The gut-to-brain axis for toxin-induced defensive responses.

After ingestion of toxin-contaminated food, the brain initiates a series of defensive responses (e.g., nausea, retching, and vomiting). How the brain detects ingested toxin and coordinates diverse defensive responses remains poorly understood. Here, we developed a mouse-based paradigm to study defensive responses induced by bacterial toxins. Using this paradigm, we identified a set of molecularly defined gut-to-brain and brain circuits that jointly mediate toxin-induced defensive responses. The gut-to-brain circuit consists of a subset of Htr3a+ vagal sensory neurons that transmit toxin-related signals from intestinal enterochromaffin cells to Tac1+ neurons in the dorsal vagal complex (DVC). Tac1+ DVC neurons drive retching-like behavior and conditioned flavor avoidance via divergent projections to the rostral ventral respiratory group and lateral parabrachial nucleus, respectively. Manipulating these circuits also interferes with defensive responses induced by the chemotherapeutic drug doxorubicin. These results suggest that food poisoning and chemotherapy recruit similar circuit modules to initiate defensive responses.

Antiemetic prophylaxis with droperidol in morphine-based intravenous patient-controlled analgesia: a propensity score matched cohort study.

BACKGROUND: There are limited real-world data regarding the use of droperidol for antiemetic prophylaxis in intravenous patient-controlled analgesia (IV-PCA). This study aimed to evaluate the antiemetic benefits and sedation effects of droperidol in morphine-based IV-PCA. METHODS: Patients who underwent major surgery and used morphine-based IV-PCA at a medical center from January 2020 to November 2022 were retrospectively analyzed. The primary outcome was the rate of any postoperative nausea and/or vomiting (PONV) within 72 h after surgery. Propensity score matching was used to match patients with and without the addition of droperidol to IV-PCA infusate in a 1:1 ratio. Multivariable conditional logistic regression models were used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: After matching, 1,104 subjects were included for analysis. The addition of droperidol to IV-PCA reduced the risk of PONV (aOR: 0.49, 95% CI: 0.35-0.67, p < 0.0001). The antiemetic effect of droperidol was significant within 36 h after surgery and attenuated thereafter. Droperidol was significantly associated with a lower risk of antiemetic uses (aOR: 0.58, 95% CI: 0.41-0.80, p = 0.0011). The rate of unintentional sedation was comparable between the patients with (9.1%) and without (7.8%; p = 0.4481) the addition of droperidol. Postoperative opioid consumption and numeric rating scale acute pain scores were similar between groups. CONCLUSIONS: The addition of droperidol to IV-PCA reduced the risk of PONV without increasing opiate consumption or influencing the level of sedation. However, additional prophylactic therapies are needed to prevent late-onset PONV.

The association between quality of life and complementary and alternative medicine use in pregnant women with hyperemesis gravidarum.

AIM: This study investigated the association between quality of life and complementary and alternative medicine (CAM) use in pregnant women with hyperemesis gravidarum in Turkey. METHODS: This cross-sectional descriptive study was conducted between October 2017 and July 2018 in Turkey. The sample consisted of 240 pregnant women with hyperemesis gravidarum. Data were collected using a Demographic Information Form, the Index of Nausea, Vomiting, Retching, and the 36-item Short-Form Health Survey. RESULTS: The majority (84.2%) of participants stated that they used CAM, mostly "biologically based therapies" (97.5%). They were most satisfied with the "mental and physical treatments" (3.71 ± 1.74). Participants who did not use CAM had a higher quality of life "emotional role" than those who used CAM (p = 0.038). However, there were no statistically significant differences in the other quality of life subscale scores between the two groups. CONCLUSION: There is limited evidence for the association between quality of life and CAM use in pregnant women with hyperemesis gravidarum in Turkey. Therefore, more evidence-based research is warranted to evaluate the association between CAM use and quality of life in pregnant women with hyperemesis gravidarum.

The gagging patient in ORL examinations: predictors, evaluation and treatment.

