靜脈注射葡萄糖預防術後噁心嘔吐

作者：Caroline Helwick  
出處：WebMD醫學新聞

　　October 20, 2009 (紐澳良) — 研究者在美國麻醉醫師協會2009年會中報告指出，手術後簡單的給予靜脈(IV)注射葡萄糖，可以顯著降低術後噁心嘔吐(PONV)的發生率，也減少在術後麻醉照護病房(PACU)時的止吐藥物需求。
　　
　　另一篇統合分析中，量化病患特定因素與麻醉相關因素用於預測術後噁心嘔吐的預測價值。
　　
　　術後靜脈注射葡萄糖之研究的主要作者、康乃迪克州紐哈芬耶魯大學醫學院的Susan Dabu-Bondoc醫師表示，在術後常見術後噁心嘔吐，頗令病患難受。
　　
　　Dabu-Bondoc醫師表示，我們可以用實用又便宜且容易取得的葡萄糖來預防；使用葡萄糖沒有任何阻礙。
　　
　　她指出，術後噁心嘔吐的副作用，包括肺內吸入異物、傷口縫合處蹦開、延長住院天數、門診手術之後意外住院、延後病患恢復日常生活功能的時間。
　　
　　之前的研究顯示，術前口服碳水化合物與靜脈輸液可減少術後噁心嘔吐。這篇新研究檢視另一種已經由耶魯的護士運用的簡單預防方法，她表示，我們決定正式研究它。
　　
　　該研究是一個雙盲隨機安慰劑控制試驗，研究對象是56名健康且非臥床、排定進行婦科腹腔鏡手術與子宮腔鏡檢查的病患。病患被隨機分組接受靜脈注射加入Ringer氏乳酸溶液的5%葡萄糖(D5LF)；控制組接受無添加的Ringer氏乳酸溶液。兩組都在術後立即給予治療，病患住進PACU時仍繼續。所有病患都接受併用sevofluorane與vecuronium的全身麻醉，且在麻醉結束前30分鐘接受1劑的止吐藥物。
　　
　　兩組的年紀、焦慮程度、體重、之前曾有術後噁心嘔吐、之前的手術史、未經口進食(NPO)狀態、麻醉時間、術前葡萄糖、手術期間使用一氧化二氮與鎮靜劑情形、根據體重給予的整體輸液量等因素都相似。
　　
　　Dabu-Bondoc醫師報告指出，接受葡萄糖溶液的病患，在抵達PACU之後30分鐘，以及出院時的術後，噁心嘔吐情形都顯著較少，整體的術後噁心嘔吐指數也比控制組低。
　　
　　標準的術後噁心嘔吐評估量表(0–4)中，葡萄糖組與控制組的分數比較如下：30分鐘時的術後噁心嘔吐分數，0.6± 1.3 vs 1.8± 2.6 (P= .03)；出院時的術後噁心嘔吐分數，0.3± 0.6 vs 1.2± 1.9 (P= .03)；整體術後噁心嘔吐分數，4.2± 5.8 vs 9.5± 10.1 (P= .02)。控制組在60分鐘和12分鐘時的分數高出許多，但是未達統計上的顯著意義。
　　
　　葡萄糖組在PACU時與需要緊急使用止吐藥物的數量是控制組的一半(P= .02)，而且比較快出院(147 vs 178分鐘；P= .08)。
　　
　　聽眾對此發表有極高興趣，Dabu-Bondoc醫師回應相當多的問題。當被問到此效果是否單純與水合作用有關時，她回應道，研究者測量給予兩組的液體量，發現並無差異；因此，不論是在手術室或者PACU，葡萄糖組並非全然都是水合作用。他們也測量術前葡萄糖值，也是沒有差異。
　　
　　聽眾之一、康乃迪克州Bridgeport醫院的資深醫師Evan Tilley表示，他對結果不感驚訝。他表示，我們使用葡萄糖快速注射(500 mL的5%葡萄糖)來加強ondansetron對於術後噁心嘔吐的效果，但是我們真的不知道這何以會發生效用。
　　
　　Tilley醫師指出，水合作用也很重要。在我們的年長病患中，我們不會讓他們NPO超過6小時。我們會允許他們使用澄明液體，這對噁心嘔吐症狀也有幫助。
　　
　　【統合分析檢視PONV的風險因素】
　　在該組會議中，加州大學舊金山分校(UCSF)的Felix M. Heidrich醫師發表一篇16個研究的統合分析，共有約90,000名病患，評估可以用來預測術後噁心嘔吐的因素。Heidrich醫師指出，在可能的諸多因素中，最明顯的預測因子是女性，勝算比增加2.6倍(P< .0001)。
　　
　　曾有術後噁心嘔吐或暈動症、非抽菸狀態、年輕、術後使用鴉片類藥物等也是顯著風險因素(全部的P值都小於0.0001)。
　　
　　麻醉相關因素中，麻醉期間與術後使用鴉片類藥物兩者都是預測因素(全部的P值都小於0.0001)。
　　
　　研究發現，8種手術分類中，膽囊切除術的機率增加1.7倍(P= .03)，但是婦科手術以及眼科手術也都是預測因素(P= 0.01)。
　　
　　來自UCSF的資深作者、Christian C. Apfel醫師發表一個術後噁心嘔吐預測模式(Apfel氏分數)，他表示，我們鼓勵大家使用這個模式來預測術後噁心嘔吐，且讓高風險病患使用預防性藥物；醫師應嘗試使用致吐性較低的藥物，以及減少使用鴉片類藥物，這些可以減少術後噁心嘔吐風險。我們也會併用止吐藥物。我們發現，你可以自由併用它們，當你使用不同作用途徑的藥物時，它們可以各自發揮效用。
　　
　　Dabu-Bondoc醫師、Tilley醫師與Apfel醫師皆宣告沒有相關財務關係。
　　
　　美國麻醉醫師協會(ASA) 2009年會：摘要A492與A494。發表於2009年10月18日。

Intravenous Dextrose Prevents Postop Nausea and Vomiting

By Caroline Helwick
Medscape Medical News

October 20, 2009 (New Orleans, Louisiana) — The simple intravenous (IV) administration of dextrose following surgery significantly reduces the occurrence of postoperative nausea and vomiting (PONV) and the need for antiemetic medication in the postoperative anesthesia care unit (PACU), investigators reported here at the American Society of Anesthesiologists 2009 Annual Meeting.

