Today, we'll focus on non-anesthetic risk factors associated with PONV.
1. What are some of patient risk factors associated with PONV?
2. Why is a history of motion sickness or a previous history of PONV among the most potent risk factors?
3. Are patients who smoke at increased risk of PONV?
4. What are some surgical factors that are associated with an increase in PONV?
今天我们重点讨论与PONV相关的非麻醉危险因素
1. 与PONV相关的患者危险因素有哪些？
2. 为什么有晕动症史或以前有PONV病史者是最常见的危险因素?
3. 吸烟是否会增加PONV的发生？
4. 与增加PONV发生相关的外科因素有哪些？
本版发展，我们携手；专业进步，我们共荣[每周一问]No.6之周中问-Postoperative Nausea and Vomiting (PONV)之参考答案
1.与PONV相关的患者危险因素有哪些？
与PONV相关的患者因素有很多，包括[1]：
女性，包括月经周期阶段和早期妊娠女性
晕动病史
极端焦虑
未完全禁食
合并症，包括病态肥胖症、颅内压增高、胃肠功能紊乱
疼痛
月经周期中性激素的波动对于PONV的影响很难解释清楚，部分是由于研究文献间的结果不一，同时伴随这些症状相关的持续时间较长。Bettie等[2]通过对接受腹腔镜手术的女性患者的一项回顾性研究发现，在1-8天与9-28天比较中，PONV的发生率分别为51.6%和21.6%，而其[3]在随后的一项前瞻性研究发现，在接受经腹腔镜输卵管结扎术的女性患者中PONV的发生率分别为71.4%和46.2%。然而，通过对引起呕吐的实际峰值进行评估发现，92.3%的患者在4-24天被认为存在疑问。比较之下，Honkavaara[4]等通过一项回顾性样本研究发现，PONV的最高发生时间为20-24天。因此，鉴于此，应该进行包括血清激素水平检测的更深层次的前瞻性研究以准确严格的评估该问题。
2.为什么有晕动症史或以前有PONV病史者是最有力的危险因素?
象其他自主反应一样，有暗示作用的呕吐反射弧的存在，并且可能变得比较活跃[5]。因此，PONV与以前有PONV史或晕动病之间的关系可能代表了一种已存在的反应（“learned” response）。
3. 吸烟是否会增加PONV的发生？
研究表明结果正好相反。虽然吸烟的益处很少，但是Chimbira[6]等通过对324接受关节镜行膝部手术患者研究发现（均接受标准化的全身麻醉剂和术后镇痛技术），在对这些患者出院前询问关于PONV时，42例（13%）患者抱怨存在PONV，而在吸烟者和非吸烟者中，出现PONV的分别为6%和15%，具有统计学差异（P＜0.05）。作者分析原因可能为烟草烟雾的酶诱导作用为相应抗呕吐作用的最可能原因。
4.与增加PONV发生相关的外科因素有哪些？
许多外科疾患及操作与PONV相关，包括：
隆胸或乳房缩小术
耳外科手术
眼部手术，特别是斜视手术和视网膜剥脱术
腹腔镜手术
Ovum retrieval
睾丸固定术
扁桃体切除术
此外，在接受长时手术以及疼痛刺激强烈的手术PONV发生率较高[7]，部分是因为用于治疗疼痛的镇痛药物所致，因为其本身可导致PONV。
1.与PONV相关的患者危险因素有哪些？
与PONV相关的患者因素有很多，包括[1]：
女性，包括月经周期阶段和早期妊娠女性
晕动病史
极端焦虑
未完全禁食
合并症，包括病态肥胖症、颅内压增高、胃肠功能紊乱
疼痛
月经周期中性激素的波动对于PONV的影响很难解释清楚，部分是由于研究文献间的结果不一，同时伴随这些症状相关的持续时间较长。Bettie等[2]通过对接受腹腔镜手术的女性患者的一项回顾性研究发现，在1-8天与9-28天比较中，PONV的发生率分别为51.6%和21.6%，而其[3]在随后的一项前瞻性研究发现，在接受经腹腔镜输卵管结扎术的女性患者中PONV的发生率分别为71.4%和46.2%。然而，通过对引起呕吐的实际峰值进行评估发现，92.3%的患者在4-24天被认为存在疑问。比较之下，Honkavaara[4]等通过一项回顾性样本研究发现，PONV的最高发生时间为20-24天。因此，鉴于此，应该进行包括血清激素水平检测的更深层次的前瞻性研究以准确严格的评估该问题。
2.为什么有晕动症史或以前有PONV病史者是最有力的危险因素?
