Acta Anaesthesiologica Taiwanica 54 (2016) 108e113

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Research Paper

Incidence of postoperative nausea and vomiting following

gynecological laparoscopy: A comparison of standard anesthetic
technique and propofol infusion
Pradipta Bhakta 1 *, Bablu Rani Ghosh 2, Umesh Singh 3, Preeti S. Govind 4,
Abhinav Gupta 4, Kulwant Singh Kapoor 5, Rajesh Kumar Jain 6, Tulsi Nag 2,
Dipanwita Mitra 7, Manjushree Ray 8, Vikash Singh 9, Gauri Mukherjee 10
1
Department of Anesthesiology and Intensive Care, University Hospital Kerry, Tralee, Ireland
2
Department of Anaesthesia and Intensive Care, Ramakrishna Mission Seva Pratishthan, Calcutta, India
3
Department of Internal Medicine, Division of Immunology/Allergy, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
4
Department of Anaesthesia and Pain Management, Indian Spinal Injuries Centre, New Delhi, India
5
Department of Biostatistics, All Indian Institute of Medical Sciences, New Delhi, India
6
Department of Anaesthesia and Intensive Care, Princess Royal Hospital, Apley Castle, Telford TF1 6TF, UK
7
Department of Anaesthesia, Dr. B.C. Roy Postgraduate Institute of Paediatric Sciences, Calcutta, India
8
Calcutta National Medical College, Kolkata, India
9
Department of Anaesthesia and Intensive Care, St. James University Hospital, Dublin, Ireland
10
Department of Anaesthesia, Calcutta National Medical College, Calcutta, India

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the safety, efficacy, and feasibility of propofol-based anesthesia in gynecological
Received 6 March 2016 laparoscopies in reducing incidences of postoperative nausea and vomiting compared to a standard
Received in revised form anesthesia using thiopentone/isoflurane.
14 September 2016
Design: Randomized single-blind (for anesthesia techniques used) and double-blind (for postoperative
Accepted 12 October 2016
assessment) controlled trial.
Setting: Operation theater, postanesthesia recovery room, teaching hospital.
Keywords:
Patients: Sixty ASA (American Society of Anesthesiologists) I and II female patients (aged 20e60 years)
emesis score;
gynecological laparoscopy;
scheduled for gynecological laparoscopy were included in the study.
ordinal logistic regression; Interventions: Patients in Group A received standard anesthesia with thiopentone for induction and
postoperative nausea and vomiting; maintenance with isofluraneefentanyl, and those in Group B received propofol for induction and
postoperative recovery; maintenance along with fentanyl. All patients received nitrous oxide, vecuronium, and neostigmine/
propofol-based anesthesia glycopyrrolate. No patient received elective preemptive antiemetic, but patients did receive it after more
than one episode of vomiting.
Measurements: Assessment for incidence of postoperative nausea and vomiting as well as other recovery
parameters were carried out over a period of 24 hours.
Main Results: Six patients (20%) in Group A and seven patients (23.3%) in Group B experienced nausea.
Two patients (6.66%) in Group B had vomiting versus 12 (40%) in Group A (p < 0.05). Overall, the inci-
dence of emesis was 60% and 30% in Groups A and B, respectively (p < 0.05). All patients in Group B had
significantly faster recovery compared with those in Group A. No patient had any overt cardiorespiratory
complications.
Conclusion: Propofol-based anesthesia was associated with significantly less postoperative vomiting and
faster recovery compared to standard anesthesia in patients undergoing gynecological laparoscopy.
Copyright © 2016, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. Department of Anaesthesia and Intensive Care,

University Hospital Kerry, Apartment No 10, Windmill Court, Windmill Road,
Drogheda, Louth A92 E680, Ireland.
E-mail address: bhaktadr@hotmail.com (P. Bhakta).

