Postoperative Nausea and Vomiting After Discharge from Outpatient Surgery Centers

Transcription

1 Postoperative Nausea and Vomiting After Discharge from Outpatient Surgery s Norman V. Carroll, PhD*, Patrick Miederhoff, PharmD, PhD*, Fred M. Cox, PhDt, and Jan D. Hirsch, PhDt *School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia; and tglaxo Research Institute, Research Triangle Park, North Carolina We examined patients experiences with nausea and vomiting after they were discharged from outpatient surgical centers. Data were collected on 211 surgical outpatients at h after discharge via a telephone interview conducted by outpatient surgery nurses, and at 5 days after discharge via a patient-completed questionnaire. Telephone interviews were conducted with 193 patients. Questionnaires were completed by 154 patients. Over 35% of patients experienced postdischarge nausea and vomiting. Most had not experienced nausea and vomiting in the recovery room. The severity of nausea for these patients averaged 5 on a lo-point scale (10 indicating very severe nausea). During the 5 days after discharge, these patients reported experiencing nausea for an average of 1.7 days and vomiting for 0.7 days. Patients who experienced postdischarge nausea and vomiting were not able to resume their normal daily activities as quickly as those who did not. Patients managed postdischarge nausea and vomiting with little contact or intervention from health professionals and with minimal product purchases. The results indicate that postdischarge nausea and vomiting is common after outpatient surgery, and that it results in substantial distress and impairment for patients who experience it. (Anesth Analg 1995;80:903-9) A ccording to Rowbotham and Smith (l), postoperative nausea and vomiting are common and distressing postsurgical symptoms. These symptoms are of particular concern in outpatient surgery because they may require additional direct resources, such as supplies and antiemetic drugs, and because they may delay discharge. Of further concern, many patients experience postoperative nausea and vomiting after they have been discharged from the surgery center (l-4). This is especially troublesome because patients are much less accessible to professional surveillance and care after discharge. Although there is growing documentation of patients experiences with nausea and vomiting in the recovery room, there is little research on their experiences with postoperative nausea and vomiting after discharge. However, the few studies available suggest that nausea and vomiting is much more common postdischarge than in the recovery room (2-5). Due to the This research was supported by the Glaxo Research Institute. Accepted for publication December 9, Address correspondence and reprint requests to Norman V. Carroll, PhD, Professor of Pharmacy Administration, School of Pharmacy, Virginia Commonwealth University, MCV Box 533, Richmond, VA medically unsupervised environment in which patients complete their postsurgical recovery, and the potential complications that can stem from vomiting (e.g., hematoma, wound dehiscence, pain), postdischarge nausea and vomiting deserves closer scrutiny. The purpose of this study was to examine patients experiences with nausea and vomiting after discharge from outpatient surgery centers. Specific objectives of the study were to determine: 1. The incidence of postdischarge nausea and vomiting; 2. The extent to which postdischarge nausea and vomiting affect patients normal functioning and daily activities after ambulatory surgery; and 3. The ways in which patients manage and/or cope with postdischarge nausea and vomiting. Methods Nurses employed in the outpatient surgical centers (OSCs) of six hospitals in the metropolitan area of a Southeastern city enrolled 211 patients into the study. Patients admitted to the OSCs from September 2,1992, through February 15,1993, were enrolled in the study if they met the following criteria: 1) 18 yr of age or by the International Anesthesia Research Society /95/$5.00 Anesth Analg 1995;80:

