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SPECIAL ARTICLE
Year : 2008  |  Volume : 52  |  Issue : 2  |  Page : 159-163 Table of Contents     

A Prospective Study of Postoperative Vomiting in Children Undergoing Different Surgical Procedures under General Anaesthesia


1 Senior Resident, Department of Anaesthesiology, J.N.M.C.H., A.M.U., Aligarh, India
2 Professor, Department of Anaesthesiology, J.N.M.C.H., A.M.U., Aligarh, India
3 Asst. Professor, Department of Anaesthesiology, J.N.M.C.H., A.M.U., Aligarh, India

Date of Acceptance16-Feb-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
S Bano
Department of Anaesthesiology, J.N.M.C.H., A.M.U., Aligarh, U. P. 202002
India
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Source of Support: None, Conflict of Interest: None


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To identify the risk factors associated with postoperative vomiting (POV) in paediatric population undergoing common surgeries. The risk factors studied for association with POV were age >5 years, female gender, previous history of POV/motion sickness, type of surgery and duration of anaesthesia >45 min. A total of 100 ASA grade I and II patients of either sex aged between 2-12 years undergoing elective surgical procedures were screened for the study. All patients underwent similar anaesthe­sia protocol and received two antiemetic agents (ondansetron 0.05mg.kg-1 and dexamethasone 0.15mg.kg-1) in premedication. The patients were observed for 24 hours postoperatively for the incidence of vomiting, number of times rescue antiemetic given and any adverse reaction to antiemetic.Overall 34% patients (34/100) developed POV of which 26 had only one episode and 8 patients had 2 episodes during first 24 h. Incidence of POV was 13% (13/100) in first 4 h whereas it was 29% (29/100) in late postoperative period. In early post operative period, POV was not associated significantly with any predicted risk factors. However, age>5years, duration of anaesthesia>45 minutes and history of motion sickness/POV were significantly associated in late postoperative period(4-24h). Female gender and type of surgery were not associated with increased POV. The combination antiemetic effectively prevented POV in early postoperative period (0-4h) only but not in late postoperative period(0-24h).

Keywords: Paediatric anaesthesia;Vomiting;Postoperative, Ondansetron;Dexamethasone


How to cite this article:
Choudhary J, Bano S, Ahmed M, Zaidi M N. A Prospective Study of Postoperative Vomiting in Children Undergoing Different Surgical Procedures under General Anaesthesia. Indian J Anaesth 2008;52:159-63

How to cite this URL:
Choudhary J, Bano S, Ahmed M, Zaidi M N. A Prospective Study of Postoperative Vomiting in Children Undergoing Different Surgical Procedures under General Anaesthesia. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 15];52:159-63. Available from: http://www.ijaweb.org/text.asp?2008/52/2/159/60614


   Introduction Top


Post operative nausea and vomiting (PONV) is one of the "big little problem" for being most common and unpleasant side effect following anaesthesia and surgery. The overall incidence of PONV has decreased from 60% when ether and cyclopropane were used, to approxi­mately 30% nowadays. [1] However, the incidence of post­operative vomiting (POV) in children remains at 40% and in certain high-risk patients it is as high as 70%. [2]

POV not only distresses the child but also de­creases parental satisfaction and is a major cause of unanticipated admission. [3] Uncontrolled vomiting may cause fluid and electrolyte imbalance, severe dehydra­tion and wound dehiscence. Children undergoing mul­tiple procedures are more likely to be uncooperative if they faced POV in post operative period. POV makes the child irritable and repeated POV might even cause behavioural changes.

Universal POV prophylaxis however, is not cost effective, is unlikely to benefit patients at low risk for POV and would put them at risk from the potential side effects of antiemetic agents. There is also lack of evi­dence that patient satisfaction is affected. [4]

Identification of patients at high risk for POV en­ables targeting prophylaxis to those who will benefit most from it. Gan et al recommended that antiemetic prophy­laxis in paediatric age group to be given only in moder­ate to high risk patients. [5] For these reasons, tools to pre­dict an increased risk for developing POV are certainly useful in clinical practice.

Causes of PONV are multifactorial and involve anaesthetic, surgical and patient risk factors. Several scoring systems have been developed for adults [6],[7] but their use is limited in paediatric population.