PURPOSE: Gagging may be a challenge in daily otorhinolaryngology (ORL) routine. This cross-sectional study aimed to examine conditions of gagging as limitation to ORL examination and the efficacy of acupressure as tool to reduce exaggerated gagging. METHODS: The study was conducted on a total of 360 study subjects. There was a survey part and a routine ORL examination with observation of gagging behaviour. Through binomial univariate logistic regression, predictors of clinically relevant exaggerated gagging were identified. Wilcoxon signed rank test was used to evaluate efficacy of acupressure point CV-24 to reduce gagging while examination. RESULTS: First gagging's relevance was indicated by over 40% of study subjects showing clinically relevant exaggerated gagging. Furthermore, we found that more psychogenic than somatogenic features proved to be predictors of exaggerated gagging. Third acupressure point CV-24 showed statistical significant reduction of gagging intensity and improved examination feasibility. CONCLUSION: Awareness of exaggerated gagging's predictors are the first step to deal with gagging in daily practice. Acupressure might be an effective tool to overcome gagging in the affected patients. LEVEL OF EVIDENCE: We suggest at least Level IV according to Oxford (UK) CEBM Levels of Evidence.

Attenuation of brain mitochondria oxidative damage by Albizia julibrissin Durazz: neuroprotective and antiemetic effects.

Medicinal plants, as new drugs, are considered for treatment of insomnia, anxiety, depression, confusion, nausea, and vomiting symptoms. The current study aimed to evaluate the neuroprotective and antiemetic effects of Albizia. julibrissin Durazz. flower extract in the chickens. Emesis was induced by copper sulfate and ipecac (60 and 600 mg/kg, orally, respectively) and the methanolic extract (50, 100, and 200 mg/kg) were injected intraperitoneally (i.p.). Mitochondrial function, lipid peroxidation (LPO), protein carbonyl (PC) content, and catalase activity as biomarkers of oxidative damage were evaluated in the brain mitochondria. All doses of extract showed significant (p < 0.001) antiemetic activity against induced emesis by copper sulfate and ipecac. Brain mitochondria function (by 50, 100, and 200 mg/kg of extract) were increased 48%, 85%, and 90% against emesis induced by ipecac and 32%, 18%, and 24% against emesis induced by copper sulfate, respectively. LPO and PC contents were significantly decreased after the administration of extract in emesis induced by copper sulfate and ipecac. A significant decrease (p < 0.01) of CAT activity was observed in the extract (200 mg/kg) group in emesis induced by copper sulfate in chickens brain mitochondria. The present study suggests that the extract had antiemetic effects against emesis induced by copper sulfate and ipecac in young chickens via peripheral and central mechanisms. Neuroprotective effect of the extract could be due to the increase in bioactive compounds, plasma antioxidants, or direct free radical scavenging that could prevent lipid and protein alteration and impede the formation of oxidative damage.

A systematic review of methodologies, endpoints, and outcome measures in randomized trials of radiation therapy-induced nausea and vomiting.

PURPOSE: Clinical trials in radiation therapy-induced nausea and vomiting (RINV) appear to have varied methodologies, endpoints, and outcome measures. This complicates trial comparisons, weakens practice guideline recommendations, and contributes to variability in supportive care patterns of practice. We systematically reviewed RINV trials to describe and compare their pertinent design features. MATERIALS AND METHODS: Ovid versions of the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, EMBASE, and MEDLINE to January/February 2017 were searched for adult phase III trials of RINV management strategies. Key abstracted data included trial interventions and eligibility criteria, standard radiation therapy (RT) metrics, symptom assessment procedures, symptom definitions and grading systems, pre-specified and reported endpoints, and other outcome measures. RESULTS: From 1166 references identified in the initial database search, we selected 34 trials for analysis that collectively randomized 4529 patients (median 61, range 11-1492). Twenty-eight trials (82%) were published prior to the year 2000. Twenty-seven trials (79%) involved multiple fraction RT and 7 (21%) single fraction RT. Twenty-four trials (71%) evaluated prophylactic interventions, 9 (26%) rescue interventions, and 1 trial did not specify. Thirty-three trials (97%) evaluated pharmacologic interventions. Twenty trials (59%) had patient report symptoms, 5 (15%) healthcare professionals or researchers, and 10 (29%) did not specify. Nausea was not defined in any trial but was reported as a stand-alone symptom in 26 trials (76%) and was graded in 20 (59%), with categorical qualitative scales being the most common method. Vomiting was defined in 3 trials (9%), was reported as a stand-alone symptom in 17 (47%), and was graded in 7 (21%), with continuous numerical scales being the most common method. Retching was defined in 3 trials, was not reported as a stand-alone symptom in any trial, and was graded in 1 (3%). Twenty-one trials (62%) created compound symptom measures that combined individual symptoms. Fifteen trials (44%) reported "emetic episode/event" measures but only 9 defined them. Seventeen trials (50%) reported complicated endpoints (e.g., "response," "control," "success") that combined multiple symptom or compound symptom measures, but 7 did not define them comprehensively. Ten trials (29%) defined a primary endpoint a priori. CONCLUSIONS: Methodologies, endpoints, and outcome measures varied considerably among 34 randomized trials in RINV.

