|Year : 2008 | Volume
| Issue : 2 | Page : 159-163
A Prospective Study of Postoperative Vomiting in Children Undergoing Different Surgical Procedures under General Anaesthesia
Jaya Choudhary1, S Bano2, Mohib Ahmed3, MN Zaidi1
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 Acceptance||16-Feb-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anaesthesiology, J.N.M.C.H., A.M.U., Aligarh, U. P. 202002
Source of Support: None, Conflict of Interest: None
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 2020 Nov 27];52:159-63. Available from: https://www.ijaweb.org/text.asp?2008/52/2/159/60614
| Introduction|| |
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.  However, the incidence of postoperative vomiting (POV) in children remains at 40% and in certain high-risk patients it is as high as 70%. 
POV not only distresses the child but also decreases parental satisfaction and is a major cause of unanticipated admission.  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. 
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.  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 , 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.  This combination is effective than single drug for prophylaxis of PONV. 
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|| |
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
Risk factors to be evaluated in the study
- Vomiting episodes in first 24 hours were assessed
- using vomiting scale:
- <2 episodes = mild vomiting
- 2 vomiting = moderate vomiting
- >2 episodes = Severe vomiting
- The numbers of times rescue antiemetics (ondansetron 0.1mg.kg -1 ) given in 24 hour period.
- Adverse effects during 24 hours i.e. headache, sedation, diarrhoea and abdominal pain were recorded.
- Age > 5 years,
- Sex: female vs male,
- Type of surgery: ENT, ophthalmology, abdominal, urological, plastic etc.,
- History of POV/ motion sickness, and
- Duration of anaesthesia (>45 min).
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|| |
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|| |
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. 
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  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.  Eberhart et al  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  and Gan et al.  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. ,, In the paediatric risk study Eberhart et al  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. ,,, 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 ,, However, Apfel et al  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|| |
|1.||Gan TJ. Postoperative nausea and vomiting-can it be eliminated? JAMA 2002; 287:1233-6. [PUBMED] [FULLTEXT] |
|2.||Rowley MP, Brown TC. Postoperative vomiting in children. Anaesthesia and Intensive Care 1982; 10:309-13. [PUBMED] |
|3.||Patel RI, Hannallah RS. Anesthetic complications following pediatric ambulatory surgery: a 3-year study. Anesthesiology 1988; 69: 1009-12. [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. |
|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. |
|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. [PUBMED] [FULLTEXT] |
|7.||Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997; 52: 443-9. |
|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. |
|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. |
|10.||Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the postoperative period. Anesth Analg 1990; 70: 160-7. [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. |
|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. |
|13.||Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999; 91:109-18. [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. [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. |
|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. [PUBMED] [FULLTEXT] |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]