2 904 AMBULATORY ANESTHESIA CARROLL ET AL. ANESTH ANALG POSTDISCHARGE NAUSEA AND VOMITING 1995;80:903-9 Table 1. Demographic Description of the Patients Studied Postdischarge nausea and Telephone interview sample vomiting Yes (n = 57) No (n = 136) Age (yr) 39.8 (13.3)* 44.4 (15.0)* Weight (lb) (42.7) (33.8) Female (%) Questionnaire sample Yes (n = 48) No (n = 106) 41.6 (14.6) 45.3 (14.4) (32.6)* (36.2)* Values are mean (SD). *Groups are significantly different at P = Table 2. Frequency of Surgical Procedures by Surgical Procedure No. % No. % No. % No. % No. % No. % No. % Laparoscopy Dilation and curettage Arthroscopy Hernia repair Table 3. Most Frequently Used Drugs for Induction of Anesthesia Anesthetic No. % No. % No. % No. % No. % No. % No. % Propofol Midazolam Thiopental Etomidate older; 2) surgery was performed under general anesthesia; and 3) admitted for one of four selected surgeries: laparoscopy, dilation and curettage, arthroscopy, or hernia repair. The latter two requirements were included because 1) higher rates of postoperative nausea and vomiting have been reported in patients undergoing general anesthesia (6-81, 2) the procedures are frequently performed under general anesthesia in OSCs, and 3) they have been associated with appreciable rates of postoperative nausea and vomiting in the outpatient setting (2,4,7,9). All participants signed informed consent forms. These forms, and the design of the study, were approved by the Medical College of Virginia Committee on the Conduct of Human Research and by the institutional review boards of the participating hospitals. Nurses recorded the number of episodes of vomiting and estimated the severity of nausea for all patients who experienced nausea or vomiting in the recovery room. Postdischarge data were collected for two different time periods. Nurses were instructed to call and interview patients by telephone on the day after discharge. The questionnaire used to conduct the interview is shown as Appendix 1. Additional data were collected by means of self-administered questionnaires which were given to patients at the time of discharge. Patients were instructed to complete and return the questionnaire 5 days after discharge. The patient self-administered questionnaire is shown as Appendix 2. Data analyses consisted of calculation of means, SDS, and frequencies. 2 tests, Wilcoxon s signed rank tests, and one-way analysis of variance were used to test for significant differences between groups. Statistical significance is reported at P < Data analyses were performed with PC-SAS software (SAS Institute, Cary, NC).

3 ANESTH 1995;80:903-9 ANALG AMBULATORY ANESTHESIA CARROLL ET AL. 905 POSTDISCHARGE NAUSEA AND VOMITING Table 4. Most Frequently Used Drugs to Maintain Anesthesia Anesthetic No. % No. % No. % No. % No. % No. % No. % Enflurane Nitrous oxide Isoflurane Halothane Fentanyl Alfentanil Propofol Table 5. Most Frequently Used Neuromuscular Blocking Drugs Atracurium Vecuronium Succinylcholine d-tubocurarine Gallamine Mivacurium None No. % No. % No. % No. % 5 No. % 6 No. % Total No. % Table 6. Times at Which Nausea and/or Vomiting Were Experienced by 143 Patients Completing Both Telephone Interview and Questionnaire Nausea and vomiting Postdischarge Time No. % No None Recovery room only Total Yes Recovery room + postdischarge Only <48 h postdischarge Only >48 h-5 d postdischarge Total Total patients Results Telephone interviews were completed with 193 patients (91.5% of patients enrolled in the study). The mean time elapsed between discharge and completion of the telephone interview was SD days. Questionnaires were returned by 154 patients (73.0% of patients enrolled). The mean time elapsed between discharge and completion of the questionnaire was days. Table 1 compares demographic information for the groups who did and did not experience postdischarge nausea and vomiting and for the samples completing the telephone interview and questionnaire. The frequencies with which the four surgical procedures were performed in each OSC are reported in Table 2. The most frequently used anesthetics and neuromuscular blocking drugs are reported in Tables 3-5. Fifty-seven (29.5%) of the 193 patients contacted by telephone and 48 (31.2%) of the 154 patients who returned questionnaires experienced nausea and vomiting after discharge from the OSC. A total of 143 patients completed both the telephone interview and the 5-day follow-up questionnaire. Fifty-one of these patients (35.7%) experienced postoperative nausea and vomiting after discharge from the OSC (Table 6). The data in Table 7 show the incidence of nausea and vomiting for each surgical center and time period (recovery room, 24- to 48-h telephone call, and 5-day questionnaire). Table 8 reports the severity and duration of nausea and vomiting during each time period. Table 9 reports the rates of postdischarge nausea and vomiting for each of the four surgical procedures.

4 906 AMBULATORY ANESTHESIA CARROLL ET AL. ANESTH ANALG POSTDISCHARGE NAUSEA AND VOMITING 1995;80:903-9 Table 7. Incidence of Postoperative Nausea and Vomiting by Surgical and Time Period No. % No. % No. % No. % No. % No. % No. % Recovery room (n = 211) Nausea Vomiting Total patients Follow-up telephone call (n = 193) Nausea Vomiting Total patients Patient take-home questionnaire (n = 154) Nausea Vomiting Total patients Table 8. Mean Severity and Duration of Nausea and Vomiting by Time Period Severity of nausea Duration of nausea (days) No. of days on which vomiting was experienced Episodes of vomiting Telephone 5-Day follow-up Recovery room interview questionnaire Mean SD Mean SD Mean SD 4.5 NA NA Not measured NA = not applicable. Severity was measured on a IO-point scale for which 1 indicated no nausea and 10 indicated very severe nausea. Not measured Table 9. Number and Percent of Patients Experiencing Postoperative Nausea and/or Vomiting by Time and Surgical Procedure Surgical procedure 5-Day follow-up Recovery room Telephone interview questionnaire n No. % n No. % n No. % Laparoscopy * Dilation and curettage Arthroscopy * Hernia repair * * Total n = number in sample. * P value from the signed rank test for related samples < Patients who experienced postdischarge nausea and/or vomiting reported minimal interventions to help them manage or cope with the problem. They seldom contacted health professionals. Of the 154 patients who returned the 5-day questionnaire, only two reported calling a physician, one called the surgery center, and one visited a pharmacy. Purchases typically cost little (Table 10) and no patient hired help. Table 10. Number and Percent of Patients Making Purchases and Cost of Purchases for Treatment of Postdischarge Nausea and Vomiting Type of purchase No. % Mean SD Prescription medicines $ Over-the-counter medicines $ Beverages $ Special foods $

5 ANESTH ANALG 1995;80:903-9 AMBULATORY ANESTHESIA CARROLL ET AL. 907 POSTDISCHARGE NAUSEA AND VOMITING Table 11. Number and Percent of Patients Reporting Problems Performing Normal Daily Activities Did patient experience nausea or vomiting? Telephone interview 5-Day follow-up questionnaire Yes (n = 57) No (n = 136) Yes (n = 48) No (n = 106) Activity No. % No. % No. % No. % Taking care of yourself Taking care of others Preparing meals Eating meals Running errands Performing usual household tasks Doing things with friends Taking your medications * P -c P < ** * ** ** % ** ** ** ** ** ** Patients who reported experiencing nausea and vomiting in the 24- to 48-h period immediately after discharge were significantly more likely to have problems performing their normal daily activities than were those not experiencing postdischarge nausea and vomiting (Table 11). Differences between the groups were more pronounced for the longer postdischarge period reported on the questionnaire (Table 11). Discussion Postdischarge nausea and vomiting were experienced by more than 35% of patients in this study, many of whom had not experienced nausea and vomiting in the recovery room. During the 5-day period after discharge, these patients were significantly more likely to report impairment in performing their normal daily activities than were patients who did not experience nausea and vomiting. Despite the prevalence and perceived impact of postdischarge nausea and vomiting, few patients called health professionals for advice or purchased products to treat the problem. However, lack of intervention does not necessarily indicate a minimal problem. Patients in the study were counseled prior to discharge that nausea and vomiting might occur. They were, however, given only general instructions for management (e.g., dietary cautions, drinking carbonated beverages, taking pain medications on a full stomach). Given that surgical outpatients are not under direct medical supervision during their postdischarge recovery period, and that significant nausea and vomiting, aside from being distressing, may place patients at risk for complications and impede resumption of normal activities, it may be prudent to provide patients with more detailed instructions for preventing or managing nausea and vomiting episodes. The present study was confined to patients undergoing one of four procedures under general anesthesia in six surgical centers within one metropolitan area. The incidence, severity, duration, impact, and effectiveness of management techniques for postdischarge nausea and vomiting using larger and more diverse patient populations is unknown. The majority of patients reporting problems in our study did not experience nausea or vomiting until several hours after discharge (with considerable variability in onset among patients during the 5-day period). Further, there was little correlation between the occurrences of pre- and postdischarge nausea and vomiting. This may suggest a multifactoral etiology for postdischarge nausea and vomiting which may include not only the factors commonly associated with postoperative nausea and vomiting but additional factors, such as motion, premature ambulation, and pain medications, which may come into play at various points during the postdischarge recovery period. Closer scrutiny of these factors may provide insight for identifying patients most at risk for postdischarge nausea and vomiting and for developing effective prophylaxis and intervention strategies. Appendix 1 Questions Asked at 24-h Follow-up Telephone Interview 1. Have you experienced any nuuseu or vomiting since leaving the center? Yes/No 2. How would you rate the severity of your nausea on a scale of 0 to 10 (with 0 being no nausea and 10 being very severe nausea)? (Circle only one number on the scale.)

