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Original Investigation |

Use of Aprepitant and Factors Associated With Incidence of Postoperative Nausea and Vomiting in Patients Undergoing Facial Plastic Surgery FREE

Scott J. Trimas, MD1; Morgan D. Trimas2
[+] Author Affiliations
1Beaches Facial Plastic and Nasal Surgery Center, Jacksonville Beach, Florida
2Department of Biology, Washington and Lee University, Lexington, Virginia
JAMA Facial Plast Surg. 2015;17(4):251-255. doi:10.1001/jamafacial.2015.0307.
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Published online

Importance  Patients who experience immediate postoperative nausea and vomiting (PONV) after their facial plastic surgery procedure have a higher incidence of complications and dissatisfaction.

Objectives  To determine whether a single dose of aprepitant administered preoperatively can decrease the incidence of immediate PONV in patients undergoing facial plastic surgery compared with patients who are administered ondansetron hydrochloride alone and whether patient-related factors pose a greater risk of developing immediate PONV after surgery.

Design, Setting, and Participants  In this retrospective study, we reviewed 172 patients undergoing facial plastic surgery with general anesthesia at an accredited office-based surgery practice from January 1, 2012, through December 31, 2013.

Interventions  All patients received prophylactic treatment to mitigate against immediate PONV. Fifty-six patients received aprepitant in addition to ondansetron as prophylaxis for PONV.

Main Outcomes and Measures  Patients undergoing facial plastic surgery were assessed during the immediate postoperative period for PONV. In addition, patient age, type of procedure, duration of surgery, and sex were reported.

Results  The addition of aprepitant preoperatively effectively reduced the PONV rate from 15.5% to 1.8% (P = . 02). Logistic regression analysis revealed that duration of surgery longer than 90 minutes (odds ratio [OR], 2.936; 95% CI, 0.560-15.385; P = .20), female sex (OR, 1.893; 95% CI, 0.379-9.448; P = .44), and type of procedure increased the likelihood of PONV after facial plastic surgery with an odds ratio of greater than 1 in this sample population. However, the odds ratios were not statistically significantly greater than 1 for the 95% CIs. Of the 19 patients who experienced PONV, 17 were women, and 17 patients had a duration of surgery longer than 90 minutes. Patient age did not appear to affect the rate of PONV (P = .32).

Conclusions and Relevance  Preoperative aprepitant administered within 1 hour before facial plastic surgery in patients at risk of developing PONV effectively reduce the rate of immediate PONV. Female patients and patients with facial surgery duration of longer than 90 minutes might benefit from the added expense of aprepitant to further reduce the likelihood of PONV.

Level of Evidence  3.

Postoperative nausea and vomiting (PONV) is a common symptom reported on patient satisfaction surveys1 and affects nearly one-third of all surgical patients.24 It can lead to unattended surgical consequences, such as hematoma formation, wound and suture dehiscence, or wound contamination and aspiration.16 Reducing the incidence of PONV requires careful assessment of the patient preoperatively to reduce risk factors. In addition, it has been previously reported that patients undergoing surgery with volatile anesthetics and long operative duration have an increased incidence of PONV.2,7 Nausea and emesis after the surgical procedure are the most significant reasons described by patients as precipitating events for poor patient satisfaction postoperatively and are big factors in patients who elect to not undergo additional surgical procedures.1,5

The cause of PONV is believed to be multifactorial.4,810 Multiple anatomical sites are ultimately involved in the development of PONV. The vomiting center, which is the central control site of nausea and vomiting, is located within the lateral reticular formation of the brainstem.4 This control center receives input from the cerebral cortex, vestibular system, visceral afferents via the vagal and glossopharyngeal nerves, and the chemoreceptor trigger zone.4,10 All these sites have multiple receptors specific to the following neurotransmitters: acetylcholine, serotonin, dopamine, and histamine.4,10 Because no single treatment to date can affect all areas responsible for PONV, a single treatment approach has not been found to be efficacious.2,4,8,11 Therefore, a multitreatment modality is often described as being the most effective approach to PONV prophylaxis.8

In 2006, aprepitant (Merck Sharp & Dohme Corp),12 a new antiemetic medication, was approved by the US Food and Drug Administration. Aprepitant is a selective high-affinity antagonist of human substance P and neurokinin 1 (NK1) receptors. The primary approval was for use as an antiemetic in chemotherapy treatment when used with other antiemetic agents. However, unlike other antiemetic treatments, it has little or no affinity for serotonin, dopamine, and corticosteroid receptors. Animal and human studies12,14 using positron emission tomography have found that it crosses the blood-brain barrier and occupies brain NK1 receptors. Aprepitant also augments the activity of the serotonin receptor antagonist ondansetron and the corticosteroid dexamethasone sodium and inhibits the acute and delayed phases of cisplatin-induced emesis. Therefore, because of its synergetic effect and absence of direct effect on the neurotransmitters, it is recommended that treatment with aprepitant include the use of other known antiemetics, which target the primary neurotransmitters involved in the PONV cascade. The normal recommended dosage for surgical prophylaxis is 40 mg administered within 1 to 3 hours of the surgical procedure.12

Elective plastic surgery is not immune to the problems of PONV. In fact, reports have indicated that nearly one-third of all patients undergoing plastic surgery experience PONV.2,4,7 It is a widely held belief that patients undergoing facial plastic surgery are at a higher risk although no specific studies addressing PONV have been quantitated to this patient population.2,4 Furthermore, female sex and duration of surgery longer than 90 minutes have been ascribed to patients undergoing plastic surgery as being better predictors of PONV.2,4,8,13

The purposes of this retrospective study were to identify a treatment approach for patients undergoing facial plastic surgery and to demonstrate whether a multitherapy approach to the prevention of PONV was effective in reducing the incidence of immediate nausea and vomiting. In addition, it would be advantageous to identify those patients who are at an additional risk of PONV. Finally, for those patients who are at a greater risk of PONV, it would be beneficial to see whether the addition of aprepitant could further reduce the incidence of PONV in patients who receive a multimodality, prophylactic regimen of antiemetics.

We retrospectively reviewed the medical records of 172 consecutive patients who underwent facial plastic surgery from January 1, 2012, through December 31, 2013. Only patients who received general anesthesia were included in the analysis. The following types of procedures were performed in this patient population: rhinoplasty, rhytidectomy, endoscopic browlift, carbon dioxide laser resurfacing, blepharoplasty, otoplasty, chin implant, and neck liposuction. A total of 66 (38.4%) of the 172 patients underwent multiple procedures. Patients undergoing concomitant body procedures were excluded from the analysis.

Patients were stratified into 2 age groups for comparison: those younger than 60 years and those 60 years and older. Another group for comparison were those patients who underwent a surgical procedure with a duration of longer than 90 minutes and those patients who underwent a surgical procedure with a duration of 90 minutes or less.

In addition, 56 patients received aprepitant within 1 hour of their surgical procedure. Aprepitant was primarily offered to those patients who were female, had a strong history of nausea and vomiting, or were thought to be at an increased risk of nausea and vomiting (eg, those with a history of PONV after surgery, those with motion sickness, and nonsmokers). All female patients, aged 25 to 65 years, were offered aprepitant preoperatively; however, many of those patients declined because of the added cost of the drug, or the patient declined for various other reasons, including self-reported lack of nausea history, noncoverage of drug by third-party payer, or the patient’s belief that the additional drug regimen was not necessary.

All patients undergoing general anesthesia followed the same guidelines to minimize perioperative nausea and vomiting. Patients received intraoperative dexamethasone sodium, 8 to 12 mg dependent on their weight, ondansetron, 4 mg intravenously at the time of anesthetic induction, and fluid hydration. Intraoperative narcotics were avoided. Patients underwent induction of anesthesia with propofol, received inhalational sevoflurane on induction, and were maintained with isoflurane and nitrous oxide. Intermittent doses of propofol were also used during the surgery if additional relaxation of the patient was required during the procedure.

Electronic medical record information was collected in the nursing notes and anesthesia records before discharge. Records were maintained, and the presence or absence of immediate PONV was noted for all patients.

Three types of statistical analyses were performed. First, 1-sample tests of proportions were used to compare the proportions of patients in the study with various characteristics to known or hypothesized values of the proportions. For example, we compared the proportion of patients with postoperative nausea when taking aprepitant to the value of 33% of patients who have postoperative nausea. Second, 2-sample tests of proportions were used to compare proportions of patients experiencing postoperative nausea in various subgroups (eg, sex). Third, logistic regression analysis was used to determine significant predictors of postoperative nausea from a list that included the use of aprepitant, sex, surgery duration, and several types of surgery. All analyses were performed using SAS statistical software, version 9.4 (SAS Institute Inc), with P < .05. Institutional review board approval and informed consent were not required.

A total of 172 patients (23 men and 149 women) were included in the study. Of this group, 1 man and 55 women took aprepitant preoperatively in addition to the standard perioperative nausea regimen that was used. Patients underwent a range of facial plastic procedures, and 106 patients (61.6%) underwent a single procedural site vs 66 patients (38.4%) who underwent multiple procedures (Table 1).

Table Graphic Jump LocationTable 1.  Patient Characteristics and Surgical Procedures

Eight distinct facial surgical procedures were performed in this patient population. Table 2 provides a breakdown of the procedures that were performed and the number of PONV events that occurred per procedure. The incidence of PONV is greater than the total number of occurrences (n = 19) because of the 66 patients (38.4%) who underwent multiple procedures. A simple 2-sample proportion test for each of the procedure types vs PONV found no statistically significant difference in the percentage of nauseated patients between those with and without each procedure type.

Table Graphic Jump LocationTable 2.  Breakdown of Surgical Procedures

Of the 172 patients undergoing facial plastic surgery, the mean patient age was 54 years, and the mean surgery duration was 147 minutes. Fifty-five female patients and 1 male patient received aprepitant preoperatively. A total of 19 patients (11.0%) undergoing surgery were reported to be nauseated immediately postoperatively. Only 1 female patient (1.8%) who received aprepitant preoperatively was nauseated postoperatively. Of the female patients who did not receive aprepitant preoperatively, 16 (17.0%) experienced PONV immediately postoperatively vs 2 male patients (9.1%) who did not take aprepitant preoperatively. Table 3 provides a breakdown of the patient population who received aprepitant and those patients who got nauseated with or without taking aprepitant.

Table Graphic Jump LocationTable 3.  PONV Rates in Patient Population

Solely looking at the occurrence of postoperative nausea in the 172 patients, 19 patients (11.0%) experienced nausea. Using the known statistic that approximately 33% of all patients undergoing surgery experience postoperative nausea, it was determined that there is sufficient evidence that our percentage was highly likely to be much lower than 33% by a factor other than chance (P < .001). Therefore, we have sufficient evidence that the true proportion of patients who experienced postoperative nausea was not 33%.

In this study, the 19 patients who experienced postoperative nausea were split into 2 age groups (≤59 years and ≥60 years). We tested to see whether more than 50% of the nauseated patients were 60 years or older. With a test statistic greater than 0.05 (P = .32), we did not have significant evidence to support our alternative hypothesis and therefore must support the claim that age has no or minimal effect on the likelihood of postoperative nausea. There is not enough evidence that the 10 patients who experienced postoperative nausea and were 60 years or older experienced the nausea because of some other chance or factor besides age.

A 2-sample test of proportions was used to determine whether there were any differences in the proportions of patients experiencing nausea depending on whether the surgery lasted more than 90 minutes. Of the study patients, 17 (12.9%) whose surgery lasted more than 90 minutes experienced nausea, whereas 2 (5.0%) of those whose surgery lasted 90 minutes or less experienced nausea. The difference in these proportions was not statistically significant (P = .16).

A 2-sample test of proportions was also performed to compare the proportions of males and females who experienced PONV. Of the female patients, 17 (11.4%) experienced nausea, whereas 2 (8.7%) of the male patients experienced nausea. These proportions were not statistically significantly different (P = .70).

Logistic regression analysis was used to determine which variables were significant predictors of PONV. The predictors included were use of aprepitant, sex, duration of surgery (>90 vs ≤90 minutes), and 4 procedures. Four other procedures (browlift, chin implant, otoplasty, and neck liposuction) were excluded because there were too few cases in the study. Table 4 gives the results of the logistic regression analysis. Of the predictors, only use of aprepitant was a statistically significant predictor of postoperative nausea. The odds ratio of 0.039 indicates that patients who did not receive aprepitant were approximately 25 times more likely to have nausea than patients who received it.

Table Graphic Jump LocationTable 4.  Logistic Regression for Predicting Postoperative Nausea and Vomiting

We determined that 1 patient (1.8%) of the 56 who took aprepitant still experienced postoperative nausea vs 18 (15.5%) of the 116 who did not take aprepitant. This observation indicated that the real proportion of patients who contracted postoperative nausea after taking aprepitant was 1.8% (P = .02).

Ondansetron is a known medication prescribed to prevent PONV in certain patients.2,4,11 In July 2006, a new antiemetic, aprepitant, was approved by the US Food and Drug Administration, which acts by a different mechanism. Aprepitant (Merck & Co) is a selective antagonist against human substance P and NK1 receptors.12 The NK1 receptors in the brainstem are thought to produce substance P, which is a potent inducer of emesis; therefore, a highly selective antagonist to this NK1 receptor would antagonize the central effects of substance P.14 The US Food and Drug Administration approved this drug based on 2 multicenter, randomized, and double-blind clinical trials of aprepitant against ondansetron. Both those studies12,14 revealed superior efficacy with aprepitant vs ondansetron in the prevention of PONV through 24 and 48 hours postoperatively.

Because ondansetron lowers PONV in the patient undergoing plastic surgery, this study was performed to assess the known correlations that cause postoperative nausea in that of a less frequently used medication, aprepitant, and its effectiveness based on a study performed with ondansetron alone.2 An observational study was performed with 172 patients undergoing facial plastic surgery with general anesthesia to examine the correlation between certain factors and postoperative nausea symptoms. Again, all comparative statistics were used based on known data from a similar study performed with ondansetron.2 Logistic regression analysis was also performed to determine which of several variables may have been a predictor for PONV (Table 4).

In previously reported studies,2,4 the incidence of PONV averages 33% and has been reported to be even higher in the plastic surgery literature. There currently are no specific studies related to facial plastic surgery; however, some of the previous studies and multivariate analyses2,4,11 have suggested that patients undergoing facial plastic surgery tend to have higher rates of PONV.

Prevention of PONV is paramount in the perioperative period for patients undergoing facial plastic surgery. Higher incidences of hematoma formation, wound breakdown, and dehiscence and lower patient satisfaction rates have all been previously reported as associated with PONV.1,3,5,6 Various paradigms have also been espoused as being effective in lowering PONV levels. However, currently there is no generally accepted method other than using ondansetron and avoiding narcotics that is statistically effective in lowering nausea rates in patients undergoing plastic surgery.2,4

Our current regimen in preventing PONV includes a multimodality approach using preoperative ondansetron, intravenous dexamethasone, fluid hydration, and avoidance of intraoperative narcotics. Induction of all patients is performed with propofol, and patients undergoing general anesthesia are maintained with inhalational anesthetics and nitrous oxide. If additional anesthesia is required during the procedure, additional doses of propofol are given with supplementation of local anesthesia with lidocaine; narcotics are avoided intraoperatively. Aprepitant is offered to all nonsmoking female patients and those patients who are at an increased risk of PONV because of underlying patient-related factors. A single 40-mg dose is administered orally within 1 hour of the surgical procedure.

In this comparative study, we looked at our current regimen of PONV suppression and various patient-related factors to determine whether there was any correlation as has been previously reported in other patient populations in regard to patient age, sex, and duration of surgery. We further looked to objectively determine whether the use of aprepitant in at risk patients could lead to an even lower rate of PONV.

Solely looking at the occurrence of postoperative nausea in the 172 patients, 19 patients (11.0%) experienced nausea. Using the known statistic that approximately 33% of all patients undergoing surgery experience postoperative nausea, it was determined that there is sufficient evidence that our percentage was highly likely to be much lower than 33% by a factor other than chance (P < .001). Therefore, we have sufficient evidence that our current regimen of intraoperative ondansetron, fluid hydration, intravenous dexamethasone, and avoidance of narcotics is statistically lower than the current levels reported in the literature of PONV occurring in approximately 33% of patients. The addition of aprepitant further lowered the incidence of PONV to 1.8% in at risk women who received this medication within 1 hour of their surgical procedure.

It has also been suggested that patients with surgery durations longer than 90 minutes are more likely to experience PONV than patients with surgery durations of 90 minutes or less. Of the 172 patients in this study, 19 experienced PONV, and of those patients, 17 had surgery durations longer than 90 minutes. Furthermore, women are more likely to contract PONV than men. Of the 19 patients who felt nauseated, 17 were women in this patient population. The odds ratios for female sex, duration of surgery longer than 90 minutes, and undergoing facial plastic surgery are greater than 1, indicating that there was a greater likelihood of PONV in the sample of patients participating in the study. However, the odds ratios were not statistically significantly greater than 1, indicating that there is not enough evidence to make the claim about the entire population of patients who might undergo facial plastic surgery (Table 4).

Another claim is that age may have, at most, a minimal effect on the likelihood of PONV. In this study, the 19 patients who experienced PONV were split into 2 age groups (≤59 years and ≥60 years). We tested to see whether more than 50% of the nauseated patients were 60 years or older. With a test statistic greater than 0.05 (P = .32), we did not have significant evidence to support our alternative hypothesis and therefore must support the claim that age has no or minimal effect on the likelihood of PONV. There is not enough evidence that the 10 patients who experienced PONV and were 60 years or older experienced the nausea because of some other chance or factor besides age.

Finally, in the comparative study, 15.5% of the patients who took ondansetron alone still experienced PONV.2 We used this percentage as a comparison to our 1.8% of patients who took aprepitant and experienced PONV. Using logistic regression analysis, we found that patients who did not receive aprepitant were approximately 25 times more likely to have PONV than patients who received the medication. There is sufficient evidence in this observation that the real proportion of patients who contracted postoperative nausea after taking aprepitant was 1.8% (P = .02). Therefore, aprepitant appears to reduce PONV more frequently than ondansetron alone.

After performing this observational study, we can state that based on these results aprepitant may potentially reduce the likelihood of postoperative nausea to a greater extent than ondansetron alone. Factors that can potentially affect the likelihood of PONV include sex, surgery duration, and facial plastic surgery. Therefore, because ondansetron is known to reduce the likelihood of these factors that lead to PONV and because this study found that aprepitant could further reduce nausea more frequently than ondansetron alone in which all the stated factors were involved, surgeons should consider recommending aprepitant more frequently for prevention of PONV, at least in the facial plastics realm.

Accepted for Publication: March 12, 2015.

Corresponding Author: Scott J. Trimas, MD, Beaches Facial Plastic and Nasal Surgery Center, 1361 13th Ave S, Ste 125, Jacksonville Beach, FL 32250 (beachesfacial@comcast.net).

Published Online: May 14, 2015. doi:10.1001/jamafacial.2015.0307.

Author Contributions: Drs S. J. Trimas and M. D. Trimas had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: S. J. Trimas.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: M. D. Trimas.

Critical revision of the manuscript for important intellectual content: S. J. Trimas.

Statistical analysis: M. D. Trimas.

Administrative, technical, or material support: Both authors.

Study supervision: S. J. Trimas.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Statistical analysis was performed by Steven J. Naber, PhD, senior consulting research statistician, The Ohio State University, Columbus. The Department of Statistics was compensated for their statistical services.

Lehmann  M, Monte  K, Barach  P, Kindler  CH.  Postoperative patient complaints: a prospective interview study of 12,276 patients. J Clin Anesth. 2010;22(1):13-21.
PubMed   |  Link to Article
Marcus  JR, Few  JW, Chao  JD, Fine  NA, Mustoe  TA.  The prevention of emesis in plastic surgery: a randomized, prospective study. Plast Reconstr Surg. 2002;109(7):2487-2494.
PubMed   |  Link to Article
Beer  GM, Goldscheider  E, Weber  A, Lehmann  K.  Prevention of acute hematoma after face-lifts. Aesthetic Plast Surg. 2010;34(4):502-507.
PubMed   |  Link to Article
Buck  DW, Mustoe  TA, Kim  JYS.  Postoperative nausea and vomiting in plastic surgery. Semin Plast Surg. 2006;20(4):249-255.
Link to Article
Hirsch  J.  Impact of postoperative nausea and vomiting in the surgical setting. Anaesthesia. 1994;49(suppl):30-33.
PubMed   |  Link to Article
Mustoe  TA, Park  E.  Evidence-based medicine: face lift. Plast Reconstr Surg. 2014;133(5):1206-1213.
PubMed   |  Link to Article
Candiotti  KA, Ahmed  SR, Cox  D, Gan  TJ.  Palonosetron versus ondansetron as rescue medication for postoperative nausea and vomiting: a randomized, multicenter, open-label study. BMC Pharmacol Toxicol. 2014;15(1):45-52.
PubMed   |  Link to Article
Steely  RL, Collins  DR  Jr, Cohen  BE, Bass  K.  Postoperative nausea and vomiting in the plastic surgery patient. Aesthetic Plast Surg. 2004;28(1):29-32.
PubMed   |  Link to Article
Williams  KS.  Postoperative nausea and vomiting. Surg Clin North Am. 2005;85(6):1229-1241, xi.
PubMed   |  Link to Article
Watcha  MF, White  PF.  Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology. 1992;77(1):162-184.
PubMed   |  Link to Article
Apfel  CC, Korttila  K, Abdalla  M,  et al; IMPACT Investigators.  A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350(24):2441-2451.
PubMed   |  Link to Article
Emend (Aprepitant) Prescribing Information. Whitehouse Station, NJ: Merck & Co; 2006:1-24.
Apfel  CC, Roewer  N.  Risk assessment of postoperative nausea and vomiting. Int Anesthesiol Clin. 2003;41(4):13-32.
PubMed   |  Link to Article
Diemunsch  P, Joshi  GP, Brichant  JF.  Neurokinin-1 receptor antagonists in the prevention of postoperative nausea and vomiting. Br J Anaesth. 2009;103(1):7-13.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Patient Characteristics and Surgical Procedures
Table Graphic Jump LocationTable 2.  Breakdown of Surgical Procedures
Table Graphic Jump LocationTable 3.  PONV Rates in Patient Population
Table Graphic Jump LocationTable 4.  Logistic Regression for Predicting Postoperative Nausea and Vomiting

References

Lehmann  M, Monte  K, Barach  P, Kindler  CH.  Postoperative patient complaints: a prospective interview study of 12,276 patients. J Clin Anesth. 2010;22(1):13-21.
PubMed   |  Link to Article
Marcus  JR, Few  JW, Chao  JD, Fine  NA, Mustoe  TA.  The prevention of emesis in plastic surgery: a randomized, prospective study. Plast Reconstr Surg. 2002;109(7):2487-2494.
PubMed   |  Link to Article
Beer  GM, Goldscheider  E, Weber  A, Lehmann  K.  Prevention of acute hematoma after face-lifts. Aesthetic Plast Surg. 2010;34(4):502-507.
PubMed   |  Link to Article
Buck  DW, Mustoe  TA, Kim  JYS.  Postoperative nausea and vomiting in plastic surgery. Semin Plast Surg. 2006;20(4):249-255.
Link to Article
Hirsch  J.  Impact of postoperative nausea and vomiting in the surgical setting. Anaesthesia. 1994;49(suppl):30-33.
PubMed   |  Link to Article
Mustoe  TA, Park  E.  Evidence-based medicine: face lift. Plast Reconstr Surg. 2014;133(5):1206-1213.
PubMed   |  Link to Article
Candiotti  KA, Ahmed  SR, Cox  D, Gan  TJ.  Palonosetron versus ondansetron as rescue medication for postoperative nausea and vomiting: a randomized, multicenter, open-label study. BMC Pharmacol Toxicol. 2014;15(1):45-52.
PubMed   |  Link to Article
Steely  RL, Collins  DR  Jr, Cohen  BE, Bass  K.  Postoperative nausea and vomiting in the plastic surgery patient. Aesthetic Plast Surg. 2004;28(1):29-32.
PubMed   |  Link to Article
Williams  KS.  Postoperative nausea and vomiting. Surg Clin North Am. 2005;85(6):1229-1241, xi.
PubMed   |  Link to Article
Watcha  MF, White  PF.  Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology. 1992;77(1):162-184.
PubMed   |  Link to Article
Apfel  CC, Korttila  K, Abdalla  M,  et al; IMPACT Investigators.  A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350(24):2441-2451.
PubMed   |  Link to Article
Emend (Aprepitant) Prescribing Information. Whitehouse Station, NJ: Merck & Co; 2006:1-24.
Apfel  CC, Roewer  N.  Risk assessment of postoperative nausea and vomiting. Int Anesthesiol Clin. 2003;41(4):13-32.
PubMed   |  Link to Article
Diemunsch  P, Joshi  GP, Brichant  JF.  Neurokinin-1 receptor antagonists in the prevention of postoperative nausea and vomiting. Br J Anaesth. 2009;103(1):7-13.
PubMed   |  Link to Article

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