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1、Postoperative Nausea and Vomiting: Prevention and Treatment,Phillip E. Scuderi, M.D. Department of Anesthesiology Wake Forest University School of Medicine Winston-Salem, NC 27157-1009,Postoperative Nausea and Vomiting: Prevention and Treatment,http:/www.wfubmc.edu/anesthesia pscuderiwfubmc.edu,Hist
2、orical Perspective on PONV,Postoperative Nausea and Vomiting: Its Etiology, Treatment, and Prevention Mehernoor F. Watcha and Paul F. White Anesthesiology 1992;77:162-184,Quality of Clinical Trials,Appearance of control treatment Blinding of randomization process Blinding of patients and observers,
3、Sample size estimate and power analysis Confidence intervals Statistical analyses Withdrawals Side effect discussions,Greenfield et al. Anesth Analg 2003;96:S88,Quality of Clinical Trials,Greenfield et al. Anesth Analg 2003;96:S88,Quality of Clinical Trials,Investigators Improve rigor of study proto
4、cols Improve quality of data analysis Peer Reviewers Process of randomization Power analysis Blinding,Suggestions for Improvement,Greenfield et al. Anesth Analg 2003;96:S88,Critical Evaluation of Data,Quality of individual clinical trials Type and adequacy of controls used Blinding process Sample si
5、ze, power analysis Appropriateness of endpoints chosen Confidence limits particularly for negative studies Statistical analysis,Critical Evaluation of Data,Quality of individual clinical trials Evaluation of data in aggregate,Evidence Based Medicine Rating Scale,Level of evidence based on study desi
6、gnI. Large randomized, controlled trial (n100 per group)II. Systematic reviewIII. Small randomized, controlled trial (n100 per group)IV. Nonrandomized controlled trial or case reportV. Expert opinion Strength of Recommendation based on expert opinionA. Good evidence to support the recommendationB. F
7、air evidence to support the recommendationC. Insufficient evidence to recommend for or against,Critical Evaluation of Data,Quality of individual clinical trials Evaluation of data in aggregate Estimation of treatment consequences,Measures of Treatment Consequences,Relative Risk Reduction The reducti
8、on of adverse events achieved by a treatment, expressed as a proportion of the control rate Odds Ratio The traditional expression of the relative likelihood of an outcome expressed as P/(1 - P) where P = probability Absolute Risk Reduction The difference in event rates between the control and treatm
9、ent groups Numbers Needed to be Treated (NNT) The number of patients who must be treated in order to prevent one adverse event. It is mathematically equivalent to the reciprocal of the absolute risk reduction.,Laupacis et al. NEJM 1988;318:1728-1733,Measures of Treatment Consequences,Laupacis et al.
10、 NEJM 1988;318:1728-1733,Topics,Risk factors Pharmacologic approaches to management Adjuvants (nonpharmacologic) Efficacy versus outcome Prevention versus treatment Postdischarge nausea and vomiting Multimodal management,Topics,Risk factors,Risk Factors,Non-anesthetic factors Anesthetic related fact
11、ors Postoperative factors,Risk Factors,Age Gender Body habitus Hx motion sickness Hx PONV Anxiety Concomitant disease Operative procedure Duration of surgery,Non-anesthetic Factors,Risk Factors,Preanesthetic medication Gastric distension Gastric suctioning Anesthetic technique Anesthetic agents,Anes
12、thetic Related Factors,Risk Factors,Pain Dizziness Ambulation Oral intake Opioids,Postoperative Factors,Risk Factors Patient Specific,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.,Koivur
13、anta M, Lr E, Snre L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997;52:443-49.,Apfel CC, Greim CA, Haubitz I, et al. A risk score to predict the probability of postoperative vomiting in adults. Acta Anaesthesiol Scand 1998;42:495-501.,Logistic Regression,Risk Factors Pa
14、tient Specific,Younger age Nonsmoking history Female Hx of motion sickness Hx of PONV Increased duration of operation,Logistic Regression,Risk Factors Patient Specific,Female Nonsmoking history Hx of motion sickness or PONV Use of postoperative opioids,Simplified Scoring System,Incidence of PONV,Apf
15、el CC et al. Anesthesiology 1999;91:693-700.,Risk Factors Anesthetic Related,Apfel et al. BJA 2002;88:659-668,* Compared to propofol,Volatile Anesthetics,Risk Factors Anesthetic Related,Nitrous Oxide and PONV,Risk Factors Anesthetic Related,Decreases POV significantly only if the baseline risk is hi
16、gh Does not affect nausea or complete control of emesis Increases the incidence of intraoperative awareness,Omitting nitrous oxide from general anesthesia:,Tramer et al. BJA 1996;76:186-193,Nitrous Oxide and PONV,Risk Factors Surgical Risk Factors,Duration of Surgery,Type of Surgery,Apfel et al. BJA 2002;88:659-668 Sinclair et al. Anesthesiology 1999; 91:109-118,Sinclair et al. Anesthesiology 1999; 91:109-118 Apfel et al. BJA 2002;88:659-668 Fabling et al. Anesth Analg 2000;91:358-361 Gan et al. Anesthesiology 1996;85:1036-1042,