In a separate presentation, a meta-analysis quantified the strong predictive value of patient-specific and anesthesia-related factors as independent predictors of PONV.

PONV is common after surgery and is more than just uncomfortable for the patient, said Susan Dabu-Bondoc, MD, from Yale University School of Medicine in New Haven, Connecticut, the lead author of the study of the effectiveness of postoperative IV dextrose.

"We can prevent this with dextrose, which is universally available, inexpensive, and very practical," Dr. Dabu-Bondoc said. "The use of dextrose is really a no-brainer."

Adverse effects of PONV can include aspiration, wound suture opening, prolonged hospital stays, unanticipated admission after outpatient surgery, and delayed return of a patient's ability to function in daily activities, she pointed out.

Previous studies have shown that preoperative oral carbohydrate and intravenous fluid decreases PONV. This new study examined another easy means of prevention that Yale nurses are already employing, she said, "and we decided to formally study it."

The study was a double-blind randomized placebo-controlled trial of 56 healthy ambulatory surgery patients scheduled for gynecologic laparoscopic and hysteroscopic procedures. Patients were randomized to receive IV treatment with dextrose 5% in a Ringer's lactate solution (D5LF); the control group received plain Ringer's lactate solution. Both treatments were given immediately after surgery and were continued as patients were admitted to the PACU. All patients underwent sevofluorane–vecuronium general anesthesia and received 1 dose of an antiemetic 30 minutes before the end of anesthesia.

The groups were similar in age, anxiety level, weight, previous PONV, previous surgery, nothing by mouth (NPO) status, anesthetic time, preoperative glucose, intraoperative nitrous oxide and narcotic use, and total weight-based fluid volume received.

Patients who received the dextrose solution had significantly lower PONV scores 30 minutes after arriving in the PACU and at discharge, and lower overall PONV scores than the control group, Dr. Dabu-Bondoc reported.

On a standard PONV evaluation scale (0–4), the scores for the dextrose vs control group were as follows: PONV score at 30 minutes, 0.6?± 1.3 vs 1.8?± 2.6 (P?= .03); PONV score at discharge, 0.3?± 0.6 vs 1.2?± 1.9 (P?= .03); and total PONV score, 4.2?± 5.8 vs 9.5?± 10.1 (P?= .02). Scores at 60 and 120 minutes were numerically higher for the control group, but were not statistically significant.

Those in the dextrose group required half the amount of rescue antiemetic medications while in the PACU (P?= .02) and were discharged sooner (147 vs 178 minutes; P?= .08).

Audience interest in this presentation was high, and Dr. Dabu-Bondoc fielded a number of questions. When asked whether the effect might simply be related to hydration, she responded that investigators measured the amount of fluid given to both groups and found no differences; therefore, the dextrose group was not more liberally hydrated, either in the operating room or in the PACU. They also measured preoperative glucose levels and found no differences.

Evan Tilley, MD, senior attending physician at Bridgeport Hospital in Connecticut, said that he was not surprised at the findings. "We have been using a dextrose bolus (500?mL of 5% dextrose) to potentiate the effects of ondansetron in PONV," he said," but we don't really know why this works."

Dr. Tilley pointed out that hydration is also very important. "In our elderly patients, we do not allow NPO for more than 6 hours. We allow clear fluids, and this helps with nausea and vomiting."

Meta-Analysis Examines Risk Factors for PONV

In the same session, Felix M. Heidrich, MD, from the University of California, San Francisco (UCSF), presented a meta-analysis of 16 studies, involving almost 90,000 patients, that evaluated factors that might be predictive of PONV. Among a number of possible factors, the greatest predictor was being female, which raised the odds 2.6-fold (P?< .0001), Dr. Heidrich reported.

Positive history of PONV or motion sickness, nonsmoking status, young age, and postoperative opioid use were also significant risk factors (P?< .0001 for all).

Among anesthesia-related factors, both the duration of anesthesia and the postoperative use of opioids were predictive (P?< .0001 for all).

Of 8 surgical categories, cholecystectomy raised the odds by 1.7 (P?= .03), but gynecologic surgery and ophthalmologic procedures were also predictive (P?= 0.01), the study found.

Senior author Christian C. Apfel, MD, PhD, from UCSF, who developed a predictive model (Apfel score) for PONV, said: "We encourage the use of models to predict PONV, and the use of prophylactic medication for patients at high risk." Clinicians can also try to give drugs that are less emetogenic and to reduce the use of opioids, which has been shown to reduce the risk for PONV, he said. "We also give combinations of antiemetics," he added. "We have found you can combine them freely, and when you use drugs that act by different pathways, they act independently."

Dr. Dabu-Bondoc, Dr. Tilley, and Dr. Apfel have disclosed no relevant financial relationships.

American Society of Anesthesiologists (ASA) 2009 Annual Meeting: Abstracts A492 and A494. Presented October 18, 2009.