Various antiemetics are available for the prophy­laxis of POV in children such as metoclopramide, droperidol, perphenazine, midazolam, ondansetron and dexamethasone. Till date, no single drug has been found as an effective antiemetic agent that can inhibit the path­way of vomiting reflex and antagonize all receptor sites involved in emetic response.

Prophylaxis in children at moderate to high risk of emesis should include a combination of 5HT 3 antagonist and a second drug. [5] This combination is effective than single drug for prophylaxis of PONV. [8]

We conducted this study to identify the risk factors associated with POV in paediatric population undergo­ing common surgeries. Ondansetron and dexamethasone combination was used as prophylaxis of PONV and the anaesthetic technique used was same for all patients so as to identify risk factors other than the type of anaes­thesia. The risk factors investigated in this study for as­sociation with POV were age >5 years, female gender, previous history of POV, type of surgery and anaesthe­sia for more than 45 min duration.


   Methods Top


The prospective, observational, cohort study was done at our institution for a period of one year. One hun­dred ASA grade I and II patients of either sex aged be­tween 2-12 years undergoing elective surgical proce­dures were randomly selected. Exclusion criteria from the study were patients with ASA grade III and above, full stomach, emergency surgical procedure or patients on any antiemetic drugs.

All patients underwent a thorough pre anaesthetic check-up (PAC) in the PAC clinic and followed similar anaesthesia protocol. They were premedicated with midazolam 0.1 mg.kg -1 IM/0.03 mg.kg -1 IV, tramadol 2mg.kg -1 IV, glycopyrrolate 0.01mg.kg -1 IV, ondansetron 0.05mg.kg -1 IV and dexamethasone 0.15 mg.kg -1 IV.

Following preoxygenation for 3 min with 100% oxygen, patients were induced with thiopentone 5mg.kg­-1 IV and vecuronium 0.1 mg.kg -1 was given as neuro­muscular blocker. Intubation was done with appropriate size tracheal tube after adequate relaxation.

Anaesthesia was maintained with 0.5-1% halothane in 50-50 % mixture of nitrous oxide and oxygen. Ventila­tion was controlled manually using Mapleson F circuit. Standard monitoring (pulse rate, HR, NIBP, SpO 2 , tem­perature) was done throughout anaesthesia and surgery. At conclusion of surgery, residual paralysis was reversed with neostigmine 0.04 mg.kg -1 and glycopyrrolate 0.01 mg.kg -1 .

Parameters recorded in postoperative period

  1. Vomiting episodes in first 24 hours were assessed
  2. using vomiting scale:
  3. <2 episodes = mild vomiting
  4. 2 vomiting = moderate vomiting
  5. >2 episodes = Severe vomiting
  6. The numbers of times rescue antiemetics (onda­nsetron 0.1mg.kg -1 ) given in 24 hour period.
  7. Adverse effects during 24 hours i.e. headache, se­dation, diarrhoea and abdominal pain were recorded.
Risk factors to be evaluated in the study

  1. Age > 5 years,
  2. Sex: female vs male,
  3. Type of surgery: ENT, ophthalmology, abdominal, urological, plastic etc.,
  4. History of POV/ motion sickness, and
  5. Duration of anaesthesia (>45 min).
Statistical analysis

All the data are expressed as Mean±SD. The vomit­ing incidences in various groups were compared using Chi square test. Values were taken as significant when p<0.05.


   Results Top


One hundred paediatric patients aged between 2.5 years to 12 years were studied during one year period for the incidence of POV. The mean (SD) age, weight, dura­tion of anaesthesia and male : female ratio of the patients was 6.4 (2.9) years, 19.4 (6.6) kg, 71.5 (32.3) min and 62 : 38 respectively [Table 1]. These patients were operated for various surgical procedures [Table 2] and assessed for various risk factors for POV [Table 3].

A total of 34 patients suffered from postoperative vomiting episodes in 24 hours (34%), of which 26 had only one episode and 8 patients had 2 episodes. No pa­tient suffered from severe vomiting (>2 episodes). Only 13% (13/100) patients suffered from vomiting in first 4 h whereas it was 29% (29/100) in late postoperative pe­riod (4-24 h).

As evident in [Table 4], none of the predicted risk factors was found to be statistically significant for caus­ing POV during first 4 hours. However, in the late post­operative period, vomiting was present in 37% patients (23/63) aged more than 5 years whereas it was present in 16% patients (6/37) aged less than 5 years. The dif­ference in the incidence was statistically significant (P=0.03).