Pyloric stenosis in a patient with pure esophageal atresia: A difficult diagnosis.

Hypertrophic pyloric stenosis is brought to attention by its characteristic non-bilious vomiting. In a patient with pure esophageal atresia and a feeding gastrostomy, the symptoms were modified and the diagnosis was delayed. This case report highlights the clinical features of this rare combination, whose diagnosis was easily established once the entity was considered.

Effect of Acupressure at PC6 on Nausea and Vomiting During Pregnancy: a Randomized Controlled Trial.

Background: Nausea and vomiting are among the most common medical problems during pregnancy, affecting 80% of mothers. Objectives: This study was conducted as a randomized controlled experimental study to determine the effect of acupressure applied by a wristband to the pericardium 6 (PC6) point on nausea and vomiting during pregnancy. Methods: The study population consisted of 74 pregnant women between 6-14 weeks of gestation who were experiencing nausea and vomiting. The study data was collected with personal information from the Pregnancy-Unique Quantification of Emesis Scale (PUQE). Experimental and control groups were selected by a simple random method. The experimental group wore acupressure wristbands for one week, while the control group did not use any method to alleviate nausea and vomiting. One week later, the PUQE scale was applied to both groups. Results: The acupressure wristbands decreased the nausea and vomiting scores of the pregnant women in the experimental group without statistical significance but did not change the nausea and vomiting scores of the pregnant women in the control group. Conclusion: Acupressure wristbands can be used to prevent nausea and vomiting during pregnancy.

Efficacy of press needle treatment in reducing chemotherapy-induced nausea, vomiting, and retching gastrointestinal cancer patients: A randomized controlled trial.

Objective: Chemotherapy-induced nausea and vomiting (CINV) and retching often pose challenges in managing patients with gastrointestinal cancer. This randomized controlled trial sought to evaluate the effectiveness of press needle therapy in mitigating CINV and retching following chemotherapy. Methods: Two hundred patients with gastrointestinal cancer undergoing folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy were randomly assigned to either the press needle group or the control group. The control group received 5-hydroxytryptamine-3 (5-HT3) antagonists and dexamethasone 30 min before chemotherapy, followed by dexamethasone on days 2 and 3 after chemotherapy. In contrast, the press needle group received press needle treatment 30 min prior to chemotherapy. The primary outcome was the Index of Nausea, Vomiting, and Retching (INVR), assessed at seven time points: before chemotherapy and at 12, 24, 36, 48, 60, and 72 h post-chemotherapy. Results: All patients completed their respective treatments, and no significant adverse effects related to press needle treatment (such as skin allergies, acupoint infections, headaches, or dizziness) were reported. A two-way repeated-measures analysis of variance (ANOVA) revealed significant differences in INVR scores between the two groups (P < 0.05). Further analysis with a t-test indicated that INVR scores in the press needle treatment group were significantly lower than those in the control group at 12, 24, and 36 hours after chemotherapy (P < 0.05), with no significant difference observed thereafter. Conclusions: Press needle treatment effectively alleviated nausea, vomiting, and retching in patients with gastrointestinal cancer undergoing chemotherapy. It represents a safe, efficient, and convenient complement to preventive treatment with 5-HT3 antagonists. Trial registration: Chinese Clinical Trial Registry (No. ChiCTR1900024554).

An Anatomic Red Herring Found in the Diagnosis of Functional Vomiting.

This report describes the case of a previously healthy 16-year-old patient who initially presented with emesis of unknown etiology that was refractory to standard medical interventions. The initial imaging revealed duodenum inversum, a rare anatomic abnormality that provided additional diagnostic complexity to this case. Though the final diagnosis was found to be functional vomiting, this case gives an instructive review of this rare anatomic abnormality, the significant effects it may cause, and how making a diagnosis of exclusion can be challenged by unusual turns in an otherwise straightforward presentation.

A scoping review of nausea, vomiting and retching measurement methods in children with cancer.

Evaluation of chemotherapy-induced nausea and vomiting (CINV) in the pediatric population is subject to diverse approaches. This scoping review summarizes the methods used in clinical studies that assessed nausea, vomiting or retching in children with cancer. We conducted a literature search of studies indexed in EMBASE and Ovid MEDLINE after 2000. Studies were included if they involved patients ≤18 years of age diagnosed with cancer, and had nausea, vomiting or retching as a primary study outcome. We excluded studies that reported only parent- or clinician-proxy measures without including the child's self-reported NVR, and those without specifying the NVR data collection process. The literature search identified twenty-four studies evaluating pediatric nausea, vomiting or retching. In the assessment of NVR, structured surveys were the most commonly used instrument for NVR assessment (75%) and the use of patient diaries (50%). Nine studies (38%) relied solely on self-reports from children as the outcome measure, while fifteen studies (62%) solicited input from parents/ caregivers and healthcare providers in addition to children's self-reports. Almost all the studies reported the frequency (n = 24) and/or severity (n = 23) of NVR symptoms and the use of antiemetic therapy (n = 19). Fewer studies evaluated distress caused by the symptoms (n = 2) and the effects of symptoms on activities of daily living (n = 4). Incorporating NVR measurement tools as part of standard of care for pediatric patients undergoing chemotherapy is strongly advocated. Based on the age group, we recommend the use of such tools comprising Likert scale, pictorial scales and structured scripts to assess various dimensions of a child's NVR experience.

Metoclopramide and Propofol to Prevent Nausea and Vomiting during Cesarean Section under Spinal Anesthesia: A Randomized, Placebo-Controlled, Double-Blind Trial.

BACKGROUND: Intra-operative nausea, vomiting and retching (NVR) are frequently associated with subarachnoid anesthesia (SA) in women undergoing cesarean section (CS). In this study performed in women undergoing CS under SA with a risk factor control strategy, we compared saline (placebo), propofol, metoclopramide and both drugs to prevent NVR. METHODS: We recorded NVR events in 110 women undergoing CS who were randomized after umbilical cord clamping to receive saline (S; n = 27), metoclopramide 10 mg (M; n = 28), propofol 1 mg/kg/h (P; n = 27) or both drugs (PM; n = 28). RESULTS: The proportion of women with intra-operative nausea was: S: 17/27 (63%); P: 15/27 (56%); M: 13/28 (46%); PM: 6/28 (21%) (p = 0.012, Cramér's V = 0.31 (large effect). The proportion of women with intra-operative vomiting/retching was: S: 9/27 (33%); M: 7/27 (25%); P: 3/28 (11%); PM 2/28 (7%) (p = 0.049, Cramér's V = 0.26 (medium effect). Post-hoc multiple comparisons revealed a significant reduction in NVR episodes and NRS scores between the PM group and control. Sedation scores did not differ among groups. CONCLUSION: In women undergoing CS under SA with a risk factor control strategy, combined propofol and metoclopramide reduce nausea and vomiting.

A Case of Prolapsed Gastropathy Syndrome Presenting as Hematemesis and Acute Blood Loss Anemia.

A 45-year-old male with hypertension and alcohol use disorder presented to the hospital after being found intoxicated, with bright red blood in the toilet and around his mouth. He was found to be tachycardiac and required intubation due to his inebriated state to establish a secure airway. Initial workup revealed a hemoglobin decrease from 16.7 g/dL to 8.7 g/dL, as well as lactic acidosis. He quickly underwent an upper endoscopy to evaluate his source of hematemesis. An actively bleeding lesion was found in the proximal stomach consistent with prolapse gastropathy syndrome. This case highlights a unique presentation of hematemesis that requires endoscopic evaluation for both diagnosis and treatment.

Frequency, severity, and impact on daily life of delayed and intercycle chemotherapy-induced nausea, vomiting, and retching.

INTRODUCTION: Chemotherapy-induced nausea, vomiting, and retching (CINVR) remains a common side effect of treatment. Most previous studies have focused on vomiting control; nausea and retching have been less explored. This study aimed at describing the incidence, severity, and impact on daily life (IDL) of CINVR in the acute (0-24 hours), delayed (>24-120 hours), and overall (0-120 hours) postchemotherapy periods and beyond 120 hours (until next chemotherapy administration); and the pharmacologic and nonpharmacologic strategies adopted by patients to relieve symptoms. METHODS: This was a single-center, cross-sectional study of 60 patients undergoing chemotherapy. Participants reported the frequency, severity, and IDL of CINVR from the day of chemotherapy administration up to 120 hours thereafter and nausea and vomiting that occurred beyond 120 hours, as well as pharmacologic and nonpharmacologic remedies used. RESULTS: Forty-seven (78.3%, 95% confidence interval [CI] 66.4-86.9), 37 (61.7%, 95% CI 49.0-72.9), and 35 (58.3%, 95% CI 45.7-69.9) patients reported no nausea (Numeric Rating Scale ⩽1), vomiting, or retching in the acute, delayed, and overall periods, respectively. Nausea was more frequent, more severe, and had a greater IDL than did vomiting and retching across the overall observation period; beyond 120 hours, 11 (18.3%, 95% CI 10.6-29.9) patients reported nausea and none reported vomiting, with a median IDL of 1/10 (interquartile range: 0.75-5.00; 95% CI 0-7.6). Metoclopramide (n = 57 administrations), dexamethasone (n = 28), eating small servings of food (n = 13), and aloe (n = 11) were the most commonly used rescue therapies. CONCLUSIONS: Future studies should set hard outcomes, such as the absence of any symptoms, as a primary end point, and these should be assessed across and beyond the 120-hour period.

Effect of Foot Massage on Patients with Chemotherapy Induced Nausea and Vomiting: A Randomized Clinical Trial.

Introduction: Cancer is a global problem and it is a leading cause of death worldwide. Nausea, vomiting and retching (NVR) are one of the common side effects that are seen among the majority of the patients undergoing chemotherapy. Foot massage is a complementary therapy that reduces chemotherapy-induced nausea and vomiting and improves the quality of life among cancer patients undergoing chemotherapy. This study aim to measure the effectiveness of foot massage in reduction of nausea, vomiting & retching on patients undergoing chemotherapy treatment. Methods: A randomized clinical trial study was used to assess the effect of foot massage on patients with Chemotherapy-induced nausea and vomiting among patients undergoing highly emetogenic chemotherapy. Simple random sampling by the lottery method was used to select newly diagnosed cancer patients who underwent highly emetogenic chemotherapy (N = 82). Rhodes index of nausea, vomiting and retching questionnaire were used for data collection. SPSS 19, two-sample t test, paired t test and chi-square test were used for data analysis. Results: Nausea, vomiting, and retching were significantly reduced in the experimental group compared to the control group after the intervention. There was a significant difference between pre-intervention and post-intervention scores within the group. Conclusion: The findings of the study revealed that the foot massage therapy is effective in reducing chemotherapy-induced nausea and vomiting among patients undergone highly emetogenic chemotherapy. The study helped to conclude that foot massage can be considered effective intervention in chemotherapy patients.

Vomiting and retching as presenting signs of focal epilepsy in children.

Ictal vomiting is a rare condition easily misdiagnosed as a common disease. We report two children presenting with retching and vomiting as the main ictal manifestation. Patient 1 was a four-year-old girl with a history of daily nocturnal vomiting for two months, first interpreted as a functional disorder, then as a viral infection. She presented with vomiting accompanied by focal right-sided hemifacial clonic jerking, occurring multiple times per day. Video-EEG demonstrated ictal discharges associated with the retching and vomiting, over a normal background, and occasional interictal focal spikes. MRI was normal. PET demonstrated left-sided opercular hypometabolism. Patient 2 was a girl with a history of focal epilepsy, secondary to a right central dysembryoplastic tumour, first resected with subsequent seizure freedom at the age of three years. At five years of age, she presented with recurrent episodes of retching and vomiting initially diagnosed as migraine. Video-EEG showed ictal discharges, clinically correlating with retching, vomiting and clonic facial jerking, with normal interictal activity. Brain MRI showed a progression of the tumour. A second resection resulted in seizure freedom. Ictal vomiting often goes undiagnosed, especially in children, causing treatment delays. An ictal origin should be considered, particularly when the episodes are recurrent and stereotyped. [Published with video sequences].

Postfundoplication retching: Strategies for management.

BACKGROUND: Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right. METHODS: A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered. CONCLUSIONS: Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future. Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided. LEVEL OF EVIDENCE: II-V.