http://dx.doi.org/10.1016/j.aat.2016.10.002
1875-4597/Copyright © 2016, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Incidence of PONV in gynecological laparoscopy
1. Introduction
Pain and postoperative nausea and vomiting (PONV) are two
important causes of postoperative morbidity.1e3 Essentially, these
factors are interrelated.4 Untreated postoperative pain is an
important cause of PONV,4 and use of opioids for its management
also results in PONV.5e9
In spite of the extensive understanding of the pathophysiology
of PONV and the availability of a variety of antiemetics, certain
surgical procedures such as gynecological laparoscopy, are still
associated with unacceptably high incidence of PONV.10e13 PONV is
frequently the cause of great distress to the patient. Excessive PONV
may lead to dehydration, electrolyte imbalance, and dreaded
complications such as pulmonary aspiration syndrome. There is
also economic implication of PONV in day case surgeries such as
gynecological laparoscopy, as it may result in prolonged hospital
stay.14
The multifactorial nature of PONV makes it unlikely that a
single therapy will be fully effective in all conditions. 5-
Hydroxytryptamine-3 (5-HT3) receptor antagonists, the most
commonly used antiemetics, are very effective in chemotherapy-
induced nausea and vomiting, but not as effective in opioid-
induced emesis or motion sickness. It is understandable that
5-HT3 antagonists will not be that effective as these two factors are
most relevant in PONV.15 Anesthetic drugs and techniques can also
influence the occurrence of PONV.16 Laparoscopic techniques are
highly standardized; therefore, anesthetic technique remains the
main variable to influence the incidence of PONV.3
Despite the lack of substantial evidence about the advantage of
any anesthetic technique in reducing the incidence of PONV,
propofol-based anesthesia has been found to be more effective for
such outcomes.6,11,16,17 Because of the high incidence of PONV in
gynecological laparoscopy there is an unmet need for an ideal
technique to minimize PONV. Thus, the current study aimed to
compare the advantage of propofol-based anesthesia over thio-
pentoneeisoflurane anesthesia in reducing incidence of PONV and
time for postoperative recovery.
2. Materials and methods
After obtaining the approval of the institutional ethics com-
mittee and informed consent, 60 nonpregnant ASA (American So-
ciety of Anesthesiologists) I and II female patients between the ages
20 and 60 years were included in the study. The study was pro-
spective, randomized, single blind (for anesthesia techniques used)
and double blind (for postoperative assessment). However, the
same anesthesiologist assessed all the postoperative variables to
avoid interobserver variation. Sixty patients were randomized
equally into two groups to receive either thiopentoneeisoflurane
(Group A) or propofol (Group B). Pregnant or nursing mothers,
women in their perimenstrual period, those having a history of
PONV, smokers, those with hypersensitivity to any of the study
drugs, and those who have taken antiemetics within 24 hours of
anesthesia were excluded from the study.
All patients were premedicated with oral midazolam (0.5 mg/
kg) 2 hours prior to anesthesia. Baseline monitoring of noninvasive
blood pressure (NIBP), electrocardiogram (ECG), and peripheral
oxygen saturation (SpO2) were commenced in the preanesthesia
room. After adequate preoxygenation, Group A patients were
induced with intravenous thiopentone (3e5 mg/kg), fentanyl (2 mg/
kg), and vecuronium (0.08 mg/kg). Anesthesia was maintained with
60% nitrous oxide (N2O) in oxygen (O2), isoflurane, and intermittent
vecuronium. The concentration of isoflurane was adjusted to
maintain an adequate depth of anesthesia. Isoflurane was dis-
continued after termination pneumoperitoneum. Patients in Group
109
B were induced with intravenous propofol (2e2.5 mg/kg), fentanyl
(2 mg/kg), and vecuronium. Anesthesia was maintained with 60%
N2O in O2, propofol infusion and intermittent vecuronium. A step-
down propofol infusion regimen was used.18 Infusion was started at
a rate of 166 mg/kg/min and then reduced to 133 mg/kg/min after 10
minutes. Infusion was reduced further to and maintained at 100 mg/
kg/min after another 20 minutes. We used this technique as
compared to the effector site concentration-based technique as we
did not have a state-of-the-art target control infusion pump or
highly sophisticated pump. Infusion rate was adjusted in between
to maintain adequate surgical anesthesia and hemodynamic sta-
bility. All patients were intubated with endotracheal tube after
induction of anesthesia, and ventilation was controlled. Elective
hyperventilation was used in both the groups to keep end tidal
carbon dioxide (EtCO2) within the range of 4.5e5.3 kPa. Propofol
infusion and isoflurane were discontinued after termination of
pneumoperitoneum. Any elective antiemetic medication was
withheld as this study was designed to estimate the effect of two
anesthesia techniques on incidences of PONV.
Surgical procedures were identical in both groups. Pneumo-
peritoneum was created using carbon dioxide (CO2) as insufflating
gas. Intra-abdominal pressure was kept within 14 mmHg. An oro-
gastric tube was inserted to deflate the stomach. All the port
insertion sites were infiltrated with bupivacaine prior to insertion.
Patients were positioned in 15
Trendelenburg with lithotomy.
NIBP, ECG, SpO2, end tidal capnography (EtCO2), airway, and intra-
abdominal pressure were monitored in every case. In addition,
inspired and expired isoflurane concentrations were monitored in
Group A. At the end of the surgery, residual neuromuscular block
was reversed with neostigmine (0.05 mg/kg) and glycopyrrolate
(0.01 mg/kg). After achieving adequate recovery, the patients were
transferred to the postanesthesia care unit (PACU).
In the PACU, basic postoperative monitoring (NIBP, ECG, and
SpO2) was continued. Assessment of PONV and recovery parameters
was carried out using a predesigned scoring system (Table 1).17
Scoring was done initially at 30-minute intervals for the first 2
hours, then every 6 hours for the following 24 hours. Thus, emesis
score (ES) was recorded at each of the specified time points (0.5
hours, 1 hour, 1.5 hours, 2 hours, 6 hours, 12 hours, 18 hours, and 24
hours postoperatively) on an ordinal scale (Table 1).
Table 1
Postoperative assessment chart.
Variables Parameters Score
Emesis score No nausea/vomiting 0
Nausea 1
Retching 2
Vomiting 3
Recovery score Fully awake 3
Drowsy 2
Arousable by shouting 1
Not arousable 0
Ventilation score Airway patent cough/cry present 2
Airway patent, breathes easily 1
Airway needs attention 0
Movement score Purposeful and spontaneous movement 3
Purposeful on demand 2
Spontaneous but not purposeful 1
No movement 0
Retching is the imminent sense of expulsion of gastric content with active sense of
antiperistalsis, but without any regurgitation or expulsion of gastric content.
Vomiting is the next stage of active expulsion of gastric content with massive mass
reflex and antiperistalsis.
Note. From “Nausea and vomiting after laparoscopic surgery: a comparison of pro-
pofol and thiopentone/halothane anaesthesia,” by A. Klockgether-Radke, V. Piorek,
T. Crozier, D. Kettler, 1996, Eur J Anaesthesiol, 13, p. 3e9. Copyright 2016. Name of
the Copyright Holder: Authors. Reprinted with permission.
110
Postoperative analgesia was provided with oral or intravenous
paracetamol (1 g every 6 hours) and oral or intramuscular diclo-
fenac (1 mg/kg every 8 hours) in both groups. As opioids are
associated with PONV, they were withheld in the postoperative
period. However, rescue analgesia was provided with boluses of
intravenous fentanyl (0.25e0.5 mg/kg) when deemed necessary.
Rescue antiemetic in the form of intravenous ondansetron (4 mg)
was given to any patients who had more than one episode of
vomiting. After adequate recovery from anesthesia (as judged by
recovery score), all patients were encouraged to take oral fluids. The
time for first oral intake varied from patient to patients. Again, it
was determined by recovery and ward nurse as per our fixed pro-
tocol. Also, when a patient felt sick with oral intake, further oral
fluid was stopped, and the score was noted as well as rescue anti-
emetic prescribed as per our protocol. Once the patient feels alright
again and expressed the desire to have oral fluid, it was allowed.
Solid food was only allowed whenever they tolerated oral fluid and
was free of any PONV. All patients had uneventful recovery from
anesthesia and were discharged after 24 hours of follow-up.
2.1. Data analysis
The demographic and intraoperative parameters of all patients
were analyzed using Student t test. Comparison of intraoperative
parameters in each group between baseline and end of anesthesia
values was done using paired t test. Fisher’s exact test was used to
compare PONV and recovery parameters in between the groups. A
p value < 0.05 was considered statistically significant.
2.2. Determining relevance of predictor variables on outcomes for
comparison
Classification and Regression Tree analysis was performed to
determine the relevance of predictor variables in determining the
outcome (i.e., ES; Figure S1). The data on ES could be distinctly
partitioned based on whether the patients received postoperative
antiemetic. As shown in Figure S1, the right branch at split 1 rep-
resents the counts of ES at which the patients of either group
received an antiemetic, and the left includes the counts of ES
without antiemetic. Conditional on the ES without antiemetic (first
left branch), the anesthetic (i.e., propofol-based anesthesia vs. thi-
opentone/isoflurane) during surgery becomes an important factor
in predicting the severity of ES during the postoperative period.
Moreover, the early postoperative period between 0.5 and 2 hours
was more significant for predicting the highest probabilities of
nausea and vomiting than later on (as shown on left-branch split 3).
This figure also shows a table that summarizes the ability of the
model to predict ES severity. It shows the R2 for the training data
(255 observations) and validation data (n ¼ 225) to be 0.40 and
0.24, respectively. This R2 value indicates that the model fits the
training data (the data used to create the model). The fact that this
number is low hints that the model can be enriched, perhaps by
adding more predictor variables in similar studies in the future.
After determining the relevance of this model, ordinal logistic
regression model was used to test whether treatment with Group B
versus Group A had an effect on postoperative ES over time. The
levels of ES (0e3) were specified in descending order during ordinal
logistic regression analysis, with the higher scores ranked higher in
the order. Effect of “time” of recording ES and “group” were
determined in the final multivariate model. Because the use of
antiemetics was significantly different between Group A and Group
B, this effect was excluded from the final model. This model used in
the analysis reduced the log likelihood that yielded a likelihood
ratio chi-square value of 37.05 for the whole model with 8 degrees
of freedom, and showed the difference in ESs between groups to be
P. Bhakta et al.
highly significant (p < 0.0001). The “lack of fit” test determined the
ordinal response model compared to the nominal model. The
nonsignificance (p ¼ 0.1154) of “lack of fit” justified the rationality
of the ordinal model.
The partitioning model was also evaluated by receiver operating
characteristic (ROC) analysis (Figure S2). In this analysis, the power
of the model's predicted values to discriminate between Group A
and Group B patients was quantified by the area under the ROC
curve (AUC). The c-statistic (or concordance index) values for
vomiting, retching, nausea, and no symptoms (ES ¼ 3, 2, 1, and 0) in
the immediate and early recovery period were 0.8525, 0.9427,
0.8817, and 0.8525, respectively. Thus, this curve indicates that
incidences of PONV are more sensitive, and are therefore more
influenced in Group B versus Group A in the immediate post-
operative period (2 hours).
2.3. Ethical statement
The study involved human patients. Patients' consent was ob-
tained for the study as well as publication of the data.
3. Results
Demographic and intraoperative vital parameters (heart rate,
BP, SpO2, and EtCO2) were comparable between both groups except
for the requirement of antiemetics, which was significantly less in
Group B (p < 0.001; Tables 2 and 3). There were no episodes of
significant bradycardia, hypotension, hypoxia, or arrhythmia
(Table 3). Only one patient in Group A momentarily developed
hypercarbia (EtCO2 ¼ 6.11 kPa).
It is thus evident from this study that propofol-based anesthesia
had a favorable outcome in relation to PONV (Table 4, Figure 1).
Seven (23.33%), four (13.33%), and 12 (40%) patients had nausea,
retching, and vomiting in Group A, respectively. A total of 23 pa-
tients (76.66%) in Group A had PONV. The corresponding figures in
Group B were eight (26.66%), one (3.33%), two (6.66%), and 11
(36.66%), respectively (Table 3; p < 0.01; Figure 1).
While comparing patients having emesis or no emesis between
the groups, a statistically significant difference was found in Group
B (Table 4). As shown in Table 5, in the Type 3 analysis of effects, the
“group” effect is statistically significant (p < 0.0001). Although for
the overall effect of the time of recording the ES did not reach
statistical significance, the ESs at 0.5 hours, 1 hour, and 1.5 hours
were significantly higher than the ES at 24 hours (i.e., at the time of
discharge; Table 5). The negative coefficients of “Group B versus
Group A” (est. ¼ e1.5169, p < 0.0001) meant a significant negative
relationship of Group B with ES, and likewise the statistically sig-
nificant positive coefficients (est. ¼ 1.57, 1.47, and 1.52 at 0.5 hours, 1
hour, and 1.5 hours after anesthesia) corresponded to a significantly
high ES at these time points compared to ES at discharge (Table 5).
Table 2
Demographic parameters between Groups A and B.
Variables Group A (n ¼ 30) Group B (n ¼ 30) p
Age (y) 27.83 ± 5.10 27.57 ± 5.07 0.84
Body weight (kg) 50.83 ± 6.49 48.50 ± 9.32 0.26
ASA status (I/II) 20/10 22/8 0.57
Duration of 21.63 ± 3.45 21.27 ± 2.89 0.66
surgery (min)
Duration of 30.30 ± 3.57 28.10 ± 2.78 0.09
anesthesia (min)
No. of patients 14 2 <0.001
received antiemetic
ASA ¼ American Society of Anesthesiologists.
Incidence of PONV in gynecological laparoscopy 111

Table 3
Comparison of vital parameters between the groups.

Parameters 0 min 10 min 20 min 30 min p

Pulse Group A 91.43 ± 12.66 77.93 ± 11.55 84.63 ± 10.61 88.33 ± 03.38 0.0066
Group B 84.57 ± 09.73 77.47 ± 09.45 80.87 ± 09.82 77.80 ± 07.85 0.0661
p 0.06 0.86 0.15 0.46
MAP Group A 95.66 ± 4.02 92.04 ± 6.15 94.95 ± 4.81 97.21 ± 2.51 0.4854
Group B 93.88 ± 5.74 90.55 ± 5.18 91.88 ± 4.52 94.62 ± 5.05 0.0681
p 0.16 0.31 0.36 0.29
SpO2 Group A 98.23 ± 1.16 99.17 ± 0.83 99.57 ± 0.72 99.33 ± 1.21 <0.001
Group B 98.50 ± 1.43 99.03 ± 0.99 99.70 ± 0.75 99.20 ± 0.83 <0.001
p 0.42 0.55 0.49 0.84
EtCO2 Group A 4.84 ± 0.28 5.13 ± 0.24 5.17 ± 0.27 4.85 ± 0.91 <0.0001
Group B 5.00 ± 0.29 5.21 ± 0.20 5.21 ± 0.21 5.04 ± 0.18 0.0081
p 0.57 0.16 0.52 0.65

EtCO2 ¼ end tidal carbon dioxide; MAP ¼ mean arterial pressure; SpO2 ¼ peripheral oxygen saturation.

