Does preoperative hydration affect postoperative nausea and vomiting?
Abstract
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Background
I work in the Post- Care Unit where the practice in dealing with postoperative nausea and vomiting (PONV) is treating nausea and stopping vomiting. Since there are a number of anesthesia techniques that can be employed to decrease the incidence of PONV, the observation of staff is that hydration may lead to the decrease of the incidence of PONV. Therefore, I decided to find out the possibility of conducting a research to investigate the impact of hydration on PONV through a literature review,
Literature Review
The literature review revealed that PONV is extensively addressed though the impact of hydration has received a limited attention. Even the studies carried out had limitation and in one or two of them generalization was not possible. The most relevant research for my topic (Adanir et al, 2008) was concerned with replacement of deficit fluid pre- and intra-operatively.
Conclusion
My conclusion was that there is a justifiable need for researching the impact of hydration on PONV and that it should be designed to involve the professional staff of pre-, intra- and postoperative surgical units.
Introduction
Patients of surgical operations are usually distressed by a number of postoperative complaints. A significant concern of patients is the postoperative nausea and vomiting (PONV). Working as a nurse anesthetist in the post-anesthesia care unit, it is my observation that patients are concerned with PONV and the professional staff would prefer to prevent PONV rather than dealing with it in the care unit. It is also an observation that many patients come to the operation room either fasting or undergo bowl preparation. Therefore, they are behind in fluids before the surgery and as a result the incidence of PONV is higher in this category of patients.
The problem is also the concern of researchers and is extensively discussed in the literature (Adanir etal, 2008; Amponsah, 2007; Kovac, 2000; McCaffrey, 2008). It is reported in the literature that PONV is not only a side effect of surgery and anesthesia that causes discomfort to patients but it can lead to further postoperative complications such as aspiration (McCaffrey, 2008). The incidence of PONV has been reported as being between 20 – 30% (Sweeney, 2006 as cited in McCaffrey, 2007; Kovac, 2000). The concern of patients about PONV was reported in these studies as more than their concern about pain. It was also reported as a main concern of patients with previous experience of surgery as they fear the recurrence of PONV more than the surgery itself (Amponsah, 2007).
In this paper I intend to investigate the problem of PONV in the literature in order to propose an empirical research in my work place dealing particularly with the incidence of PONV related to dehydration. This is necessary to recommend changes in the current practice or to support the practice with evidences.
I am going to address the problem in hand under the following headings:
– Literature review
– Discussion and Analysis
– Conclusions
Literature Review
PONV is thought to be multifactorial, as its risk factors may be related to patient, anesthesia and surgery (habib & Gan, 2004). It was also observed that patient factors are related to characteristics such as age, gender, obesity, and previous history of PONV or motion sickness (Aftab et al, 2008). Nevertheless the consequences of PONV make it essential to investigate the causes and work towards preventing or decreasing PONV. While the most common consequence is the complaint of patients that PONV is distressing and unpleasant there are a number of more serious consequences including the increase in cost of post anesthesia care. These serious consequences are summarized in the following quote:
“The consequences of PONV are patient-, physiological-, medical-, surgical-, anesthesia-, hospital and cost-related (table II). Prolonged vomiting may lead to electrolyte imbalances (hypokalaemia, hypochloraemia, hyponatraemic metabolic alkalosis) and dehydration. Aspiration of gastric contents in the perioperative period is an important anaesthesia related concern and consequence of PONV.[15] A MalloryWeis tear, oesophageal rupture, wound dehiscence and haematoma formation beneath skin flaps are important postoperative surgical-related concerns that may occur with PONV following abdominal, vascular, eye or plastic surgeries” (Kovac, 2000).
For the purposes of this paper the main concern is anesthesia related PONV and its prevention by hydration. According to Kovac (2000) factors related to anesthesia are premedication, anaesthetic gases, intravenous anaesthetic agents, reversal of muscle relaxation, preoperative fasting, nasogastric suctioning, long operations, regional anaesthesia, postoperative pain and orthostatic hypotension.
Opioids (morphine, fentanyl, alfentanil) used as premedication can increase the incidence of PONV. However, there are alternative medications that may decrease the incidence of PONV (Dundee et al, 1965 cited in Kovac, 2000).
