postoperative nausea and vomiting free for all a solution from propofol

Postoperative nausea and/or vomiting PONV is an annoyance, particular during anesthesia emergence1, and its influence on the cost of medical care is significant.. Also in this issue of AAT

Editorial view

Postoperative nausea and vomiting free for all: A solution from propofol?

Postoperative nausea and/or vomiting (PONV) is an annoyance,

particular during anesthesia emergence1, and its influence on the

cost of medical care is significant It is estimated that more than

230 million major surgeries are performed annually around the

globe2, and about 30% of the patients, with an incidence of 80% in

high-risk group, suffered from PONV3,4; it sums up to more than

69 million people in the world every year Furthermore, about 1%

of ambulatory surgical patients are admitted overnight because of

intractable PONV3 Treatment of PONV and associated

complica-tions, and time lost from related works are estimated about

mil-lions of US dollars annually5 Yet, since it is self limiting in nature,

seldom chronic, and almost non-lethal, it rarely becomes a big issue

for anesthesiologists; and its impact is usually underestimated,

however, it matters to patients Sometimes, patients would rather

suffer from pain than PONV, and are willing to pay substantial

amounts of money for effective prevention and treatment1 No

wonder Kapur described postoperative nausea and vomiting-the

“big little problem”6

The prevalence of PONV has stayed unchanged over past

de-cades, regardless of the introduction of new antiemetic drugs,

short-acting anesthetics, and minimally invasive surgeries7 The

“big little problem” PONV depicted by Kapur is still a truth

nowa-days despite the hard works of anesthesiologists and

pharmaceu-tical companies As an editorial aiming at the prevention of

PONV, when PONV and its annihilation are addressed, doctors

have in mind the mental attitude: “we're tired of waiting”8

Although the persisted high incidence of PONV has been partly

due to the remarkable increase in ambulatory surgery and the

growing emphasis on earlier mobilization and discharge

postoper-atively9, a key barrier to the development of an effective treatment

for PONV has been the lack of a suitable animal model

Conse-quently, anesthesiologists have to count on the results of

number-less clinical trials, most of which are small-sized and even some

with suspicious power1

In this issue of Acta Anaesthesiologica Taiwanica (AAT), Bhakta

and colleagues report the results of a randomized controlled trial

determining the safety, efficacy and feasibility of

propofol-based-anesthesia in gynecological laparoscopies in reducing incidences

of PONV compared to a standard anesthesia using

thiopentone/iso-flurane10 Surprisingly, with a sample size of 30 patients in each

groups, the authors demonstrated that propofol-based-anesthesia

was associated with significantly less PONV, implying a strong

pre-ventive potential for this strategy Also in this issue of AAT, to

over-come the aforementioned doubtful validity associated with small

sample sizes, Matsuura and colleagues compared the incidence

and duration of PONV between propofol anesthesia and sevo flur-ane flur-anesthesia utilizing a retrospective analysis of an institutional registry11 Interestingly, with a large original sample size of 21,606 general anesthesia cases, a higher incidence of PONV received propofol anesthesia compared to sevoflurane anesthesia, however less PONV occurred after propofol anesthesia in propen-sity score matched 2,554 patient pairs This result supported the preventive potential of propofol-based anesthesia, and also demon-strated a good model for PONV research

As patients are more satisfied with PONV prophylaxis than with the treatment of symptoms after their occurrences, prophylactic strategy has become the customary approach to curtail postopera-tive emetic symptoms7 However, the mechanisms underlying PONV are complex that a general cure-all is almost implausible, therefore a multimodal approach serves better prevention and treatment9 To accomplish this objective, there is more than one option to consider Thefirst approach would be to wait and see, and to treat PONV once the symptoms do arise However, this idea obviously requires a vigilant clinical setting, and quick and aggressive management Such approach is incompatible with busy environments, at least 24 h after anesthesia, when emetic symptoms, especially nausea, are frequently missed It makes this approach impossible12 The second major option would be the so called ‘stratified medicine’, i.e to tailor the remedial decisions based on the patients' risks estimated by validated prognostic models However, the results on whether use of PONV risk scores can significantly decrease the rate of PONV remains controversy13, and there has been a strong dispute and discussion whether this approach truly works in a busy clinical scenario14,15 A third approach would be that all patients are given one or more anti-emetics during the course of surgery to reduce the incidence of PONV as possible Given the fact that the easy accesses are safe and low-priced, there is little indication to deny these strategies for fear of side effects16 We believe, with the new support from the articles in this issue of AAT, patients might be benefit from incorporation of propofol into regular anesthesia practice Conflicts of interest

All contributing authors declare no conflicts of interest References

1 Tramer MR Treatment of postoperative nausea and vomiting BMJ 2003 Oct 4;327(7418):762e3

Contents lists available atScienceDirect

Acta Anaesthesiologica Taiwanica

j o u r n a l h o me p a g e :w w w e - a a t c o m

Acta Anaesthesiologica Taiwanica xxx (2016) 1e2

http://dx.doi.org/10.1016/j.aat.2016.12.002

1875-4597/Copyright © 2017, Taiwan Society of Anesthesiologists Published by Elsevier Taiwan LLC This is an open access article under the CC BY-NC-ND license ( http:// creativecommons.org/licenses/by-nc-nd/4.0/ ).

Please cite this article in press as: Chang C-C, Wong C-SPostoperative nausea and vomiting free for all: A solution from propofol?, Acta Anaes-thesiologica Taiwanica (2016), http://dx.doi.org/10.1016/j.aat.2016.12.002

2 Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR,

Gawande AA An estimation of the global volume of surgery: a modelling

strat-egy based on available data Lancet 2008 Jul 12;372(9633):139e44

3 Tramer MR A rational approach to the control of postoperative nausea and

vomiting: evidence from systematic reviews Part I Efficacy and harm of

anti-emetic interventions, and methodological issues Acta Anaesthesiol Scand 2001

Jan;45(1):4e13

4 Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, Watcha M,

Chung F, Angus S, Apfel CC, Bergese SD, Candiotti KA, Chan MT, Davis PJ,

Hooper VD, Lagoo-Deenadayalan S, Myles P, Nezat G, Philip BK, Tramer MR,

Society for Ambulatory Anesthesia Consensus guidelines for the management

of postoperative nausea and vomiting Anesth Analg 2014 Jan;118(1):85e113

5 Hooper VD PONV/PDNV: why is it still the “big little problem?” J Perianesth

Nurs 2015 Oct;30(5):375e6

6 Kapur PA The big “little problem” Anesth Analg 1991 Sep;73(3):243e5

7 White PF Prevention of postoperative nausea and vomitingea multimodal

solution to a persistent problem N Engl J Med 2004 Jun 10;350(24):2511e2

8 Lichtor JL, Glass PS We're tired of waiting Anesth Analg 2008 Aug;107(2):

353e5

9 Sweeney B Postoperative nausea and vomiting BMJ 2006 Aug 12;333(7563):

313e4

10 Bhakta P, Ghosh BR, Singh U, Preeti S, Govind PS, Gupta A, Kapoor KS, Jain RK,

Nag T, Mitra D, Ray M, Singh V, Mukherjee G Incidence of postoperative nausea

and vomiting following gynaecological laparoscopy: a compassion of standard

anesthetic technique and propofol infusion.

11 Matsuura H, Inoue S, Kawaguchi M The risk of postoperative nausea and

vomiting between surgical patients received propofol and sevoflurane

anes-thesia: a matched study Acta Anaesthesiol Taiwan 2016 Nov 4 http://

dx.doi.org/10.1016/j.aat.2016.09.002 pii: S1875e4597(16)30004-2.

12 Franck M, Radtke FM, Apfel CC, Kuhly R, Baumeyer A, Brandt C, Wernecke KD,

Spies CD Documentation of post-operative nausea and vomiting in routine

clinical practice J Int Med Res 2010 May-Jun;38(3):1034e41

13 Kappen TH, Moons KG, van Wolfswinkel L, Kalkman CJ, Vergouwe Y, van

Klei WA Impact of risk assessments on prophylactic antiemetic prescription

and the incidence of postoperative nausea and vomiting: a cluster-randomized trial Anesthesiology 2014 Feb;120(2):343e54

14 Eberhart LH, Morin AM Risk scores for predicting postoperative nausea and vomiting are clinically useful tools and should be used in every patient: cone‘life is really simple, but we insist on making it complicated’ Eur J Anaes-thesiol 2011 Mar;28(3):155e9

15 Kranke P Effective management of postoperative nausea and vomiting: let us practise what we preach! Eur J Anaesthesiol 2011 Mar;28(3):152e4

16 Scuderi PE PRO: anatomical classification of surgical procedures improves our understanding of the mechanisms of postoperative nausea and vomiting Anesth Analg 2010 Feb 1;110(2):410e1

Chuen-Chau Chang, Section Editor* Department of Anesthesiology, Taipei Medical University Hospital,

Taipei, Taiwan Health Policy Research Center, Taipei Medical University Hospital,

Taipei, Taiwan Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 250 Wuxing St., Taipei, 11031,

Taiwan Chih-Shung Wong Department of Anesthesiology, Cathay General Hospital, #280, Renai

Road, Section 4, Taipei, 10630, Taiwan

*Corresponding author E-mail address:nekota@tmu.edu.tw(C.-C Chang)

C.-C Chang, C.-S Wong 2

Please cite this article in press as: Chang C-C, Wong C-SPostoperative nausea and vomiting free for all: A solution from propofol?, Acta Anaes-thesiologica Taiwanica (2016), http://dx.doi.org/10.1016/j.aat.2016.12.002