Nausea and Vomiting
Postoperative nausea and vomiting is a serious problem that is
a major concern for anesthesiologists.[269]
[270]
The etiology, treatment, and prevention of postoperative nausea and vomiting have
been investigated extensively ( Fig.
11-10
).[271]
The intraoperative use of
opioids is a well-known risk factor for postoperative nausea and vomiting. Opioids
stimulate the chemoreceptor trigger zone in the area postrema of the medulla possibly
through δ-receptors, leading to nausea and vomiting. Alfentanil, compared
with approximately equipotent doses of fentanyl and sufentanil, is associated with
a lower incidence of postoperative nausea and vomiting.[272]
The use of propofol in balanced or total intravenous anesthesia
(TIVA) significantly reduces the incidence of opioid-induced nausea and vomiting.
[273]
The incidence of postoperative nausea and
vomiting can be as low as 5% to 20% after propofol-alfentanil anesthesia.
When opioids are employed, antiemetic prophylaxis should be considered,
which includes drugs with anticholinergic activity, butyrophenones, dopamine antagonists,
serotonin antagonists and acupressure. Ondansetron, a serotonin type 3 receptor
antagonist, was proved to be effective for postoperative opioid-induced nausea and
vomiting.[274]
Cannabinoid receptor agonists have
been demonstrated to be effective antiemetics in some clinical settings. Animal
experiments have shown that the cannabinoid agonists suppress opioid-induced retching
and vomiting by activation of the cannabinoid CB1 receptor.[275]
Figure 11-10
The chemoreceptor trigger zone and the emetic center
with the agonist and antagonist sites of action of various anesthetic-related agents
and stimuli. (From Watcha MF, White PF: Postoperative nausea and vomiting.
Its etiology, treatment, and prevention. Anesthesiology 77:162–184, 1992.)
