1 Department of Cardiothoracic Surgery and 2 Department of Anesthesiology, Rabin Medical Center, Beilinson Campus, Petah-Tiqva 49100, Israel.Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Corresponding author. E-mail: akogan@clalit.org.il
Accepted for publication: March 13, 2003
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Abstract |
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Methods. A prospective study was performed in the cardiothoracic ICU (CTICU) of a university hospital; 1221 consecutive patients undergoing fast-track anaesthesia (FTCA) in cardiac surgery were enrolled in the study. Severity of PONV was assessed immediately after extubation and then every hour until discharge from the CTICU. Metoclopramide 10 mg i.v. was used as a first-line rescue medication and ondansetron 4 mg i.v. as second-line rescue medication for PONV.
Results. Nausea was reported in 240 (19.7%) patients, and vomiting in 53 (4.3%). A total of 269 (22%) patients were treated with metoclopramide and 38 (3.1%) with metoclopramide and ondansetron. The latter was effective in all cases. Risk factors for PONV were age less than 60 yr, female gender and previous history of PONV. Discharge from the CTICU was delayed for a few hours because of PONV in eight patients, all of whom were discharged the same day.
Conclusions. The incidence of PONV is relatively low after FTCA and does not prolong ICU stay. Prophylactic administration of anti-emetic drugs before FTCA is not necessary.
Br J Anaesth 2003; 91: 21417
Keywords: anaesthesia, cardiac fast-track; surgery, cardiovascular; vomiting, nausea, postoperative
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Introduction |
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Methods |
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Anaesthesia was standardized. Patients were premedicated with midazolam syrup 0.1 mg kg1. Anaesthesia was induced with fentanyl 1015 µg kg1 and midazolam 0.020.04 mg kg1. Pancuronium bromide was administered to facilitate tracheal intubation. A gastric tube was inserted in all patients. The lungs were ventilated with an oxygen/air mixture (FIO2 0.50.6) with a tidal volume of 810 ml kg1 to maintain normocapnia. Anaesthesia was maintained with isoflurane, fentanyl and midazolam. Total dose of fentanyl was 2040 µg kg1, which was higher than previously reported for fast-track anaesthesia by Cheng and colleagues,12 and of midazolam was 0.150.2 mg kg1. After completion of surgery, patients were transferred to the ICU, where they were treated with warm air heaters to ensure normothermia. Inotropic drugs were continued when needed. Sedation with i.v. midazolam was allowed before extubation. No propofol was used for postoperative seda tion. Analgesia was provided by i.v. morphine injections. Midazolam and morphine were given by intermittent boluses according to patient status. Weaning from the ventilator and extubation were performed according to the protocol proposed by the fast-track cardiac care team.13 Episodes of PONV (nausea, retching and vomiting) were recorded by the nurses every hour, beginning from time of extubation until discharge from the ICU. For the purpose of this study, both actual vomiting and retching were considered as vomiting. I.V. metoclopramide 10 mg was prescribed for all patients as a first-line rescue anti-emetic medication and given as required by the nurse caring for the patient. I.V. ondansetron 4 mg was prescribed by an attending intensivist as a second-line medication in patients who continued to vomit or experienced persistent nausea 30 min after metoclopramide administration. No other anti-emetic medication, including dexamethasone, was used.
Statistical analysis
Numerical data are expressed as mean (SD). Univariate analysis was initially performed to identify risk factors associated with PONV using 2 analyses. P<0.05 was considered statistically significant and odds ratio was calculated. Variables associated with PONV with a P value <0.05 in the univariate analyses were entered into multiple logistic regression analyses to identify independent risk factors. The odds ratio, 95% confidence interval and P values were calculated for each risk factor. P <0.05 was considered statistically significant. Differences in complication rates and lactate concentrations between PONV and non-PONV groups were calculated using Students t-test. Differences were considered statistically significant at P <0.05. Statistical analysis was performed using SPSS 8.0 for Windows.
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Results |
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Discussion |
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Grebenic and Allman7 and Woodwarg and colleagues8 have previously reported a 4649% incidence of nausea and 3742% incidence of vomiting in their patients after cardiac surgery. In our study, the incidence of PONV was considerably lower: 19.7% of patients had nausea and 4.3% had vomiting. This may be related to our practice of using low-to-moderate doses of fentanyl (2040 µg kg1) and relatively low doses of morphine (515 mg) during the postoperative period. Doses of fentanyl for FTCA used in our study are higher than reported by Cheng and colleagues12 and Silbert and colleagues13 (15 µg kg1).
Nausea can be associated with a high concentration of cathecholamines.15 However, inotropic support was stopped a few hours before extubation in most cases. Only 108 (8.8%) patients received mild inotropic support at the time of extubation. Gan and colleagues9 consider the use of gut hypoperfusion during CPB as another possible cause of PONV. The duration of CPB in our patients was relatively short: 67.2 (11.3) min. No signs of hypoperfusion were recorded.
Anti-emetics may be administered before, during or after surgery to prevent PONV or may be given after surgery to treat established PONV. The latter approach is a satisfactory option for patients undergoing surgical procedures with a low frequency of PONV, such as FTCA. It is considered reasonable to employ rescue perioperative anti-emetic as needed and to avoid routine prophylactic administration. This strategy avoids side-effects and the cost of unneeded anti-emetic therapy while still providing reasonable control of emesis.16 According to our regimen, metoclopramide 10 mg i.v. is effective in most cases, while ondansetron 4 mg i.v. can be added when complete resolution of PONV is necessary.
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References |
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