Whilst both gender groups were similar in the inci­dence of vomiting, the incidence of POV was higher in patients with duration of anaesthesia exceeding 45 min. POV was present in 38% patients (23/61) when the duration of anaesthesia exceeded 45 min while it was 15% (6/39) when duration of anaesthesia was short (<45 min). The difference was statistically significant. (P=0.02).

Out of one hundred patients, twenty patients had either a positive history of POV or motion sickness [Table 3]. As evident in [Table 4], 25% patients (5/20) with a positive history of POV/motion sickness had vomiting in first 4 hours whereas 10% patients (8/80) without his­tory of POV or motion sickness had vomiting. The dif­ference in the two groups was not statistically signifi­cant. Also evident in [Table 4], the incidence of vomiting was not associated with any particular surgical proce­dure.

No rescue antiemetic ( ondansetron 0.1mgkg -1 ) was administered to 66 patients in first 24 hours postop­eratively. However, 26 patients required one dose whereas 8 patients required two doses of antiemetic. [Table 5]

Four patients developed abdominal cramps and two patients developed diarrhoea as an adverse reaction to antiemetic prophylaxis. None developed headache, ex­cess sedation or erythema at injection site. [Table 6]


   Discussion Top


Postoperative vomiting remains a major cause of patient distress, delayed hospital discharge, unanticipated hospital admission and increased use of resources leading to increased cost of care both in adults and children. [3]

Unremitting vomiting leads to dehydration, fluid& electrolyte imbalance and unwarranted side effect like pulmonary aspiration in children. Despite incidence of POV hanging around 35-40% in children, the benefit of routine prophylactic antiemetic treatment has been ques­tioned because antiemetics have their own side effects (sedation, lethargy& extrapyramidal). However, totally neglecting the potential of prophylactic antiemetic is by no mean acceptable but cost of prophylaxis can be con­tained by identifying "at high risk" patients.

The overall incidence of vomiting in our study was 34% in 24 hours period with a lower incidence of 13% during first 4 hours but higher incidence (29%) during 4­24 hour time period. Rowley et al [2] found similar inci­dence of POV in children. Lower incidence of POV during early postoperative period signifies extended ac­tion of antiemetic prophylaxis given as premedication. Thus lower incidence of POV during first 4 hours as compared to 4-24 hours (13% vs 29%) signifies that combined premedication of ondansetron 0.05mg.kg -1 and dexamethasone 0.15 mg.kg -1 IV is highly effective in preventing POV in paediatric patients undergoing sur­gery under general anaesthesia.

Younger age is a risk factor that is identified in adults 9 however, in our study we found young children (<5years) are less susceptible to emetic stimuli. 16% (6/37) patients of age <5 years developed vomiting whereas 37% (23/63) aged > 5 years had vomiting episode in 4-24 hours period. The comparison was found to be statistically significant.

Our findings are similar to those of Cohen et al. [10] Eberhart et al [11] also found that risk factor for develop­ing POV increases dramatically in patients aged more than 3 years. The difference in findings of two studies may be because of selection criteria. We studied chil­dren aged 2-12 years whereas Eberhart had studied POV in children aged 0-14 years

No statistical difference in the incidence of POV in the two gender groups was found. This was compa­rable to findings of Rowley et al [2] and Gan et al. [5] In­creased emesis observed in adult female patients is prob­ably due to hormonal changes occurring post puberty. Most of the girls in our study were in pre-pubertal age group so the incidence was similar in both gender groups.

Our study reveals significantly different incidence of POV in patients exposed to >45 min of anaesthesia when compared with <45 min duration. It can be ex­plained by the fact that longer presence of emetic stimu­lus intraoperatively (volatile anaesthetics, N2O, opioids) increases the likelihood of vomiting in postoperative pe­riod. Similar observations have been made in adult POV scoring studies. [7],[12],[13] In the paediatric risk study Eberhart et al [11] however found higher emetic episodes in surger­ies longer than 30 min duration.

History of motion sickness/POV has been associ­ated with increased POV in paediatric as well as adult patient studies. [7],[11],[12],[13] Positive history of POV/motion sickness was found to be statistically associated with increased POV in our study.