象其他自主反应一样，有暗示作用的呕吐反射弧的存在，并且可能变得比较活跃[5]。因此，PONV与以前有PONV史或晕动病之间的关系可能代表了一种已存在的反应（“learned” response）。
3. 吸烟是否会增加PONV的发生？
研究表明结果正好相反。虽然吸烟的益处很少，但是Chimbira[6]等通过对324接受关节镜行膝部手术患者研究发现（均接受标准化的全身麻醉剂和术后镇痛技术），在对这些患者出院前询问关于PONV时，42例（13%）患者抱怨存在PONV，而在吸烟者和非吸烟者中，出现PONV的分别为6%和15%，具有统计学差异（P＜0.05）。作者分析原因可能为烟草烟雾的酶诱导作用为相应抗呕吐作用的最可能原因。
4.与增加PONV发生相关的外科因素有哪些？
许多外科疾患及操作与PONV相关，包括：
隆胸或乳房缩小术
耳外科手术
眼部手术，特别是斜视手术和视网膜剥脱术
腹腔镜手术
Ovum retrieval
睾丸固定术
扁桃体切除术
此外，在接受长时手术以及疼痛刺激强烈的手术PONV发生率较高[7]，部分是因为用于治疗疼痛的镇痛药物所致，因为其本身可导致PONV。
[每周一问]No.6之周中问-Postoperative Nausea and Vomiting (PONV)之参考答案[英语]
What are some of patient risk factors associated with PONV?
A number of patient factors have been associated with PONV, including (1):
• Female gender, including phase of menstrual cycle and early pregnancy
• History of motion sickness
• Previous PONV
• Extreme anxiety
• Fasting noncompliance
• Coexisting diseases, including morbid obesity, increased intracranial pressure, gastrointestinal dysfunction of disease processes
• Pain
The effect of sex hormone fluctuations during the menstrual cycle on PONV is difficult to decipher, in part because the literature is conflicting and presents a very broad range of days associated with these symptoms. Bettie et al. (2), in a retrospective study of women undergoing laparoscopy, noted a 51.6% versus a 21.6% incidence of PONV in days 1-8 versus days 9-28 of the cycle, respectively. A follow up, prospective study by the same investigators (3) in women undergoing laparoscopic tubal ligation had similar results, noting a 71.4% versus a 46.2% incidence of PONV on days 1-8 versus days 9-28 of their cycles. However, when the actual peak of emetic sequelae was evaluated, days 4-24 were found to be problematic in 92.3% of patients. By contrast, Honkavaara et al. (4) in a retrospective fashion, noted that the highest incidence of PONV occurred during days 20-24. Further prospective work, which should include measurement of serum levels of hormones, will need to be conducted to rigorously evaluate this question.
Why is a history of motion sickness or a previous history of PONV among the most potent risk factors?
Like other types of autonomic responses, there is a suggestion that a reflex arc for vomiting exists and may become well-developed (5). As such, the relationship between PONV and prior histories of PONV or motion sickness may represent a “learned” response.
Are patients who smoke at increased risk of PONV?
It appears exactly the opposite is true. Although the possible benefits to smoking are vanishingly rare, Chimbira et al.
in 327 consecutive patients undergoing arthroscopic day case knee surgery with a standardized general anesthetic and postoperative analgesic technique, were queried prior to discharge regarding PONV. A total of 42 (13%) complained of PONV. Of the smokers and nonsmokers, 6% and 15%, respectively complained of PONV (p < 0.05). The authors postulated that enzyme induction may be the most likely reason for this apparent antiemetic effect of tobacco smoking.
What are some surgical factors that are associated with an increase in PONV?
A number of specific procedures have been associated with PONV including (1):
• Breast augmentation/reduction
• Ear surgery
• Eye surgery (especially strabismus and retinal detachment surgery)
• Extracorporeal shock wave therapy
• Laparoscopy
• Ovum retrieval
• Orchiopexy
• Tonsillectomy
In addition, and perhaps to no surprise, patients undergoing longer, and more painful procedures have been noted to have a higher rate of PONV (7). In part this may be because pain, as well as analgesics utilized to treat it, can both by themselves produce PONV.
Question Author: Lawrence Tsen, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School
References:
1. Kaller SK, Everett LL. Nausea and vomiting: etiology, prophylaxis, and therapy. In: McGoldrick KE, ed. Anesthesiology: A problem-oriented approach, Baltimore: Williams & Wilkins, 1995;619-32.
2. Bettie WS, Lindblad T, Buckley DN, et al. The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is influenced by the day of the menstrual cycle. Can J Anaesth 1991;38:298-302.
3. Bettie WS, Lindblad T, Buckely DN, et al. Menstruation increases the risk of nausea and vomiting after laparoscopy. Anesthesiology 1993;78:272-6.
4. Honkavaara P, Lehtinen AM, Hovorka J, et al. Nausea and vomiting after gynecological laparoscopy depends on the phase of the menstrual cycle. Can J Anaesth 1991;38:876-9.
