The effect of duration of dose delivery with patient‐controlled analgesia on the incidence of nausea and vomiting after hysterectomy

Abstract

Aims Postoperative nausea and vomiting (PONV) may be exacerbated by postoperative opioid analgesics and may limit patients’ successful use of these medications when used with patient controlled analgesia (PCA). We tested the hypothesis that the rapid change in blood morphine concentration associated with PCA bolus delivery contributed to PONV, and that prolonging its delivery to a brief infusion would result in decreased PONV. Methods Patients, who were receiving morphine for pain relief via patient‐controlled analgesia (PCA) after total abdominal hysterectomy, received 1 mg morphine sulphate incremental doses either over 40 s with a 5 min lockout interval or over 5 min delivery with a 1 min lockout interval. Episodes of nausea, retching and vomiting, along with the use of morphine and the pain relief obtained, were recorded. Results Data from 20 patients in each group were analysed. Contrary to expectations, most patients in both groups reported nausea postoperatively. Those patients receiving morphine over 5 min experienced more episodes of emesis (36) than those receiving the dose over 40 s (17). Most patients receiving the 40 s doses vomited in the first 12 h (median time 8 h), while those receiving the 5 min doses vomited between 12 and 24 h (median time 19 h) (P=0.01). There were no differences between groups in the visual analogue pain scores or use of morphine between groups. Conclusions Reasons for these unexpected findings remain speculative. The high incidence of PONV appears to be inherently high in gynaecological surgery patients and standard antiemetic medication regimens appear to be poorly efficacious. Reasons for the differences in the time‐course of emetic episodes between the two groups may be related to differences in the time‐course of central opioid receptor occupancy.

A randomized, multicenter, pilot study comparing the efficacy and safety of a bupivacaine-collagen implant (XaraColl®) with the ON-Q PainBuster® Post-op Pain Relief System following open gynecological surgery

“…For managing moderate to severe pain, intravenous morphine is often administered via a patient-controlled analgesia pump. However, the large doses required can often lead to fatigue, nausea, and vomiting, as well as the inability to mobilize because of drowsiness 1,2. Patients usually require patient-controlled analgesia for at least 24 hours before switching to oral analgesic medication.…”

Postoperative Nausea and Vomiting Are Strongly Influenced by Postoperative Opioid Use in a Dose-Related Manner

“…In populations that include a wide range of operative procedures, the incidence ranges from 22% to 52% (1,2). The incidence seems to increase in patients receiving patientcontrolled analgesia (PCA), where rates of 68%-100% for PON and POV have been recorded (3,4).…”

Patient-controlled analgesia combined with either ondansetron or ondansetron plus prochlorperazine for control of pain and nausea and vomiting in patients undergoing abdominal surgery

“…However, side effects associated with PCA opioids often include postoperative nausea and vomiting (PONV) [1]. While other factors may contribute to PONV, the reported incidence associated with PCA opioids is between 20% and 88% [2][3][4]. Since PONV is seen as an undesirable side effect and may impede optimal use of the PCA system, numerous reports have described techniques to minimize it.…”

“…Since PONV is seen as an undesirable side effect and may impede optimal use of the PCA system, numerous reports have described techniques to minimize it. Woodhouse et al [4] examined the speed of opioid administration to determine if it affected PONV. It was believed that rapid changes in blood opioid concentrations increase emetic symptoms.…”