Watcha M F, White P F
Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri.
Anesthesiology. 1992 Jul;77(1):162-84. doi: 10.1097/00000542-199207000-00023.
In a recent editorial, Kapur described perioperative nausea and vomiting as "the big 'little problem' following ambulatory surgery."257 Although the actual morbidity associated with nausea is relatively low in health outpatients, it should not be considered an unavoidable part of the perioperative experience. The availability of an emesis basin for every patient in the postanesthesia recovery unit is a reflection of the limited success with the available therapeutic techniques.257 There had been little change in the incidence of postoperative emesis since the introduction of halothane into clinical practice in 1956. However, newer anesthetic drugs (e.g. propofol) appear to have contributed to a recent decline in the incidence of emesis. Factors associated with an increased risk of postoperative emesis include age, gender (menses), obesity, previous history of motion sickness or postoperative vomiting, anxiety, gastroparesis, and type and duration of the surgical procedure (e.g., laparoscopy, strabismus, middle ear procedures). Anesthesiologists have little, if any, control over these surgical factors. However, they do have control over many other factors that influence postoperative emesis (e.g., preanesthetic medication, anesthetic drugs and techniques, and postoperative pain management). Although routine antiemetic prophylaxis is clearly unjustified, patients at high risk for postoperative emesis should receive special considerations with respect to the prophylactic use of antiemetic drugs. Minimally effective doses of antiemetic drugs can be administered to reduce the incidence of sedation and other deleterious side effects. Potent nonopioid analgesics (e.g., ketorolac) can be used to control pain while avoiding some of the opioid-related side effects. Gentle handling in the immediate postoperative period is also essential. If emesis does occur, aggressive intravenous hydration and pain management are important components of the therapeutic regimen, along with antiemetic drugs. If one antiemetic does not appear to be effective, another drug with a different site of action should be considered. With the availability of new antiserotonin drugs, the incidence of recurrent (intractable) emesis could be further decreased. Research into the mechanisms of this common postoperative complication may help in improving the management of emetic sequelae in the future. As suggested in a recent editorial, improvement in antiemetic therapy could have a major impact for surgical patients, particularly after ambulatory surgery. Patients as well as those involved in their postoperative care look forward to a time when the routine offering of an emesis basin after surgery becomes a historical practice.
在最近的一篇社论中，卡普尔将围手术期恶心和呕吐描述为“门诊手术之后的重大‘小问题’”。尽管在健康门诊患者中，与恶心相关的实际发病率相对较低，但它不应被视为围手术期体验中不可避免的一部分。麻醉后恢复室为每位患者配备一个呕吐盆，这反映了现有治疗技术的成效有限。自1956年氟烷引入临床实践以来，术后呕吐的发生率几乎没有变化。然而，新型麻醉药物（如丙泊酚）似乎导致了近期呕吐发生率的下降。与术后呕吐风险增加相关的因素包括年龄、性别（月经）、肥胖、既往晕动病或术后呕吐史、焦虑、胃轻瘫以及手术类型和持续时间（如腹腔镜手术、斜视手术、中耳手术）。麻醉医生对这些手术因素几乎没有控制权。然而，他们确实可以控制许多其他影响术后呕吐的因素（如麻醉前用药、麻醉药物和技术以及术后疼痛管理）。尽管常规使用止吐药预防显然不合理，但术后呕吐高风险患者在止吐药的预防性使用方面应得到特殊考虑。可以给予最低有效剂量的止吐药以降低镇静及其他有害副作用的发生率。强效非阿片类镇痛药（如酮咯酸）可用于控制疼痛，同时避免一些与阿片类药物相关的副作用。术后即刻轻柔护理也至关重要。如果发生呕吐，积极的静脉补液和疼痛管理是治疗方案的重要组成部分，同时使用止吐药。如果一种止吐药似乎无效，应考虑使用作用部位不同的另一种药物。随着新型抗血清素药物的出现，复发性（难治性）呕吐的发生率可能会进一步降低。对这种常见术后并发症机制的研究可能有助于未来改善呕吐后遗症的管理。正如最近一篇社论所指出的，止吐治疗的改善可能对手术患者产生重大影响，尤其是在门诊手术后。患者以及参与其术后护理的人员都期待着手术后备有呕吐盆成为历史的那一天。
