Metoclopramide Reduces the Incidence of Vomiting After Tonsillectomy in Children Lynne R. Ferrari,
MD,
and John V. DonIon,
MD
Departments of Anesthesia, Massachusetts Eye & Ear Infirmary and Harvard Medical School, Boston, Massachusetts
The efficacy of intravenous metoclopramide in controlling vomiting in children after tonsillectomy was determined in a prospective randomized, doubleblind investigation. One hundred two unpremedicated, ASA physical status I or I1 children between the ages of 1and 15 yr who were undergoing surgical removal of the tonsils, with or without adenoidectomy, were studied. Anesthesia was induced either with halothane, nitrous oxide, and oxygen by mask or by intravenous thiopental and was maintained with halothane, nitrous oxide, oxygen, and intravenous morphine (0.1 mgkg). Each child randomly
T
onsillectomy, one of the most frequently performed surgical procedures in pediatric patients, is often performed as an outpatient procedure in some medical centers. Although postoperative bleeding is the most serious complication, vomiting is the most frequent (1,2). Persistent vomiting and poor oral fluid intake are leading causes of unscheduled overnight admission after ambulatory surgery (2). Metoclopramide has been shown to reduce postoperative vomiting in ambulatory pediatric strabismus patients; therefore, this study was designed to determine its efficacy as an antiemetic in children undergoing tonsillectomy (3).
Methods The study was approved by the Human Studies Committee, and written, informed consent was obtained from the parents of 102 children, ASA physical status I or 11, between the ages of 1 and 15 yr undergoing tonsillectomy with or without adenoidectomy. There was no history of motion sickness or other factor predisposing to postoperative vomiting in any patient enrolled in the study. Children were randomly assigned to a postoperative intravenous medAccepted for publication April 17, 1992. Address correspondence to Dr. Ferrari, Department of Anesthesia, Massachusetts Eye & Ear Infirmary, 243 Charles Street, Boston, MA 02114.
received either 0.15 mg/kg of metoclopramide or saline solution placebo intravenously after transfer to the postanesthesia care unit. All episodes of vomiting were recorded for 24 h after completion of surgery. The incidence of vomiting in the saline solution group was 70%, compared with 47% in the metoclopramide group (P = 0.026). The authors conclude that the administration of intravenous metoclopramide in a dose of 0.15 mg/kg on arrival in the postanesthesia care unit significantly decreases the incidence of vomiting in children after tonsillectomy. (Anesth Analg 1992;753514)
ication group, either metoclopramide (0.15 mg/kg) (group A) or sterile saline solution placebo (group B). All children were unprernedicated and had not ingested solid food or milk products after midnight on the evening before surgery. Ingestion of clear liquids was permitted until 6 h before the time of surgery. Patients were transported to the operating room accompanied by one parent, and after placement of standard monitoring consisting of automated blood pressure cuff, pulse oximeter probe, electrocardiogram, and precordial stethoscope, anesthesia was induced. Younger patients received increasing concentrations of halothane, nitrous oxide, and oxygen delivered by mask, and older patients who consented to placement of an intravenous cannula while awake received thiopental followed by inhalation of halothane, nitrous oxide, and oxygen. Endotracheal intubation was accomplished in all patients without the aid of muscle relaxant so that reversal of neuromuscular blockade could be avoided, as the use of neostigmine is associated with an increased incidence of nausea and vomiting (4).Anesthesia was maintained with inhalation of halothane, nitrous oxide, and oxygen and intravenous morphine (0.1 mgkg). After placement of an intravenous catheter, patients received lactated Ringer's solution in a volume to restore calculated fasting fluid deficit, deliver maintenance fluid for the duration of surgery, and compensate for measured blood loss. After removal of the tonsils was completed and hemostasis achieved, the
01992 by the International Anesthesia Research Society 0003-2999/92$5.00
Anesth Analg 1992;75:3514
351
352
PEDIATRIC ANESTHESIA FERRARI AND DONLON METOCLOPRAMIDE DECREASES FOS~ONSILLECTOMYVOMITING
Table 1. Clinical Characteristics of 102 Pediatric Patients
Undergoing Tonsillectomy Saline solution ( n = 51) Age (yr) Incidence of vomiting No. of episodes of vomiting in patients who vomited Time to first episode (postoperative h) Results are mean
6.1 2 3.4 47%
5.6
6.4
2.5
30
T
Metoclopramide ( n = 51)
6.5 2 3.6 70% 3.1 i 2.4 '-c
ANESTH ANALG 1992;75:3514
1.1 ? 1.5 '-c
2.8
2 SD.
stomach was decompressed by passing an orogastric tube under direct vision while the surgical mouth gag was still in place. After the trachea was extubated, patients were transferred to the postanesthesia care unit (PACU). Immediately on arrival at the PACU, each patient was given the coded intravenous study drug by a nurse who was unaware of the agent administered. The time of drug administration was noted and recorded. All episodes of vomiting (nausea and retching were not included) that occurred both in the PACU and on the inpatient pediatric floor were timed and recorded by the nurse caring for the patient. No additional prophylactic antiemetic was administered. Oral fluid intake was not forced on patients, and children resumed oral intake voluntarily. The anesthesia, surgical, and nursing teams caring for these patients were unaware of the study drug given. Patients resumed oral fluid intake of their own accord. Fluids were offered and encouraged by the nursing staff; however, forced ingestion of a predetermined volume of oral fluid did not occur. All patients remained in the hospital for a minimum of 23 h and a maximum of 36 h after the completion of surgery. The drug code was broken after all 102 investigations were completed. Statistical significance (P < 0.05) was determined with the Fisher exact test (twotail), 2 analysis, and logistic regression.
Results One hundred two patients were enrolled in the study, 51 patients in each group. The ages did not vary significantly between the two treatment groups. Posttonsillectomy vomiting occurred at a rate of 47% in the metoclopramide treatment group, compared with 70% in the saline solution placebo group (P = 0.026) (Table 1).In those children who did experience postoperative vomiting, the mean frequency was 1.1 ? 1.5 episodes in the metoclopramide-treated group
0
'
2
3
4
5
6
7
8
9
10
10
EPISODES OF VOMITING
Figure 1. Frequency of postoperative vomiting in the two study groups (solid burs, metoclopramide; open burs, saline solution).
compared with 3.1 & 2.4 in the saline solution-treated group (P < 0.001) (Figure 1).Incidentally noted was the observation that patients >8 yr of age vomited less often than younger patients, regardless of treatment group. Vomiting occurred with a frequency of 29% in children >8 yr of age, compared with 68% in children 8 and
MD,
and John V. DonIon,
MD
Departments of Anesthesia, Massachusetts Eye & Ear Infirmary and Harvard Medical School, Boston, Massachusetts
The efficacy of intravenous metoclopramide in controlling vomiting in children after tonsillectomy was determined in a prospective randomized, doubleblind investigation. One hundred two unpremedicated, ASA physical status I or I1 children between the ages of 1and 15 yr who were undergoing surgical removal of the tonsils, with or without adenoidectomy, were studied. Anesthesia was induced either with halothane, nitrous oxide, and oxygen by mask or by intravenous thiopental and was maintained with halothane, nitrous oxide, oxygen, and intravenous morphine (0.1 mgkg). Each child randomly
T
onsillectomy, one of the most frequently performed surgical procedures in pediatric patients, is often performed as an outpatient procedure in some medical centers. Although postoperative bleeding is the most serious complication, vomiting is the most frequent (1,2). Persistent vomiting and poor oral fluid intake are leading causes of unscheduled overnight admission after ambulatory surgery (2). Metoclopramide has been shown to reduce postoperative vomiting in ambulatory pediatric strabismus patients; therefore, this study was designed to determine its efficacy as an antiemetic in children undergoing tonsillectomy (3).
Methods The study was approved by the Human Studies Committee, and written, informed consent was obtained from the parents of 102 children, ASA physical status I or 11, between the ages of 1 and 15 yr undergoing tonsillectomy with or without adenoidectomy. There was no history of motion sickness or other factor predisposing to postoperative vomiting in any patient enrolled in the study. Children were randomly assigned to a postoperative intravenous medAccepted for publication April 17, 1992. Address correspondence to Dr. Ferrari, Department of Anesthesia, Massachusetts Eye & Ear Infirmary, 243 Charles Street, Boston, MA 02114.
received either 0.15 mg/kg of metoclopramide or saline solution placebo intravenously after transfer to the postanesthesia care unit. All episodes of vomiting were recorded for 24 h after completion of surgery. The incidence of vomiting in the saline solution group was 70%, compared with 47% in the metoclopramide group (P = 0.026). The authors conclude that the administration of intravenous metoclopramide in a dose of 0.15 mg/kg on arrival in the postanesthesia care unit significantly decreases the incidence of vomiting in children after tonsillectomy. (Anesth Analg 1992;753514)
ication group, either metoclopramide (0.15 mg/kg) (group A) or sterile saline solution placebo (group B). All children were unprernedicated and had not ingested solid food or milk products after midnight on the evening before surgery. Ingestion of clear liquids was permitted until 6 h before the time of surgery. Patients were transported to the operating room accompanied by one parent, and after placement of standard monitoring consisting of automated blood pressure cuff, pulse oximeter probe, electrocardiogram, and precordial stethoscope, anesthesia was induced. Younger patients received increasing concentrations of halothane, nitrous oxide, and oxygen delivered by mask, and older patients who consented to placement of an intravenous cannula while awake received thiopental followed by inhalation of halothane, nitrous oxide, and oxygen. Endotracheal intubation was accomplished in all patients without the aid of muscle relaxant so that reversal of neuromuscular blockade could be avoided, as the use of neostigmine is associated with an increased incidence of nausea and vomiting (4).Anesthesia was maintained with inhalation of halothane, nitrous oxide, and oxygen and intravenous morphine (0.1 mgkg). After placement of an intravenous catheter, patients received lactated Ringer's solution in a volume to restore calculated fasting fluid deficit, deliver maintenance fluid for the duration of surgery, and compensate for measured blood loss. After removal of the tonsils was completed and hemostasis achieved, the
01992 by the International Anesthesia Research Society 0003-2999/92$5.00
Anesth Analg 1992;75:3514
351
352
PEDIATRIC ANESTHESIA FERRARI AND DONLON METOCLOPRAMIDE DECREASES FOS~ONSILLECTOMYVOMITING
Table 1. Clinical Characteristics of 102 Pediatric Patients
Undergoing Tonsillectomy Saline solution ( n = 51) Age (yr) Incidence of vomiting No. of episodes of vomiting in patients who vomited Time to first episode (postoperative h) Results are mean
6.1 2 3.4 47%
5.6
6.4
2.5
30
T
Metoclopramide ( n = 51)
6.5 2 3.6 70% 3.1 i 2.4 '-c
ANESTH ANALG 1992;75:3514
1.1 ? 1.5 '-c
2.8
2 SD.
stomach was decompressed by passing an orogastric tube under direct vision while the surgical mouth gag was still in place. After the trachea was extubated, patients were transferred to the postanesthesia care unit (PACU). Immediately on arrival at the PACU, each patient was given the coded intravenous study drug by a nurse who was unaware of the agent administered. The time of drug administration was noted and recorded. All episodes of vomiting (nausea and retching were not included) that occurred both in the PACU and on the inpatient pediatric floor were timed and recorded by the nurse caring for the patient. No additional prophylactic antiemetic was administered. Oral fluid intake was not forced on patients, and children resumed oral intake voluntarily. The anesthesia, surgical, and nursing teams caring for these patients were unaware of the study drug given. Patients resumed oral fluid intake of their own accord. Fluids were offered and encouraged by the nursing staff; however, forced ingestion of a predetermined volume of oral fluid did not occur. All patients remained in the hospital for a minimum of 23 h and a maximum of 36 h after the completion of surgery. The drug code was broken after all 102 investigations were completed. Statistical significance (P < 0.05) was determined with the Fisher exact test (twotail), 2 analysis, and logistic regression.
Results One hundred two patients were enrolled in the study, 51 patients in each group. The ages did not vary significantly between the two treatment groups. Posttonsillectomy vomiting occurred at a rate of 47% in the metoclopramide treatment group, compared with 70% in the saline solution placebo group (P = 0.026) (Table 1).In those children who did experience postoperative vomiting, the mean frequency was 1.1 ? 1.5 episodes in the metoclopramide-treated group
0
'
2
3
4
5
6
7
8
9
10
10
EPISODES OF VOMITING
Figure 1. Frequency of postoperative vomiting in the two study groups (solid burs, metoclopramide; open burs, saline solution).
compared with 3.1 & 2.4 in the saline solution-treated group (P < 0.001) (Figure 1).Incidentally noted was the observation that patients >8 yr of age vomited less often than younger patients, regardless of treatment group. Vomiting occurred with a frequency of 29% in children >8 yr of age, compared with 68% in children 8 and
