There has been much discussion about post-operative vomiting (PONV) in recent decades. Research interest in this annoying complication, which has been referred to1 as ‘the big little problem’ still continues.2–5 The number of commentaries available on this topic is overwhelming and the conclusions are confusing; about 70 editorials have been published in Medline-indexed journals focussing on PONV in a broad sense (http://www.ncbi.nlm.nih.gov/pubmed; limitation: ‘editorial’, search term: ‘PONV’, last access: 9 September 2010). The interested reader can discover the whole history of research into PONV simply by glancing at the titles of these commentaries, written usually by renowned experts in the field. If you believe that these facts render any further engagement in the topic superfluous, you may have missed the point that the big problem today is not PONV per se,6 but the fact that the overwhelming clinical and experimental evidence is not translated into improved comfort and safety for patients. Therefore, we need to focus on PONV and should heed the problem present today, not because of poor knowledge but because of poor implementation (and lack of a patient-centred approach?).
Studying these editorials and commentaries, we learn that transdermal hyoscine (scopolamine), a substance that has experienced a renaissance recently,7,8 may be an option to cope with PONV.9 ‘Cost containment’10 and ‘cost-effective management of post-operative nausea and vomiting’11 were often referred to, in a time period when many antiemetic interventions or modifications of anaesthesia, for example, using propofol and administering ondansetron, were expensive. In conjunction with non-pharmacological interventions, the question was raised as to whether these ‘… techniques (are) useful alternatives to antiemetic drugs for the prevention of nausea and vomiting’.12 Regarding the investigation of PONV, a question was raised as to whether ‘surrogate end-points (e.g. PONV) are (really)… meaningful’13 and later it was concluded that they are not.14 During the 1990s, review articles offered a long list of supposed risk factors which, for the clinician who has many other responsibilities, rendered any meaningful risk assessment impossible. However, that was also the decade in which the first clinically useful risk scores to predict PONV were presented.15 In an editorial accompanying one of these attempts to predict PONV,16 Professor Kari Kortilla raised the interesting and revolutionary question which is the focus of a ‘Pro and Con’ debate in this issue of the European Journal of Anaesthesiology:17,18 ‘can we predict who will vomit after surgery?’.19
In a comprehensive review by Eberhart and Morin17 of problems associated with risk prediction in general and PONV prediction in particular, the authors conclude – taking into account the experiences and developments of a further decade (from 1997 until now) – that risk scores to predict PONV are not useful in clinical practice. Instead, they suggest the use of simplified algorithms that could lead to a benefit for a larger proportion of patients. Clearly, such a risk score-adapted preventive strategy for PONV may be viewed as a feasible and efficient way for nurses and anaesthesiologists to tackle PONV. A viewpoint by Pierre18 highlights the fact that, rather than focussing on the criticism of scoring systems, we need to centre our attention on promoting and explaining useful clinical algorithms and encouraging implementation reminders in order to change clinical behaviour.
From 2000 onwards, again taking into account pharmacoeconomic reflections, the question arose as to whether prophylaxis was, on balance, better than treatment.20 Only small and insignificant improvements in patient satisfaction were observed if a single antiemetic agent was administered in patients with no increased risk. However, the limited absolute risk reduction resulting from administration of a single antiemetic agent in high-risk patients provoked the question of whether it was ‘…time for balanced antiemesis’.21 That concept was investigated in a large multicentre trial, which used a factorial design to provide much useful information about the prevention of PONV.22 Following publication of the results, the naive reader might think that ‘a multimodal solution to a persistent problem’ has now been found.23 In fact, ‘multimodal antiemetic management’ of PONV had been identified much earlier as a promising tool to cope with PONV.24
In view of the question how ‘do we move further in research on post-operative nausea and vomiting?’,25 reports of new and promising drug developments were published and viewed as ‘a step change in prevention of post-operative nausea and vomiting’.26 Neither NK-1 antagonists (e.g. aprepitant) nor a newer generation of 5-HT3 antagonists (i.e. palonosetron) provided a magic bullet. Editorials commented that ‘we do not know everything yet’27 and noted the prevailing attitude of many anaesthesiologists who were ‘tired of waiting’ for the problem of nausea and vomiting to be solved.28 Although pharmacogenomics is useful in selecting drugs for optimum treatment of an individual patient in many areas of clinical care and pharmacological treatment, it does not currently offer improvements in the management of PONV.29 A more pragmatic approach, which I believe is the challenge we face today, suggested ‘the rule of three’:30 a simple and straightforward – some critics may argue, too simplistic – approach to cope with PONV.
