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Three Part Question

What is the [incidence of post-operative nausea and vomiting] in [fast track patients] after [cardiac surgery]?

Clinical Scenario

PONV is a common problem after general anesthetic and has the possibility to cause delays from the recovery room. What is the incidence of post-operative nausea and vomiting (PONV) in fast-track patients after cardiac surgery?

Search Strategy

PubMed (no date limitations).
References from selected articles.
("nausea"[MeSH Terms] OR "nausea"[All Fields]) AND ("heart"[MeSH Terms] OR "heart"[All Fields] OR "cardiac"[All Fields]) AND bypass[All Fields]

Search Outcome

58 articles found, 5 appropriate for question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
A. Kogan 2003 Israel	1221 patients undergoing coronary artery bypass grafting, valve-related and combined procedures who are were undergoing fast-track cardiac anesthesia.	To assess the incidence of post-operative nausea and vomiting in fast-track patients after cardiac surgery.	Nausea	19.7%	Morphine used for post-operative pain control. Good study with large numbers.
			Vomiting	4.3%
G. Morton 2004 London	106 cardiac surgery patients (fast-track and non fast-track)	Prospective audit of PONV after "on-pump" cardiac surgery	Nausea	10.4%	Use propofol for sedation post-operatively which could explain the lower rate of nausea. Small, prospective audit.
			Vomiting	15.1%
D. K. Woodward 1999 United Kingdom	216 patients post cardiopulmonary bypass for first time elective cardiac surgery. Must be extubated within 12 hours of procedure to be included.	Examining the effects of Ondansetron vs. Metoclopramide on post operative nausea and vomiting.	Nausea at any time	Overall = 42%	Patients were given Morphine plus the study drug (either Ondansetron or Metaclopramide) 1-2 hours pre-operatively thus not a true indication of unprophylaxed nausea and vomiting.
			Vomiting at any time	Overall = 34.3%
Grebenik 1996 England	442 patients undergoing elective or urgent open heart surgery.	To determine the incidence of PONV during intensive care stay after cardiac surgery, and to study the effect of addition of droperidol to an infusion of morphine used for postoperative analgesia.	Nausea in the post op morphine group	46.5%	The incidence of nausea is confounded by postoperative morphine infusion. Patient's were not all fast track patients. Propofol used to sedate if patient not extubatable; Propofol is an antiemetic (no mention of how many patients received propofol and for what duration).
			Nausea in post op morphine + droperidol	23%
			Vomiting in the post op morphine group	36.9%
			Vimiting in the post op morphine + droperidol	22%
Riha, H. 2004 Czech Republic	142 patients post CABG with CPB. Preserved EF >45%	Prospective double-blind randomized trial examining the incidence of PONV in cardiac surgery, its relation to cardiopulmonary bypass duration, and the efficacy of different antiemetic drugs for PONV prevention (given 30 min before end of procedure).	PONV	placebo = 27.1%	Post-operative pain was controlled with Morphine which is known to be pro-emetic. The abstract was published but insufficient information about whether the patients were truly fast-track is not available.
			PONV	droperidol 1.25mg = 18.5% (p>0.05)
			PONV	thiethylperazine 6.5mg= 18% (p>0.05)
			PONV	ondansetron 4mg = 18% (p>0.05)

Comment(s)

Only one study examines the incidence of PONV in fast track patients after cardiac surgery and bypass. Other evidence is inferred from trials in which the patient population is not truly "fast-track" or in patients which have received medications that confound the incidence of nausea and vomiting post-operatively.

Clinical Bottom Line

According to the best available evidence for the population group of fast-track patients post cardiac surgery, the incidence of post-op nausea is 19.7% and vomiting is 4.3%.

References

1. A. Kogan Nausea and vomiting after fast-track cardiac anaesthesia British Journal of Anesthesia 2003 Aug;91(2):214-7
2. G. Morton Nausea and vomiting after fast-track cardiac anaesthesia British Journal of Anesthesia 2004 Nov;93(5):748-9
3. D. K. Woodward Antiemetic prophylaxis in cardiac surgery: comparison of metaclopramide and ondansetron British Journal of Anesthesia 1999 Dec;83(6):933-5
4. Grebenik Nausea and vomiting after cardiac surgery British Journal of Anesthesia 1996;77:356-359
5. Riha, H. PONV in cardiac surgery [abstract] European Journal of Anaesthesiology 2004; 21(Suppl 32): A-43