Paediatric operations considered to be at high risk for PONV are strabismus surgery, adenotonsillectomy, hernia repair, orchidopexy, penile surgery and middle ear procedures [14],[15],[16] However, Apfel et al [12] did not find any association between type of surgery and the risk of PONV. In our study also, association of POV with any particular surgical procedure was not found. We, however, could not study association of strabismus surgery with POV as none of the patients underwent strabismus surgery.

Certain other risk factors like use of opioid, volatile anaesthetics and use of regional anaesthesia have been found to influence vomiting. However, the anaesthesia technique was kept common to all patients in this study. By identifying these "at risk" children and selectively premedicating them we can decrease incidence of POV, improve parental satisfaction and reduce overall cost.

Another major finding in our study was the inci­dence of POV in high risk group. It remained high in late postoperative period (4-24 hours) despite the use of com­bination therapy. Therefore, in high risk patients, not only combination antiemetic prophylaxis should be used but also the anaesthetic technique modified to further re­duce POV. Few modifications that might be helpful in­clude avoiding volatile anaesthetics, opioids and nitrous oxide in high risk group. Total intravenous anaesthesia (TIVA) with propofol is another option in these patients. Propofol infusion will not only preclude use of volatile anaesthetic but also has additional antiemetic properties. Postoperative pain is again associated with POV. Use of regional blocks whenever possible, will not only mini­mize need of parenteral opioids but also provide longer postoperative pain free period.

One of the drawbacks of our study was small sample size. Each risk factors needs to be studied in larger population group to come out with definite results. Similarly, number of patients in certain surgical group such as ophthalmic and orthopaedic surgeries was very small, making it difficult to conclude anything with cer­tainty.

 
   References Top

1.Gan TJ. Postoperative nausea and vomiting-can it be elimi­nated? JAMA 2002; 287:1233-6.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Rowley MP, Brown TC. Postoperative vomiting in children. Anaesthesia and Intensive Care 1982; 10:309-13.  Back to cited text no. 2  [PUBMED]    
3.Patel RI, Hannallah RS. Anesthetic complications following pediatric ambulatory surgery: a 3-year study. Anesthesiology 1988; 69: 1009-12.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.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.  Back to cited text no. 4      
5.Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philips BK, Trames R, Watch M. Consensus guide­lines for managing postoperative nausea and vomiting; Anesth Analg 2003; 97: 62-71.  Back to cited text no. 5      
6.Palazzo M, Evans R. Logistic regression analysis of fixed pa­tient factors for postoperative sickness: a model for risk as­sessment. Br J Anaesth 1993; 70: 135-40.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of post­operative nausea and vomiting. Anaesthesia 1997; 52: 443-9.  Back to cited text no. 7      
8.Splinter WM, Rhine EJ. Low dose ondansetron with dexam­ethasone more effectively decreases vomiting after strabismus surgery in children than does hgh dose ondansetron. Anesthesi­ology 1998; 88: 72-75.  Back to cited text no. 8      
9.Apfel CC, Greim CA, Haubitz L. A risk score to predict the probability of post operative vomiting in adults. Acta Anaesthesiol Scand 1998; 42: 495-501.  Back to cited text no. 9      
10.Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the postoperative period. Anesth Analg 1990; 70: 160-7.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Ebenhart LHJ, Geldner G, Kranke P, Morin M, Schauffelen A, Treiber H, Wulf H. The development and validation of risk score to predict the probability of postoperative vomiting in pediatric patients. Anesth Analg 2004; 99: 1630-37.  Back to cited text no. 11      
12.Apfel CC, Laara E, Koivuranta M,et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999; 91: 693-700.  Back to cited text no. 12      
13.Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999; 91:109-18.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Larsson S, Jonmarker C. Postoperative emesis after pediatric strabismus surgery: the effect of dixyrazine compared to droperidol. Acta Anaesth Scand 1990; 34: 227-30.  Back to cited text no. 14  [PUBMED]    
15.Haigh CG, Kaplan LA, Durham JM, et al. Nausea and vomiting after gynaecological surgery: a metaanalysis of factors affect­ing their incidence. Br J Anaesth1993; 71: 517-22.  Back to cited text no. 15      
16.Honkavaara P. Effect of transdermal hyoscine on nausea and vomiting during and after middle ear surgery under local anaes­thesia. Br J Anaesth1996; 76: 49-53.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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