehr and Artusio (1959) mentioned head and neck surgery as being associated with a higher incidence of emesis. Others believed site of surgery was not an influence (Knapp and Beecher, 195; Burtles and Peckett, 1957). (2) The type of anaesthetic agent and technique were major influences. Cyclopropane and diethyl ether were associated with a higher incidence of emesis while halothane, thiopentone-nitrous oxideoxygen, and conduction anaesthesia were associated with a lower incidence. When thiopentone was used for induction, the incidence of emesis was lower than when the primary agent was used. This may be related to a smoother and less irritating induction with subsequently less gas being present in the stomach. The anaesthetic agent has been a favourite object of incrimination as a cause of postoperative illness. Smessaert, Schehr and Artusio (1959) and Freund and Dodd (191) suggested that the agent was the most important influence. Recently, halothane has been praised in this regard (Novoa, 190; Freund and Dodd, 191; Haumann and Foster, 193; Dundee, Kirwan and Clarke, 195). Methoxyflurane has been similarly praised (Heal, 195). The level of anaesthesia or depth (perhaps related to total dose of agent) may be interrelated with the anaesthetic agent as a causative factor (Blumfeld, 1899). Thus, light anaesthesia has been associated with a lower vomiting incidence (Bellville et al., 190; Riding, 193). The opposite view has also been expressed (Smith, 1945). (3) The influence of pre-anaesthetic medication was not great. Those who received only an anticholinergic had the highest incidence in the present study. Narcotics have been traditionally associated with postoperative emesis and these effects may continue for hours (Dundee, Kirwan and Clarke, 195). A combination of hyoscine and pentobarbitone has been praised as having the least emetic influence (Greene et al., 191), while belladonna alkaloids may, "in certain circumstances", reduce "the sickness caused by morphine premedication" (Riding, 193). (4) Duration of anaesthesia appeared to bear no causal relationship to the incidence of emesis. This is in agreement with some findings (Knapp and Beecher, 195; Freund and Dodd, 191), but is in contrast to other findings (Burtles and Peckett, 1957; Smessaert, Schehr and Artusio, 1959). (5) Six miscellaneous factors were studied and found to bear no relationship to the incidence of emesis in the recovery room. These were oral airway insertion, muscle relaxants, oxytocics, pressor agents, blood, and antibiotics. It is concluded from this study that many variables influence emesis in the recovery room.

7 POSTANAESTHETIC VOMITING IN THE RECOVERY ROOM 149 Some may be controlled as was the case in this investigation. Others may remain absolutely uncontrolled or controlled only in a limited fashion. These variables may be interdependent and two or more may act simultaneously. It is possible that some variables remain unknown and their influence unable to be assessed. Under the conditions of this investigation, thiopentone as an induction agent was associated with a lower incidence of emesis in the recovery room regardless of anaesthetic agent used for maintenance. REFERENCES Bellville, J. W., Bross, I., and Howland, W. (190). Postoperative nausea and vomiting. IV: Factors relating to postoperative nausea and vomiting. Anesthesiology, 5, 18. Blumfeld, J. (1899). Prevention of sickness after anaesthetics. Lancet, 2, 833. Bonica, J., Crepps, W,. Monk, B., and Bennett, B. (1959). Postoperative nausea and vomiting. Surgery, 7, 132. Burtles, R., and Peckett, B. W. (1957). Postoperative vomiting: some factors affecting its incidence. Brit. J. Anaesth., 29, 114. Dundee, J. W., Kirwan, M. J., and Clarke, R. S. (195). Anaesthesia and premedication as factors in postoperative vomiting. Ada anaesth. scand., 9, 223. Freund, F., and Dodd, R. (191). Factors involved in vomiting following general anesthesia. Missouri Med., 58, 