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BJA Advance Access originally published online on August 5, 2008
British Journal of Anaesthesia 2008 101(4):498-505; doi:10.1093/bja/aen230
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Risk factors for severe postoperative nausea and vomiting in a randomized trial of nitrous oxide-based vs nitrous oxide-free anaesthesia

K. Leslie1,2,*, P. S. Myles3,4, M. T. V. Chan6,7, M. J. Paech8,9, P. Peyton10, A. Forbes5, D. McKenzie5 and the ENIGMA Trial Group

1 Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3050, Australia
2 Department of Pharmacology, University of Melbourne, Melbourne, Australia
3 Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
4 Academic Board of Anaesthesia and Perioperative Medicine
5 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
6 Prince of Wales Hospital, Hong Kong, People's Republic of China
7 The Chinese University of Hong Kong, Hong Kong, People's Republic of China
8 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
9 Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women and Royal Perth Hospital, Perth, Australia
10 Department of Anaesthesia, Austin Hospital, Melbourne, Australia

* Corresponding author. E-mail: kate.leslie{at}mh.org.au

Background: Refractory postoperative nausea and vomiting (PONV) requiring repeated treatment with antiemetic drugs is a miserable experience for the patient that may substantially increase the cost of care. As risk stratification may aid in prophylaxis and treatment, we explored risk factors for severe PONV in patients enrolled in a large international, randomized controlled trial (the ENIGMA trial).

Methods: Two thousand and fifty patients, aged ≥18 yr and undergoing surgery anticipated to exceed 2 h in duration, were recruited. Patients were randomized to nitrous oxide (N2O)-based or N2O-free anaesthesia. Choice of other anaesthetic, analgesic, and antiemetic drugs was left to the discretion of the anaesthetist. Anaesthetic depth was adjusted according to clinical judgement and, if available, bispectral index (BIS) monitoring. Severe PONV was defined as: (i) two or more episodes of expulsion of gastric contents at least 6 h apart; (ii) received at least three doses of antiemetic medication for treatment of PONV, within 24 h of surgery; or both. We used logistic regression, and classification and regression tree analysis, to define risk factors for severe PONV.

Results: Three hundred and thirty-three (16.6%) patients experienced severe PONV. Age <55 yr, female sex, abdominal surgery, N2O administration, absence of BIS monitoring, and longer duration of anaesthesia were predictors of severe PONV [area under receiver operating characteristic curve=0.70 (95% confidence interval: 0.67–0.73)].

Conclusions: Severe PONV was common and risk factors for it were similar to those reported in other studies that included all patients reporting nausea, vomiting, or both.

Keywords: anaesthetics gases, nitrous oxide; clinical trials; PONV; vomiting, nausea, anaesthetic factors; vomiting, nausea, patient factors


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