The incidence of PONV produced by potent inhalational anaesthetic gases is reported as high as 75 to 80% (Palazzo and Strunin, 1984 cited in Kovac, 2000). On the other hand Kovac (2000) reports that avoiding using potent inhalational anaesthetic gases has no significance in the decrease of PONV. “However, while potent inhalational gases contribute to PONV to some degree, the total avoidance of these volatile agents has not resulted in a marked decrease of PONV” (Kovac, 2000).
For intravenous anaesthetic agents the incidence of PONV is contrasted between two types: while the incidence of PONV is low with agents that have a slow onset and smooth recovery (i.e. thiopental, propofol), it is comparatively high with medications with a more rapid recovery (i.e. methohexital, propanidid) (Philip, 1997 as cited in Kovac, 2000).
It is also reported that reversal of muscle relaxation with an anticholinesterase medication alone (i.e. neostigmine) possibly increases the incidence of PONV though use of a muscle relaxant alone does not (King et al, 1988 cited in Kovac, 2000). However, this minor increase of PONV incidence related to reversal muscle relaxation can be adjusted by using anticholinergic medication (i.e. atropine) in combination with neostigmine due to the antiemetic effect of atropine (Salmenpera et al, 1992 cited in Kovac, 2000).
Preoperative fasting, which is of high relevance to this paper, is an important preoperative measure since aspiration of gastric contents during the induction of anaesthesia is an important anaesthesia-related concern (Salem,Wong and Fizzotti, 1972 cited in Kovac 2000). Yet postoperative dehydration is one of the undesirable conditions of surgery and that may lead to increased incidence of PONV. While fasting makes the patient behind in fluids, fluid loss during surgery cannot be avoided. The following quote illustrates:
“During a surgical procedure there are many avenues of fluid loss. Unhumidified anesthetic gasses, perspiration, evaporation, blood loss, urine, and loss of other body fluids (acities, GI contents) are among the most common causes of loss. All of these contribute to dehydration” (Monti and Pokorny, 2000)
It is also emphasized that the preoperative measures of nothing by mouth a few hours before surgery contributes to preoperative dehydration which is a risk factor for PONV. The assertion of in this quote illustrates:
“Postoperative outcomes such as thirst, dizziness, drowsiness, and nausea may be influenced by the surgical patient’s fluid status before and after surgery. Pre-operative dehydration may occur due to the preoperative nothing-by-mouth (NPO) orders that often go into effect many hours before surgery. Preoperative dehydration may be compounded in a patient whose scheduled surgery is delayed. Aggressive perioperative hydration with infusions at rates of up to 20 mL/kg/hr has been shown to effectively deter PN, as well as thirst, dizziness, and drowsiness.[79] Recently, more liberal preoperative NPO guidelines have been introduced in an effort to avoid preoperative dehydration” (Golembiewski, 2005).
Although PONV in general is addressed intensively in the literature, there are very few studies addressing the use of hydration as a technique for reducing the incidence of PONV. Monti and Pokorny (2000) report that the study of Yogendran et al (1995) which investigated the impact of preoperative fluids in two groups of ambulatory surgical patients who received a high infusion of isotonic electrolytes of 20cc/kg for one group and 2cc/kg for the other group. The conclusion of the study was that the incidences of thirst, drowsiness and dizziness were significantly low in the high infusion group. Yet the study was limited to allow for generalizations.
Monti and Pokorny (2000) cited the results of Elhakim et al in 1997 as follows:
“In 1997 Elhakim et al reported the effect of intraoperative fluid load on post operative nausea and vomiting over 3 days after day-case termination of pregnancy. In a randomized study, 100 patients were allocated into one of two groups receiving 1000 cc of compound sodium lactate solution during surgery or no intraoperative fluid. The scores of nausea were significantly lower in the fluid groups compared with the control group”
It was also observed by the Post Anesthesia Recovery Room (PACU) at Pitt County Memorial Hospital that patients who had received extra amount of IV fluid showed a decrease in the incidences of nausea and vomiting rate. It is worth mentioning that the study undertaken to explore the relationship between the degree of preoperative hydration and PONV (Pitt County Memorial Hospital. Quality assurance data. Greenville, NC:Pitt County Memorial Hospital; 1996-97 as cited in).