112. Greene, B., Berkowitz, S., Goffen, B., Anthony, C., and Katz, J. (191). Demonstration of the superior "specific" prophylactic effect of scopolamine on postanssthetic emesis. N.Y. St. J. Med., 1, 102. Haumann, J. L. R., and Foster, P. A. (193). The anti-emetic effect of halo thane. Brit. J. Anaesth., 35, 114. Heal, P. C. (195). Postoperative vomiting: methoxyflurane and halothane. Anaesthesia, 20, 275. Keats, A. (191). Editorial. Preoperative use of antiemetics. Anesthesiology, 21, 213. Knapp, M. R., and Beecher, H. K. (195). Postanesthetic nausea, vomiting, and retching: evaluation of the antiemetic drugs dimenhydrinate (Dramamine), chlorpromazine, and pentobarbital sodium. J. Amer. med. Ass., 10, 37. Novoa, R. R. (190). The anti-emetic effect of Fluothane: a comparative study in obstetrical anaesthesia. Canad. Anaesth. Soc. J., 7, 109. Riding, J. E. (193). The prevention of postoperative vomiting. Brit. J. Anaesth., 35, 180. Smessaert, A., Schehr, C. A., and Artusio, J. F. jr. (1959). Nausea and vomiting in the immediate post-anesthetic period. J. Amer. med. Ass., 170, Smith, M. (1945). Postoperative vomiting in relation to anaesthetic time. Brit. med. J., 1, 217. VOMISSEMENTS POSTOPERATOIRES DANS LA CHAMBRE DE REVEIL SOMMAIRE Pendant une periode de 21 mois gynecologiques ont ete etudiees consecutivement pendant trois heures dans la chambre de reveil. Trois anesthesiques primaires ont ete utilises en general: (a) le cyclopropane avec ou sans thiopentone; (b) l'halothane avec ou sans thiopentone; et (c) le melange thiopentone-protoxyde d'azote-oxygene. Dix pourcents des recurent des melanges varies d'anesthesiques. La frequence generate des vomissements etait de 29%. Le cyclopropane etait associe avec une frequence significativement plus elevee de vomissements que l'halothane ou le melange thiopentoneprotoxyde d'azote-oxygene. L'induction par le thiopentone suivie par un agent d'inhalation primaire donna une moindre frequence de vomissements que l'induction par l'agent volatil seul. La duree de l'anesthesie, la position de taille ou dorsale, le type de premedication et la specificite de la chirurgie gynecologique n'exercerent aucune influence significative, cela vaut aussi pour differents facteurs physiques ou pharmacologiques. La principale conclusion qu'on peut tirer de ce qui precede, c'est que la nature de l'anesthesique primaire et la presence ou l'absence de thiopentone pour l'induction sont les facteurs les plus importants qui agissent sur la frequence des vomissements postoperatoires dans la chambre de reveil. POSTANASTHETISCHES ERBRECHEN IM ERHOLUNGSZIMMER NACH OPERATION ZUSAMMENFASSUNG Ober einen Zeitraum von 21 Monaten wurden gynakologische nicht ausgewahlte Patientinnen nach der Operation im Erholungszimmer jeweils drei Stunden lang beobachtet. Die drei zur Einleitung der Narkose benutzten Anasthetika waren: (a) Zyklopropan mit oder ohne Thiopenton; (2) Halothan mit oder ohne Thiopenton und (3) Thiopenton-Stickoxydul-Sauerstoff. Bei 10 Prozent der Patientinnen wurden die Agentien kombiniert appliziert. Erbrechen trat insgesamt bei etwa 29 Prozent der Patientinnen auf. Nach Zyklopropan kam es erheblich haufiger zu Erbrechen als nach Halothan und der kombinierten Applikation von Thiopenton-Stickoxydul-Sauerstoff. Nach Thiopenton-Induktion gefolgt von einem einleitenden Inhalationsnarkotikum wurde Erbrechen seltener beobachtet als nach alleiniger Applikation des Inhalationsnarkotikums. Die Dauer der Narkose, die Lithotomie (lagerung) im Gegensatz zur flachen Ruckenlage, die Art der Pramedikation sowie die Besonderheit des gynakologischen Eingriffs waren dabei ebensowenig von Bedeutung wie viele verschiedene physikalische oder pharmakologische Faktoren. Aus der Studie kann in erster Linie geschlossen werden, daf5 das erstapplizierte anasthetische Agens und das Vorhandensein oder Fehlen einer Thiopenton- Induktion die bedeutendsten Einfliisse fur das Auftreten von postanasthetischem Erbrechen im Erholungszimmer bleiben.