6 908 AMBULATORY ANESTHESIA CARROLL ET AL ANESTH ANALG POSTDISCHARGE NAUSEA AND VOMITING 1995;80:903-9 No nausea Very severe nausea I I I I I I I I I On how many different days have you been nauseated since you were discharged from the outpatient surgical center? (If none, write in zero.) On how many different days have you vomited since you were discharged from the outpatient surgical center? (If none, write in zero.) I am going to read a list of activities you might have been prevented from doing as a result of your surgery. Please tell me which of these you have not been able to do in the past 24 h because of your surgery. A. Taking care of yourself B. Taking care of anyone else C. Preparing meals D. Eating meals E. Running errands F. Performing usual household tasks G. Doing things with friends H. Taking your medications Have you taken any prescription medicines for the treatment of your nausea and vomiting since you were discharged from the outpatient surgical center? Yes/No Please tell me all the prescription medicines you have taken for the treatment of your nausea and vomiting and when you last took each. Have you taken any prescription medicines for the treatment of your pain since you were discharged from the outpatient surgical center? Yes/No Please tell me all the prescription medicines you have taken for the treatment of your pain. Appendix 2 Questions from Patient Self-Administered Questionnaire 1. Have you experienced any nausea or vomiting since leaving the surgery center? Yes/No 2. How would you rate the severity of your nausea on a scale of 0 to 10 (with 0 being no nausea and 10 being severe nausea)? (Circle only one number on the scale.) No nausea Very severe nausea I I I I I I I I I On how many different days, if any, have you experienced nausea since being discharged from the outpatient surgery center? On how many different days, if any, have you experienced vomiting since you were discharged from the outpatient surgical center? (If none, write a zero in the blank below.) Please circle the number beside all of the following things which you have had to do since being discharged as a result of nausea and/or vomiting. Also, write in the number of different times you had to do each thing: 1. Call a physicians office? No. of times 2. Call the surgery clinic? No. of times 3. Call a pharmacist? No. of times 4. Visit a physicians office? No. of times 5. Visit a pharmacy? No. of times 6. Visit an emergency room? No. of times Please circle the number beside all of the following items or services which you have had to buy to treat the nausea and/or vomiting from your surgery. Also indicate the amount you had to spend for each Prescription medicines: Amount spent $ Over the counter medicines: Amount spent $ Hired help: Amount spent $ Special beverages: Amount spent $ Special food(s): Amount spent $ Other purchases (please explain the type of other purchases in the space below): Amount spent $ 7. On how many of the last 5 days were you unable to carry out your normal responsibilities-such as working, homemaking, or going to school-because of your surgery? Questions about employment of patient and caregiver. 13. Which of the following activities were you prevented from doing during the past 5 days as a result of your surgery? (Circle all that you were prevented from doing.) 1. Taking care of yourself 2. Taking care of anyone else 3. Preparing meals 4. Eating meals 5. Running errands 6. Performing usual household tasks 7. Doing things with friends 8. Taking your medications Questions about satisfaction with outpatient surgical center experience.

7 ANESTH ANALG 1995;80:903-9 AMBULATORY ANESTHESIA CARROLL ET AL. 909 POSTDISCHARGE NAUSEA AND VOMlTING Questions about source of payment for medical care and prescriptions. References 1. Rowbotham DJ, Smith G. Introduction to supplement on postoperative nausea and vomiting. Br J Anaesth 1992;69(1 Suppl): 1s. 2. Lerman J. Surgical and patient factors involved in postoperative nausea and vomiting. Br J Anaesth 1992;69(1 Suppl):24S-32s. 3. Philip BK. Patients assessment of ambulatory anesthesia and surgery. J Clin Anesth 1992;4: Sanchez LA, Hirsch JD, Carroll NV, Miederhoff PA. Estimation of the cost of post-operative nausea and vomiting in an ambulatory surgery center. J Res Pharmaceutical Economics In press. 5. Young ML, Kitz DS, Andrews R, et al. Efficacy of antiemetic prophylaxis in patients receiving general anesthesia for outpatient surgery. Anesthesiology 1988;69:3A. 6. Rabey PG, Smith G. Anaesthetic factors contributing to postoperative nausea and vomiting. Br J Anaesth 1992;69(1 Suppl): 4oS-45s. 7. Wetchler BV. Postoperative nausea and vomiting in day-case surgery. Br J Anaesth 1992;69(1 Suppl):33S-39s. 8. Weinstein CM. Outpatient techniques. In: Klein SL, Landers DF, eds. Anesthesiology. East Oradell, NJ: Medical Economics Books, 1990~ Watcha MF, White PF. Postoperative nausea and vomiting. Anesthesiology 1992;77: