Puke, Barf, Retch: Maybe the Worst Side Effect of Surgery

Surgery and its aftermath aren’t easy, but you can decrease your risk of possibly the worst side effect of surgery — nausea and vomiting — with any number of these effective steps.

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If you’ve ever had surgery, there’s a good chance you’ve had some nausea and vomiting (N&V) afterwards. This might have happened in the recovery room where you were taken to wake up, in the car driving home, or even once you got home. If it happened after you left the hospital, it’s called post-discharge nausea and vomiting (PDNV). Wherever and whenever it happens, it’s unpleasant, inconvenient, and sometimes dangerous.

In surveys, many folks say they would pay more to avoid nausea and vomiting than they would to avoid pain.

If you get nauseated or vomit after surgery, you may have to suffer from one or more of the following:

  • Have more pain and generally feel awful

  • Have to stay in the recovery room and hospital longer

  • Break your stitches (from the retching and straining)

  • Accidentally open your wound (from the retching and straining)

  • Accidentally breathe in some of the junk you’re throwing up, which is called aspiration and can lead to pneumonia

In some surgeries (e.g., if your mouth has been wired shut; if you’ve had stomach or esophagus surgery; if the wound was hard to close), vomiting can be a very big deal.

But while you’re in the recovery room, you’re under close observation, which means you still have your IV line and can keep getting fluids so you don’t become dehydrated. You can also get medicines through your IV to help. If the N&V is really severe, you might end up spending quite a bit of extra time in the hospital or even have to spend the night.

But Then You’re Discharged . . .

PDNV is particularly troubling. Your IV line is out, there’s no medical staff around, and it’s much easier to get dehydrated. Without an IV line, it’s sure hard to give medicines to treat the N&V. You can’t keep medicine down very well if you’re vomiting!

Adding insult to injury, if you had a painful surgery (and many are), the narcotics your surgeon prescribed to help the pain also have the annoying habit of making you really sick to your stomach — that’s if you can even keep the pills down. And PDNV can sometimes lead to unplanned readmissions, which are a big cost to the hospital and a huge inconvenience to you. If you get to the point that you need to be readmitted, you’re definitely looking pretty green and feeling pretty terrible.

OK, so now that I’ve hopefully convinced you that it’s a very unpleasant problem, you might want to know your risk of postoperative N&V. If you are at high risk, you might also want to also know what steps you can take to prevent it.

Determining Whether You’ll Have N&V

There are many ways to estimate the chances you’ll have N&V after surgery. One popular method used by anesthesiologists and mentioned in the American Society of Anesthesiology Guidelines on prevention of post-operative N&V is the Apfel score. The Apfel score uses a points system to estimate risk, so the more points you have, the higher the risk.

In Apfel’s system, you get a point for each of the following:

  • Non-smoker

  • History of N&V after surgery

  • Need for narcotics for pain in the recovery room

  • Female Gender

With no points, your risk of N&V is around 10%, but with points it gets much higher:

  • 1 point = 20% risk

  • 2 points = 40% risk

  • 3 points = 60% risk

  • 4 points = 80% risk

Moreover, there’s a similar but slightly different Apfel score system for PDNV (again, a point for each of the following):

  • Non-smoker

  • History of N&V after surgery

  • Need for narcotics for pain in the recovery room

  • Female gender

  • Age < 50

Using the Apfel point system, the risk of PDNV is:

  • 0 points = 10%

  • 1 point = 20%

  • 2 points = 30%

  • 3 points = 50%

  • 4 points = 60%

  • 5 points = 80%

Although not perfect, the Apfel score is pretty good at estimating your risk.

We don’t know ahead of time if someone will need a bunch of narcotics in the recovery room, but everything else would be known. When someone is discharged, we do know all five-point categories. So if you’re at risk or are having a surgery where N&V just can’t happen (such as with gastric surgery), or you really don’t want to be sick because you’ve had an extremely unpleasant experience in the past and had to be readmitted, or you throw up whenever you’re on a boat . . . what do you do?

The Importance of the Perioperative Surgical Home (PSH)

Luckily, the answer is really easy if your hospital surgery and anesthesia departments participate in the American Society of Anesthesiology’s perioperative surgical home (PSH). With PSH, you’ll meet with your anesthesia provider well before the surgery to go over all your choices. But here’s stuff to know even before you have that meeting, since these steps always lower your risk:

If you can avoid general anesthesia by using local anesthesia and sedation or — even better — by using spinal or epidural anesthesia, do it.Your anesthesiologist will know if that’s an option for your type of surgery. Local, spinal, or epidural anesthesia has the important added benefit (among many benefits) of reducing pain and thereby reducing the need for postoperative narcotic medicines. Narcotics after the operation is over are highly associated with N&V.

If you need to have general anesthesia or don’t want a spinal or epidural, the anesthesia provider can use a propofol-based anesthetic usually referred to as total intravenous anesthetic (TIVA). Propofol is really helpful in reducing risk of N&V and is equally as safe and effective as general anesthetics with gases. This way, you can also avoid nitrous oxide (another anesthetic agent that is associated with N&V).

Use as little in the way of intraoperative and postoperative narcotics as possible. These make the risk of N&V much greater.

Be hydrated when you arrive at the hospital. That means drinking lots of Gatorade, water, tea, black coffee, etc. until two hours before your scheduled surgery. Without the PSH, it’s likely you’ll get a call the night before your surgery from a nurse you never met saying, “Don’t eat or drink anything after midnight!” Not only is this advice just plain wrong, it’s also dangerous.

Now that we’ve looked at the forest, let’s get into the trees:

Antiemetics Can Save the Day!

If you are at high risk of N&V or PDNV or are undergoing the type of surgery that makes N&V unacceptable, then the steps above will help but usually won’t be enough to avoid the problem. In that case, drugs to reduce N&V called antiemetics are necessary.

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There are many drug classes of antiemetics, and the more drugs from different classes you use, the lower your risk. There’s really a “buffet” of antiemetics and you want to definitely sample a few. Many of these drugs aren’t cheap, and they all usually have very minor side effects. For a 40 year old non-smoking woman with a history of motion sickness having a laparoscopic exam for abdominal pain, the risk of N&V is very, very high (likely higher than 80%). In that case, the anesthesia provider will usually give drugs from three or even four antiemetics of different classes. Some of the important classes of antiemetics are:

  • 5-HT3 receptor antagonists. The go-to drug in this class is called Zofranand most patients will receive a dose of Zofran in surgery.

  • Dexamethasone. This steroid is usually given along with Zofran. They have an additive and possibly synergistic effect. Dexamethasone is a great drug to prevent N&V.

  • NK-1 receptor antagonists. Aprepitant is the go-to drug in this class. Although not cheap, Aprepitant seems to work exceptionally well and for at least 24-48 hours.

  • Anticholinergics. The go-to drug here is a scopolamine or TransDerm Scoppatch that is place behind your ear for up to three days. It’s usually placed hours before surgery and prevents PDNV for at least 24 hours.

  • Gabapentin. This seizure drug is most commonly used for pain control but it does prevent N&V and its effect is additive to the other antiemetics. The bonus with gabapentin is that it also reduces narcotic needs postoperatively. (Remember: the fewer narcotics, the better both for preventing N&V and for also for minimizing the risk of addiction.) Gabapentin has few side effects and really is a “free lunch.” I have given patients Tylenol and gabapentin with a sip of water an hour or two before surgery. Tylenol is not an antiemetic but it effectively reduces postoperative narcotic needs.

There are at least eight to ten other classes of effective antiemetics available but the ones I’ve listed, especially the first four, are the most commonly used. If you can avoid general anesthesia or use a propofol TIVA anesthetic, take the first four classes of drugs, and avoid narcotics after surgery, your risk of N&V or PDNV goes way, way down.

In my experience, this technique reduces the risk of N&V well below 10%.

For those looking at a non-drug treatment, there is an item called an acupressure band that has a little button that presses on the wrist at the P6 acupressure point. Although it would seem like mumbo-jumbo, there is scientific evidence that supports its use and I’ve used it for years with my patients. It has no negative side effects and only costs around $8. It’s certainly worthwhile to use if N&V is a concern.

Precision Medicine for Different Gene Types

The Clinical Pharmacogenetics Implementation Consortium (CPIC) publishes guidelines for many common drugs for people with different gene types. For example, certain patients can’t take Plavix after a coronary stunting procedure because it doesn’t work with their genes. This is really important because these patients are at a much higher risk for a heart attack and the only way to know if they can take Plavix is by sampling their genome.

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Recently, CPIC published guidelines on 5HT-3 receptor antagonists (primarily Zofran) and showed there are certain groups of patients for whom another antiemetic would be recommended. Since Zofran is probably the most common antiemetic given by anesthesia providers, this is really important to know. Here again, as in the case of venous thromboembolism and Factor V Leiden, the $250-$300 one spends for a surgical-anesthesia gene panel is well worth the cost!

In summary, postoperative N&V and PDNV is a very common if not the most unpleasant and potentially dangerous side effect of anesthesia and surgery. It can lead to prolonged hospital stays and unplanned readmissions. However, you can easily estimate your risk using the Apfel score and take any number of effective steps to reduce the likelihood of this common complication. It isn’t easy being green!

More Information

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting