Association of nausea and vomiting in between anaesthetic or patients factors in Monitored Anaesthesia Care (MAC) after gastrointestinal endoscopies in tertiary care hospital: an audit.
Esophagogastroduodenoscopy (EGD) is a procedure during which a small flexible endoscope is introduced through the mouth (or with smaller caliber endoscopes, through the nose) and advanced through the pharynx, esophagus, stomach, and duodenum. An enteroscope, a longer endoscope, can be introduced beyond the ligament of Treitz into the jejunum. EGD is used for both diagnostic and therapeutic procedures.
There is no standard and ideal protocol for sedation and a variety of anaesthetic techniques have been described, including intravenous (i.v) or inhalational anaesthesia with or without tracheal intubation. (1,2) Conscious sedation is one of the commonly used methods for EGD. The use of monitored anesthesia care and propofol, fentanyl and midazolam are gaining wide acceptance because of the shorter recovery time and less incidence of nausea vomiting. (3)
Nausea and vomiting (PONV) remains one of the most common and distressing complications, resulting in pain, hematoma, and wound dehiscence, which require additional resources and may delay in the discharge of patient from hospital. (4)
Purpose of Audit
The aim of this audit was to determine the association of nausea and vomiting in between anaesthetic technique or patients factors after gastrointestinal endoscopic procedures under MAC.
Material and methods
After finishing 3 hours of endoscopic procedure one of the investigators evaluated and collects the patient's data in the ward and filled the predesigned assessment form and ticked the different variables which may have effect on nausea and vomiting. The severity of nausea was assessed through visual analogue Scale (VAS) in which 0 as no nausea &vomiting, 1 as mild nausea & vomiting, 2 as nausea without inquiry, 3 as vomiting occur and 4 as severe and repeated vomiting.
All adult patients more than 14 years of age who undergo upper gastro intestinal endoscopy under MAC and those in which sedation will be given by anaesthesiologist were included in the study and those patients who have their procedure under in general anaesthesia and pediatric group of patients were excluded from study.
We were also monitor certain risk factors which provoke to nausea and vomiting and we had divided them into three categories which were patients, procedural and anaesthetic factors. Patient's factors contained gender, obesity, history of chemotherapy, smoking and Diabetes mellitus. Procedural factor includes duration of endoscopy either less the one hour or more than one hour, and procedure is diagnostic or therapeutic and anaesthetic factors contained use of opioids, Hysocine, anti emetics, nitrous oxide, propofol, midazolam and ketamine.
This audit was done for 1 year (January-December 2010). Total 130 Patients were included in the audit. Patients were checked or PONV three hours after endoscopic procedure. ASA status I were 5 (3.8%), ASA II were 65 (50%), ASA III were 60 (46%) in total number of patients. 90 (69%) patients were male and 40 (30%) were belong to females among all patients. History of smoking was reported in 19%, Diabetes was 23%, and nausea & vomiting were recorded 13% in diabetic patients, and not a single patient had a history of chemotherapy. During procedure Propofol alone used in 110 patients and combination Propofol and midazolam used 20 patients as an induction agent and sedation purpose. Fentanyl 50-75 [micro]gm was used in 50 patients an as analgesic. During the all procedure we observed mild to severe nausea vomiting in those patients who have diabetes mellitus and 10 patients were need antiemetic to control vomiting.
Postoperative nausea and vomiting (PONV) is one of the major problem in postoperative recovery phase. (5-9) In high risk population for PONV, incidence varied between 70% to 80%.10 After knowing the facts about nausea and vomiting it needs to observe as variable in those cases that have been done in monitored anaesthesia care or deep sedation. In our institution major amount of gastrointestinal endoscopies are done in Monitored Anaesthesia Care (MAC) therefore we have exclusively tried to find out association of nausea and vomiting in this regard.
Sedation during endoscopic procedures has long been carried out with benzodiazepine and other hypnotic agents. Recently, multiple studies have been published on the use of Propofol. (11-18) A previous study shows almost 25% of endoscopies are performed using propofol-based deep sedation. (19) In a recent study, propofol was compared with midazolam in endoscopies, as far as sedation and early recovery propofol is more effective as compare to midazolam. (20) Propofol also has an additional advantage on its antiemetic property, (21) so propofol is the preferred choice for induction or sedation whenever nausea vomiting is concerned. In our institution, Propofol, ketamine and benzodiazepine are used for sedation. Propofol was a preferred choice, 84.6% of patients sedated by propofol.
Certainly, we have also look at some other risk factors associated with predictive of both nausea and vomiting such as (female gender, nonsmoking status, and general anesthesia). There was a clear relationship between nausea and vomiting. In previous study, the overall incidence rate for nausea and vomiting was 19%, and 10% respectively. Approximately half of the patients with nausea suffered also from vomiting. (22) Nausea and vomiting are significantly associated with the presence of diabetic complications, particularly autonomic and peripheral neuropathy. Patients are presented with gastroesophageal reflux 19 %, dyspepsia 14 %, and gastropresis 20-40%. Poor glycemic control was an independent risk factor for upper gastrointestinal symptoms. (22-24) In our audit we observed 13 % diabetic patients have nausea and vomiting. Nausea and vomiting itself one of complication after endoscopy but we did not find any relation ship in literature with endoscopies under monitored anaesthesia care.
Incidence of PONV is high after endoscopy under MAC especially in those patients who has high risk factors for PONV as well as in known diabetic patients. Therefore prophylactic antiemetic therapy should be commenced in those patients and further randomized controlled trial should be recommended to establish this relationship.
Knowledge of risk factors which are provoke to trigger nausea and vomiting is essential, and anesthesiologist must aware about potential outcomes. Awareness of PONV predictors would increase anesthesiologists' efforts to reduce the incidence of PONV by selecting patients for antiemetic therapy. In future avoidance of perioperative opioids when possible by substituting drugs which cause less PONV may lead to better gainful and cost effective experience.
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Khalid Maudood Siddiqui (1) *, Faraz Shafiq (2), Ali Asghar (3)
(1) FCPS; Assistant Professor, Department of Anaesthesia, Aga Khan University, Karachi
(2) FCPS; Senior Instructor, Department of Anaesthesia, Aga Khan University, Karachi
(3) FCPS; Assistant Professor, Department of Anaesthesia, Aga Khan University, Karachi
* Corresponding Author: Dr. Khalid M Siddiqui
Assistant Professor, Department of Anaesthesia, Aga Khan University Hospital Stadium Road, P O Box 3500, Karachi--74800, Pakistan
Tel: 92 21 4930051 Ext: 4634-35 | Fax: 92 21 493-4294 | E-mail: email@example.com
Source of support: This work was funded by the resources of the Department of Anaesthesia, Aga Khan University.