We may or may not agree with opinion by Eberhart and Morin,17 but the discouraging fact is that despite the tremendous efforts of PONV researchers in recent decades, management of PONV is implemented badly in routine clinical care. Is this sufficient justification to practise ‘therapeutic nihilism’ and – by pursuing an ultraliberal approach to administration of antiemetics irrespective of the patient's risk of PONV – risk ‘throwing the baby out with the bath water’?18
There is no doubt that systematic research to elucidate risk factors for PONV has contributed to the fact that the long list of supposed risk factors is now condensed to an easily memorised number of important factors. This seems to be important for both research questions and individual risk assessment. In addition, these well proven factors allow us to teach others about the important issues which contribute to the occurrence of an annoying post-operative complication. However, in the light of the results of recent research regarding the implementation of PONV scoring systems into clinical practice and the reluctance to act according to institutional standard operating procedures,31–34I believe that complex algorithms, in conjunction with the methodological and clinical shortcomings highlighted in the review article by Eberhart and Morin, are the most dominant hurdles that prevent the elimination of an old problem for the majority of our patients. It may be astonishing, but even intensive individual feedback to anaesthesiologists failed to improve compliance with PONV standard operating procedures and thus prevented sufficient control of PONV in medium-risk and high-risk patients.35 In patients with three risk factors, to whom, according to the standard of care in that hospital, three antiemetics should have been administered,36 only one third of the patients received the scheduled treatment despite educational measures and individual feedback. For some anaesthesiologists (those who want effective solutions irrespective of other factors), this may be sufficient argument to support ultraliberal use of prophylactic antiemetics. For others, this may not be enough because of an inherent ambition to customise a treatment according to individual risk.
In my opinion, the huge body of evidence suggests that the most commonly cited arguments in favour of restricting effective antiemetic prevention in the past, for example, acquisition costs, unknown efficacy or supposed adverse effects, are no longer valid.
The question which is important today is, therefore, how we can ensure that patients really benefit from the huge number of studies that have been undertaken to add pieces of knowledge to the body of evidence (and presumably all performed with the intention of improving patient care). The answers to the questions ‘post-operative nausea and vomiting – when will it stop?’37 and whether ‘nausea and vomiting after anaesthesia will remain a ‘never ending story’38 are largely dependent on you.
Let me conclude and summarise the current trend in PONV management with a provocative statement made recently by Professor Phillip Scuderi,39 who concluded that: ‘…given the extremely low cost of all the currently available generic antiemetics and the extremely low incidence of adverse side-effects, I would suggest that all patients might benefit from three or more antiemetics during the course of surgery to reduce the incidence of PONV as much as possible’. It is of note that Professor Scuderi40 was the first author of an original research article published in 1999, which concluded that ‘antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment’. This change in attitude based on shifting environmental conditions (perception of PONV as a relevant outcome, costs of antiemetics, better understanding of their side-effect profile, and the need for smooth and predictable recovery) reflects the shift in paradigm regarding PONV prevention from a strictly risk-adapted approach to a more liberal approach ensuring that a larger group of patients will benefit from the research results of recent decades.
Returning to the state-of-the-art articles regarding the advantages and disadvantages of risk prediction for PONV in this issue of EJA, it seems to me that it is not a matter of whether or not to use scoring systems, but of implementing effective PONV protocols properly. It is up to you to make change happen so that the era of PONV for our patients will come to an end – not only in research but also in everyday practice. To this end, there is a long and windy road to go.33,41 The ideal implementation strategy may be different depending on the population and institution. ‘All theory, dear friend, is gray!’ (Mephistopheles speaks to Dr. Faust in J.W. Goethes novel ‘Faust I’) and the question of whether an ‘ultraliberal’ or ‘risk-adaptive’ approach is chosen may simply be splitting hairs provided that patients actually benefit from the recent achievements of PONV research.
The study was supported by institutional resources only.
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