Efficacy and Tolerance of Blended Diets in Children Receiving Gastrostomy Feeds.

BACKGROUND: To determine the prevalence of gastrointestinal (GI) symptoms in children receiving a blended diet via a gastrostomy tube. METHODS: This is a single-center, retrospective study of children ages 1-18 years that received a blended diet. We reviewed demographics, anthropometrics, clinical characteristics, and rationale for switching to blended diet. Fixed-effects logistic regression analysis was used to evaluate the changes in patient symptoms over the 12-month follow-up period, and fixed-effects regression was employed to test for changes in anthropometrics. RESULTS: Twenty-three patients (8 female, 15 male) were identified, and data from 89 outpatient visits were analyzed. The most common underlying diagnosis was neurological disorder. Thirty-five percent of patients received commercial whole cow milk formulas, 30% received hydrolysate formulas, and 35% received amino acid-based formulas. After formula switches were made, 65% received homemade blended diets, 17.5% received commercial blended diets, and 17.5% received a combination of both. Median duration of time on a blended diet was 17 months. Ninety-five percent of patients who were previously experiencing upper GI symptoms improved within the first 3 months after blended diet initiation. Twenty-one percent of patients developed mild constipation on the diet, which was managed with increased water intake and/or polyethylene glycol. Only 2 patients discontinued the blended diet, because of inadequate weight gain and worsening of upper GI symptoms. CONCLUSIONS: In our study population, blended diets were well tolerated in gastrostomy-fed children and were associated with clinical improvement of upper GI symptoms.

Assessment of postoperative nausea and vomiting after bariatric surgery using a validated questionnaire.

BACKGROUND: Postoperative nausea and vomiting (PONV) is known to occur after bariatric surgery, with over two thirds of patients affected. However, variability exists in how to objectively measure PONV. OBJECTIVES: The goals of the present study were to use a validated, patient-centered scoring tool, the Rhodes Index of Nausea, Vomiting, and Retching to measure the severity of PONV after bariatric surgery, to directly compare PONV between patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), and to identify risk factors for the development of PONV after bariatric surgery. SETTING: Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri, United States of America. METHODS: The Washington University Weight Loss Surgery team prospectively surveyed patients from January 1, 2017 to December 1, 2018 at the following 6 different timepoints: postoperative day (POD) 0, POD 1, POD 2, POD 3 to 4, the first postoperative outpatient visit (POV 1: POD 5-25), and the second postoperative visit (POV 2: POD 25-50). At each timepoint, a cumulative Rhodes score was calculated from the sum of 8 questions. The American Society for Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to collect patient demographic characteristics and perioperative clinical data. RESULTS: A total of 274 patients met study criteria and completed 605 Rhodes questionnaires. Two hundred fifty Rhodes questionnaires were completed by patients after SG and 355 were completed by patients after LRYGB. Total Rhodes scores are statistically higher in LSG patients compared with patients who underwent LRYGB (LSG = 5.45 ± 6.27; LRYGB = 3.08 ± 4.19, P = .0002). Additionally, at the earlier timepoints, scores were higher among patients who underwent LSG than those who had undergone LRYGB as follows: POD 0 (LSG = 6.96 ± 6.50; LRYGB = 2.89 ± 2.90, P = .0115), POD 1 (LSG = 8.20 ± 6.76; LRYGB = 2.88 ± 3.44, P < .0001), and POD 2 (LSG = 4.05 ± 4.88; LRYGB = 2.06 ± 3.43, P = .05). On subset analysis, examining patients who either underwent an LSG or LRYGB, both procedures had a statistically significant PONV peak emerge on POV 2. Last, overall Rhodes scores were statistically higher in female patients compared with male patients (female: 4.43 ± 5.46; male: 2.35 ± 3.90, P = .021). Although the magnitude of the difference varied somewhat across POD time intervals, the difference was most pronounced at POV 2. CONCLUSIONS: This is the largest study using a validated nausea and vomiting questionnaire to objectively measure PONV after bariatric surgery. The factors found to be most associated with increased PONV were LSG and female sex. Ultimately, these data can help bariatric surgery programs, including Washington University Weight Loss Surgery, identify patients who may require more intensive treatment of PONV, particularly POD 0 to 2, and help to identify patients that continue to struggle with PONV in the later surgical recovery phase.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review.

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient's risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.