Does Infusion of Colloid Influence the Occurrence of Postoperative Nausea and Vomiting After Elective Surgery in Women? (Anesth Analg 2009;108:1788 –93)
BACKGROUND • The prevention of postoperative nausea and vomiting (PONV) has been the subject of several studies • In addition to the effects of various drugs, it has been shown that the administration of high volumes of intraoperative fluid replacement, commonly crystalloids, can decrease the incidence of PONV
BACKGROUND • The impact of the type of fluid on postoperative nausea and vomiting (PONV) is not well defined. • In this study we investigated the effects of colloids or crystalloids on PONV when given in addition to a background minimal crystalloid infusion in a female population of surgical patients.
METHODS • 115 female patients with ASA I or II • elective gynecological or breast surgery • randomly allocated to receive HES 130/0.4 or 0.9% NaCl • Exclusion criteria: • <18 yr • coagulopathy（凝血） • significant hepatic or renal dysfunction（肝肾功能） • congestive heart failure（充血性心衰） • hypersensitivity to HES（过敏）
METHODS • background solution • starting at the induction of anesthesia • 5% dextrose in 0.45% NaCl • 0.5 mL /kg/h for 24 h • study solution • before the induction of anesthesia • 500 mL HES 130/0.4 or 0.9% NaCl • 1 mL /kg/ h for 24 h
METHODS • No antiemetic prophylaxis • ECG, NBP, SPO2, and CO2 • induced : • 1–2.5 mg/kg propofol • 10–20 ug sufentanil • neuromuscular blocking drug • maintained : • sevoflurane (1–2 MAC) • sufentanil and/or neuromuscular blocking drugs
Patients received IV analgesia for postoperative pain relief consisting of 1 g paracetamol 4 times per day , and 1 mg/kg diclofenac twice per day to a maximum of 75 mg twice per day
Primary End Points • The occurrence of any postoperative nausea or vomiting during the 24 h after surgery • Nausea（恶心） • the urge to vomit without expulsion of gastric contents and without effort to empty the stomach • Vomiting（呕吐） • the forceful expulsion of liquid gastric contents • Retching（干呕） • vomiting efforts, but without gastric emptying, and was considered the same as vomiting for the purpose of this study
The severity of nausea was rated on an 11-point number rating scale (NRS): any score on the 11-point NRS more than zero was considered to be a positive event • PONV was evaluated every hour for the first 4 h, and then every 3 h for 24 h.
Secondary End Points • The frequency of antiemetic rescue therapy use • Treatment : • 5 mg dexamethasone • 1.25 mg droperidol • 100 mg alizapride • 4 mg IV ondansetron • if each of the previous treatments failed • The need for antiemetic therapy and the number of times antiemetic therapy was required were noted (mono, bi, tri, or quadritherapy )
The incidence of hypotensive events (Hypotension defined as a 20% decrease in systolic blood pressure compared with the baseline) • Hypotension and nausea occurring at the time of the patient’s first mobilization after surgery • The severity of pain • In addition, pain severity was rated on an 11-point NRS and evaluated at the same intervals as PONV
DISCUSSION • Previous studies investigating the effect of colloid versus crystalloid for surgeries in which large fluid shifts or blood loss was expected showed a 50% reduction in the incidence of PONV • The present study using female patients having surgery with limited fluid shifts or blood loss was unable to demonstrate that the infusion of HES 130/0.4, in addition to a fixed background infusion of 5% dextrose in 0.45% NaCl, could produce such a profound effect on the incidence of PONV or the need for antiemetic treatment compared with 0.9% normal saline
DISCUSSION • limitations • First,there was no placebo arm, but this would have been difficult, as some fluids are required by all patients .We could perhaps have added a group with intraoperative lactated Ringer’s solution followed by 5% dextrose in 0.45% NaCl, which is our standard practice.
Second, our choice of antiemetic drugs may not have been optimal; by choosing dexamethasone as the primary rescue antiemetic, this may have delayed the treatment of PONV and hence increased the incidence of PONV; nevertheless, this effect would have been the same for the two groups
CONCLUSION • In conclusion, in women undergoing gynecological or breast surgery with no major blood loss, HES 130/0.4 and 0.9% NaCl, at the volumes used in this study, had similar effects on PONV when administered along with a low-volume baseline infusion of 5% dextrose in 0.45% NaCl • This is in contrast to when large fluid shifts or blood loss occur where colloid solutions seem to have a more profound effect on PONV