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Acceptability of chewing gum for postoperative nausea and vomiting prevention in high risk patients: a pilot study.

The use of chewing gum in the postoperative period has been well established in the treatment of ileus resulting from abdominal surgery. Postulated mechanisms of its effect include the principle of 'sham feeding': chewing resulting in propulsive gastrointestinal activity via cephalic-vagal stimulation (1). Systematic reviews have demonstrated reduced times to first flatus and bowel motion, and a trend towards earlier hospital discharge (2,3). To date, its effect on postoperative nausea and vomiting (PONV) has not been investigated. We conducted a pilot study to determine patient and nurse acceptability of chewing gum in the recovery room. We also checked whether adverse events such as airway obstruction by the gum would be a common occurrence in this group of patients.

Forty-one American Society of Anesthesiologists' physical status I or II patients of median age 31 years (range 18 to 52 years) undergoing day-case gynaecological laparoscopy were enrolled after written informed consent. Approval was gained from the hospital Human Research and Ethics Committee. Patients underwent tracheal intubation with neuromuscular blockade, with reversal prior to extubation at the end of the case. All patients received antiemetic prophylaxis at the discretion of the attending anaesthetist at induction of anaesthesia. At the end of the procedure, once an Observer's Assessment of Alertness/Sedation (4) score of 5 was achieved, and the recovery nurse was satisfied the patient was not sleeping between observations, patients commenced gum chewing, aiming for a 'treatment' period of 15 minutes. Wrigley's Extra Sugarfree Gum[R] (peppermint flavour) was used. At readiness for discharge from the recovery room, patients who were able to chew gum graded the acceptability of their anaesthetic care in general, and gum chewing in particular, with their recovery nurse also grading the acceptability of gum chewing in the recovery room.

Thirty-one patients (76%) successfully completed a period of gum chewing in the recovery room (median duration 15 minutes, range 3 to 40 minutes). The median time after arrival in the recovery room until patient readiness to chew gum was 17 minutes (range 0 to 70 minutes). The main reason for failure was excessive sedation (seven patients), with only one patient refusing gum when offered. Of these 31 patients, 26 (84%) found gum chewing in the recovery room completely acceptable, two (7%) mildly acceptable, two (7%) neither acceptable nor unacceptable and one (3%) mildly unacceptable. Similar results were obtained from recovery nurses, with 27 (87%) rating patients chewing gum as completely acceptable. Thirty pieces of chewing gum were retrieved, with one intentionally swallowed by the patient. There were no instances of airway obstruction, nor any other adverse events attributable to gum chewing.

As expected from the study population, high rates of PONV risk factors were observed across all 41 patients, with 32 (78%) having an Apfel score of 3 or 4. All patients received antiemetic prophylaxis with dexamethasone, granisetron and/or droperidol using monotherapy in nine patients (22%), dual therapy in 30 patients (73%) and three agents in two patients (5%). Despite this, 16 patients (40%) had at least one episode of nausea and/or vomiting postoperatively requiring pharmacological treatment. Encouragingly, this included only seven patients after gum chewing, of the 31 total gum chewing patients (22.6%). Thus, a paradoxically high rate of PONV was not observed in this group. Obviously we did not include a control group in our study and so cannot draw conclusions about any anti-emetic effect of chewing gum. However, the postulated mechanism of 'sham feeding' with increased intestinal peristaltic activity seen after chewing gum does not appear to markedly 'increase' PONV in the ambulatory surgery setting, at least not in this small cohort.

This study suggests that chewing gum, as an adjunct modality in the recovery room, is likely to be acceptable to most patients and recovery room nurses. We identified no safety concerns in our series. Efficacy of gum chewing in the management of PONV warrants further investigation by way of a larger randomised controlled trial.

References

(1.) Person B, Wexner SD. The management of postoperative ileus. Curr Probl Surg 2006; 4:36-65.

(2.) Fitzgerald JEF, Ahmed I. Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery. World J Surg 2009; 33:2557-2566.

(3.) Chan MKY, Law WL. Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review. Dis Colon Rectum 2007; 50:2149-2157.

(4.) Chernik DA, Gillings D, Laine H, Hendler J, Silver JM, Davidson AB et al. Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol 1990; 10:244-251.

J. N. DARVALL

S. W. SIMMONS

K. LESLIE

Melbourne, Victoria
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Title Annotation:Correspondence
Author:Darvall, J.N.; Simmons, S.W.; Leslie, K.
Publication:Anaesthesia and Intensive Care
Geographic Code:8AUST
Date:May 1, 2011
Words:771
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