5. Palazzo MGA, Strunin L. Anaesthesia and emesis: I. Etiology. Can Anaesth Soc J 1984;31:178-87.
6. Chimbira W, Sweeney BP. The effect of smoking on postoperative nausea and vomiting. Anaesthesia 2000;55:540-4.
7. Sinclair D, Chung F, Mezei G. Relation of postoperative nausea and vomiting to the surgical population (abstract). Can J Anaesth 1998;45:A25.
Site Editor: Stephen B. Corn, M.D. and B. Scott Segal, M.D.
Department of Anesthesia, Harvard Medical School
What are some of patient risk factors associated with PONV?
A number of patient factors have been associated with PONV, including (1):
• Female gender, including phase of menstrual cycle and early pregnancy
• History of motion sickness
• Previous PONV
• Extreme anxiety
• Fasting noncompliance
• Coexisting diseases, including morbid obesity, increased intracranial pressure, gastrointestinal dysfunction of disease processes
• Pain
The effect of sex hormone fluctuations during the menstrual cycle on PONV is difficult to decipher, in part because the literature is conflicting and presents a very broad range of days associated with these symptoms. Bettie et al. (2), in a retrospective study of women undergoing laparoscopy, noted a 51.6% versus a 21.6% incidence of PONV in days 1-8 versus days 9-28 of the cycle, respectively. A follow up, prospective study by the same investigators (3) in women undergoing laparoscopic tubal ligation had similar results, noting a 71.4% versus a 46.2% incidence of PONV on days 1-8 versus days 9-28 of their cycles. However, when the actual peak of emetic sequelae was evaluated, days 4-24 were found to be problematic in 92.3% of patients. By contrast, Honkavaara et al. (4) in a retrospective fashion, noted that the highest incidence of PONV occurred during days 20-24. Further prospective work, which should include measurement of serum levels of hormones, will need to be conducted to rigorously evaluate this question.
Why is a history of motion sickness or a previous history of PONV among the most potent risk factors?
Like other types of autonomic responses, there is a suggestion that a reflex arc for vomiting exists and may become well-developed (5). As such, the relationship between PONV and prior histories of PONV or motion sickness may represent a “learned” response.
Are patients who smoke at increased risk of PONV?
It appears exactly the opposite is true. Although the possible benefits to smoking are vanishingly rare, Chimbira et al.
in 327 consecutive patients undergoing arthroscopic day case knee surgery with a standardized general anesthetic and postoperative analgesic technique, were queried prior to discharge regarding PONV. A total of 42 (13%) complained of PONV. Of the smokers and nonsmokers, 6% and 15%, respectively complained of PONV (p < 0.05). The authors postulated that enzyme induction may be the most likely reason for this apparent antiemetic effect of tobacco smoking.What are some surgical factors that are associated with an increase in PONV?
A number of specific procedures have been associated with PONV including (1):
• Breast augmentation/reduction
• Ear surgery
• Eye surgery (especially strabismus and retinal detachment surgery)
• Extracorporeal shock wave therapy
• Laparoscopy
• Ovum retrieval
• Orchiopexy
• Tonsillectomy
In addition, and perhaps to no surprise, patients undergoing longer, and more painful procedures have been noted to have a higher rate of PONV (7). In part this may be because pain, as well as analgesics utilized to treat it, can both by themselves produce PONV.
Question Author: Lawrence Tsen, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School
References:
1. Kaller SK, Everett LL. Nausea and vomiting: etiology, prophylaxis, and therapy. In: McGoldrick KE, ed. Anesthesiology: A problem-oriented approach, Baltimore: Williams & Wilkins, 1995;619-32.
2. Bettie WS, Lindblad T, Buckley DN, et al. The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is influenced by the day of the menstrual cycle. Can J Anaesth 1991;38:298-302.
3. Bettie WS, Lindblad T, Buckely DN, et al. Menstruation increases the risk of nausea and vomiting after laparoscopy. Anesthesiology 1993;78:272-6.
4. Honkavaara P, Lehtinen AM, Hovorka J, et al. Nausea and vomiting after gynecological laparoscopy depends on the phase of the menstrual cycle. Can J Anaesth 1991;38:876-9.
5. Palazzo MGA, Strunin L. Anaesthesia and emesis: I. Etiology. Can Anaesth Soc J 1984;31:178-87.
6. Chimbira W, Sweeney BP. The effect of smoking on postoperative nausea and vomiting. Anaesthesia 2000;55:540-4.
7. Sinclair D, Chung F, Mezei G. Relation of postoperative nausea and vomiting to the surgical population (abstract). Can J Anaesth 1998;45:A25.
Site Editor: Stephen B. Corn, M.D. and B. Scott Segal, M.D.
Department of Anesthesia, Harvard Medical School