Monti and Pokorny, (2000) report the results of their study which was a pilot study for confirming that preoperative fluid bolus reduces the risk of post operative nausea and vomiting as: “Our findings suggest that administering a liter of saline fluid bolus decreases the incidence of nausea and vomiting in this population” They also recommended further studies “to examine the use of hydration without the use of antiemetics and control for other factors that might affect nausea and vomiting.”
The most relevant study to my paper is that of Adanir et al (2008) who sought an answer for the question: Does preoperative hydration affect postoperative nausea and vomiting? Their study was a randomized controlled trial study. They stated the objective of their study as:
“The aim of this study was to investigate the effect of pre- and intra-operative hydration on PONV. Instead of administering large amounts of fluids, we administered the necessary amount of fluids to cover the fluid deficit, which is caused by preoperative fasting 2 hours before surgery, and was observed if there was any effect on PONV” (Adanir et al, 2008).
The outcome of Adanir et al (2008) study was that replacement of any fluid deficit in surgical patients before operation reduces the incidence of PONV significantly.
Discussion ; Analysis
Through this literature review I wanted to justify an empirical research to support our present practice or to recommend changes in this practice. As a nurse in the post anesthesia care unit the way we deal with PONV is treatment which is very often pharmacologic interventions. It is suggested in the literature and sometimes in the practice situation that hydration can significantly reduce PONV.
Therefore I wanted to answer a few questions by this literature review: is a research in the impact of hydration on PONV justifiable? Are there any similar researches that can be compared with the intended research? Can the research be carried out by the PAC unit professional staff?
From the literature review it is clear that impact of hydration has not received enough attention yet. Therefore, the investigation of the impact hydration is an area that needs further investigation specially in our PACU where the practice is the treatment of PONV. The previous researches that may be used for comparison are not many but can serve the purpose of the intended research (Yogendran et al, 1995 and Elhakim et al, 1997 as cited in Monti and Pokorny, 2000; and Adanir et al, 2008).
It is apparent that hydration research cannot be carried out in PACU only but needs the collaboration pre-operation and intra-operation professional staff.
Conclusion
I can conclude that there is a justifiable need for researching the impact of hydration on PONV and that it should be designed to involve the professional staff of pre-, intra- and postoperative surgical units.
References
Alex Macario, Louis Claybon, and Joseph V Pergolizzi (2006) “Anesthesiologists’ practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit” BMC Anesthesiol. 2006; 6: 6
Anthony L. Kovac (2000) “Prevention and Treatment of Postoperative Nausea and Vomiting” Drugs 2000 Feb; 59 (2): 213-243
Birgitte Brandstrup, MD, PhD (2003) “Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens A Randomized Assessor-Blinded Multicenter Trial Ann Surg”. 2003 November; 238(5): 641–648
Gladys Amponsah (2007) “Postoperative Nausea and Vomiting in Korle Bu Teaching Hospital” Ghana Med J. 2007 December; 41(4): 181–185
Julie Golembiewski; Eric Chernin; Tania Chopra (2005) “Prevention and Treatment of Postoperative Nausea and Vomiting” Am J Health-Syst Pharm. 2005;62(12):1247-1260
Ruth McCaffrey ARNP, ND (2007) “Make PONV prevention a priority” OR Nurse March/April 2007 Volume 1 Number 2 Pages 39 – 45
Sadqa Aftab1, Abdul Bari Khan2 and Ghulam Raza (2008) “The Assessment of Risk Factors for Postoperative Nausea and Vomiting” Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (3): 137-141
Susan Monti, Marie E Pokorny (2000): “Preop Fluid Bolus Reduces Risk Of Post Op Nausea And Vomiting: A Pilot Study” The Internet Journal of Advanced Nursing Practice. 2000. Volume 4 Number 2.
Tayfun Adanir, Md, Phd, Murat Aksun, Md, Phd, Ug? Ur Özgürbüz, Md, Phd, Fahri Altin, Md, Phd, And Atilla Sencan, Md, Phd, (2008) “Does Preoperative Hydration Affect Postoperative Nausea and Vomiting? A Randomized, Controlled Trial” Journal Of Laparoendoscopic & Advanced Surgical Techniques Volume 18, Number 1, 2008
