Dose of intraoperative remifentanil administration is independently associated with increase in the risk of postoperative nausea and vomiting in elective mastectomy under general anesthesia

doi:10.1016/j.jclinane.2016.04.018

Journal of Clinical Anesthesia

Volume 34, November 2016, Pages 227-231

https://doi.org/10.1016/j.jclinane.2016.04.018 Get rights and content

Highlights

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The incidence of postoperative nausea and vomiting (PONV) was 30.5%.
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Dose of remifentanil was differed between patients with and without PONV.
•
Dose of remifentanil was independently associated with the risk of PONV.
•
The higher dose of remifentanil, the higher risk of PONV.

Abstract

Background

Postoperative nausea and vomiting (PONV) is one of the common complications in patients who have undergone surgery with general anesthesia. The association of intraoperative use of remifentanil with PONV has remained controversial. The aim of the current study was to determine the association of dose of intraoperative remifentanil administration with incidence of PONV.

Methods

The present study was a single-center retrospective observational study and included 423 female patients with American Society of Anesthesiologists physical status I or II who underwent elective mastectomy under general anesthesia between October 2011 and October 2012. The incidence of PONV within 3 days after the operation was prospectively assessed. The time-weighted average of remifentanil during the operation (twRem) was calculated. We used a multivariate regression model to assess the independent association of the twRem with the incidence of PONV.

Results

Among 423 patients, 129 patients (30.5%) had PONV during the study period. Remifentanil was administrated in 355 patients (83.9%). In the multivariate logistic regression model using categories of twRem, we found that increased twRem was independently associated with increase in the risk of PONV (P = .01). There was an independent association between twRem greater than 0.2 μg/kg per minute and increase in the risk of PONV.

Conclusion

This retrospective observational study revealed a dose-dependent association between dose of intraoperative remifentanil administration and increase in the risk of PONV. Time-weighted average of remifentanil greater than 0.2 μg/kg per minute was independently associated with risk of PONV.

Introduction

Postoperative nausea and vomiting (PONV) is one of the common complications in patients who have undergone surgery with general anesthesia and may increase patient discomfort and costs [1].

Remifentanil is an opioid with rapid clearance that is used for general anesthesia. Although the use of an opioid is a risk factor for PONV [2], the association between the use of remifentanil and the incidence of PONV is not clear. In some studies, the administration of remifentanil was associated with a decreased incidence of PONV [3], [4], whereas it was shown to be associated with an increased incidence of PONV in other studies [5], [6]. This discrepancy in results may be due to differences in the cases and doses of remifentanil. However, there is little information on the association of difference in the dose of remifentanil with incidence of PONV.

Accordingly, we conducted a retrospective observational study to assess the dose-dependent association of the use of remifentanil with the incidence of PONV. The null hypothesis of this study is that there is no dose-dependent association of administration of remifentanil and incidence of PONV.

Section snippets

Study design

This study was a single-center retrospective observational study. The Ethics Committee of the National Cancer Center approved this investigation. The committee waived the need for informed consent for studies involving the use of the database.

Patients

All female patients who underwent elective mastectomy under general anesthesia between October 2011 and October 2012 were included in this study. We excluded patients with American Society of Anesthesiologists (ASA) physical status III or higher.

Primary outcome

The

Results

During the study period, there were 423 female patients with ASA status I or II who underwent elective mastectomy under general anesthesia. We included all of them in this study. There were no missing data from these patients.

Among the 423 patients, 129 patients (30.5%) had PONV within 3 days after the operation. Table 1 shows a comparison of the characteristics of patients with PONV and those without PONV. Patients with PONV had longer durations of the operation (P = .014) and anesthesia (P =

Key findings

In this retrospective study including 423 female patients who underwent elective mastectomy with general anesthesia, the incidence of PONV within 3 days after the operation was 30.5%. We found that a higher time-weighted average of remifentanil dose was independently associated with higher risk for PONV. We further found that the adjusted odds ratio was increased according to increase of twRem. In our additional multivariate logistic model, twRem greater than 0.2 μg/kg per minute was

Conclusion

In this retrospective observational study conducted in patients who underwent elective mastectomy under general anesthesia, there was a dose-dependent association of the dose of intraoperative remifentanil administration with increase in the risk of PONV. Time-weighted average of remifentanil greater than 0.2 μg/kg per minute was independently associated risk of PONV.

Acknowledgment

The authors declare no conflict of interest. There are no grants for this study.

References (16)

K.S. Williams
Postoperative nausea and vomiting
Surg Clin North Am
(2005)
E. von Elm et al.
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies
Lancet
(2007)
T.J. Gan
Risk factors for postoperative nausea and vomiting
Anesth Analg
(2006)
P. Rama-Maceiras et al.
Less postoperative nausea and vomiting after propofol + remifentanil versus propofol + fentanyl anaesthesia during plastic surgery
Acta Anaesthesiol Scand
(2005)
K. Mukherjee et al.
A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and conditions of surgery
Anaesthesia
(2003)
R. Morino et al.
Incidence of and risk factors for postoperative nausea and vomiting at a Japanese cancer center: first large-scale study in Japan
J Anesth
(2012)
T.M. Gaszynski et al.
Post-anesthesia recovery after infusion of propofol with remifentanil or alfentanil or fentanyl in morbidly obese patients
Obes Surg
(2004)
J.B. Choi et al.
Incidence and risk factors of postoperative nausea and vomiting in patients with fentanyl-based intravenous patient-controlled analgesia and single antiemetic prophylaxis
Yonsei Med J
(2014)

There are more references available in the full text version of this article.

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Original ContributionDose of intraoperative remifentanil administration is independently associated with increase in the risk of postoperative nausea and vomiting in elective mastectomy under general anesthesia

Highlights

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Patients

Primary outcome

Results

Key findings

Conclusion

Acknowledgment

Surg Clin North Am

Lancet

Risk factors for postoperative nausea and vomiting

Anesth Analg

Less postoperative nausea and vomiting after propofol + remifentanil versus propofol + fentanyl anaesthesia during plastic surgery

Acta Anaesthesiol Scand

A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and conditions of surgery

Anaesthesia

Incidence of and risk factors for postoperative nausea and vomiting at a Japanese cancer center: first large-scale study in Japan

J Anesth

Post-anesthesia recovery after infusion of propofol with remifentanil or alfentanil or fentanyl in morbidly obese patients

Obes Surg

Incidence and risk factors of postoperative nausea and vomiting in patients with fentanyl-based intravenous patient-controlled analgesia and single antiemetic prophylaxis

Yonsei Med J

Original Contribution
Dose of intraoperative remifentanil administration is independently associated with increase in the risk of postoperative nausea and vomiting in elective mastectomy under general anesthesia