Table 4 Patients in Group B also recovered significantly faster compared

Frequency of emesis scores (ES; 0e3) by study groups controlled for time of mea- with patients in Group A. Recovery time for all variables was much
surement of ES [1.5 hours (early) or >1.5 hours (late)].
shorter in patients of Group B (Figure 2). Times for eye opening and
ES score Time  1.5 h (early) Time  1.5 h (late) response to verbal command were significantly faster in patients in
Group A Group B Total Group A Group B Total Group B compared with patients in Group A (p < 0.001). Orientation
to place, person, and date of birth was also attained earlier in Group
0 (No nausea) 63 (43%) 84 (57%) 147 123 (47%) 141 (53%) 264
1 (Nausea) 15 (79%) 4 (21%) 19 16 (67%) 8 (33%) 24 B. All patients in Group B achieved maximum score in ventilation
2 (Retching) 2 (100%) 0 2 4 (80%) 1 (20%) 5 and movement much earlier (p < 0.001; Figure 2).
3 (Vomiting) 10 (83%) 2 (17%) 12 7 (100%) 0 7
Total 90 90 180 150 150 300
4. Discussion
Fisher's exact test
p-value <0.0001 <0.0001
This study demonstrated that, in gynecological laparoscopic
surgeries, the propofol-based anesthesia technique is associated
with significantly lesser incidence of PONV as well as better and
faster recovery profile without any of the dreaded adverse effects.
Multivariate analyses in this study determined that: (1) propofol-
Group A
based anesthesia was associated with significant reduction in ES;
Group B
and (2) the odds of having a high ES are significantly higher in the
p<0.01 immediate and early postoperative periods (1.5 hours).
25
In general, laparoscopic surgeries are associated with remark-
20 p<0.01 ably high incidence of PONV (20e51%),17,19 and among them gy-
necological laparoscopy is reported to have even higher rate of
15 p < 0.01 PONV (50e80%).10e13 The reason for this higher emesis is still not
PaƟents

p = 0.77 clear; however, several hypotheses have been put forth:

10
p = 0.16
5  Mechanical factor: pressure on stomach and intestine caused by
pneumoinsufflation
0  Neurological factors: stimulation of autonomic nervous system
Nausea Retching VomiƟng PONV No PONV
and peritoneum resulting in parasympathetic stimulation
Post operaƟve nausea and vomiƟng
 Chemical factor: probable influence of hypercarbia on vomiting
Figure 1. Postoperative nausea and vomiting (PONV) scores between two groups. center17,19

Table 5
Odds ratio and MLE estimation to determine the effect of treatment (A vs. B) and
time after surgery in predicting emesis score.

Odds ratio estimates Analysis of MLE

Effects Points 95% Wald Estimates p-value

estimate confidence limits

Group (A vs. B) 0.219 0.119 0.403 e1.5169 <0.0001

Time (0.5 vs. 24 h) 4.805 1.260 18.329 1.5697 0.0216
Time (1 vs. 24 h) 4.349 1.130 16.742 1.4699 0.0326
Time (1.5 vs. 24 h) 4.559 1.189 17.472 1.5170 0.0269
Time (2 vs. 24 h) 2.972 0.738 11.962 1.0891 0.1253
Time (6 vs. 24 h) 3.748 0.959 14.655 1.3213 0.0575
Time (12 vs. 24 h) 3.327 0.839 13.192 1.2020 0.0873
Time (18 vs. 24 h) 2.439 0.588 10.119 0.8915 0.2194
Figure 2. Average minimum time to achieve maximum score of various recovery
ChiSq ¼ chi square; MLE ¼ maximal likelihood estimation. parameters.
112
This extremely high rate of PONV in laparoscopy warrants
antiemetic prophylaxis. But as our study was aimed at evaluating
superiority between two anesthetic techniques on PONV, routine
use of antiemetic was withheld. As thiopentone is a prototype
intravenous inducing agent, it was used in Group A. In comparison
to other anesthetic agents, propofol is constantly found to have
antiemetic property and quicker recovery.6,11,16,17 Thus, it was used
as the sole anesthetic in Group B to compare the difference be-
tween the two groups. Although there are several reports that
reversal agents such as neostigmine can influence PONV,20,21 it was
not possible to avoid this drug in our hospital setup, especially
when vecuronium was used for muscle relaxation. However,
whatever the effect may be, it was found to be similar in both
groups. Similarly, although opioids are incriminated for PONV,5e9
avoidance of opioid analgesia in the intraoperative period might
result in excessive pain, which leads to patient discomfort and
higher rate of PONV.4,5 However, postoperative pain in this surgical
technique is not as severe and opioid analgesia can be omitted
postoperatively. Instead, nonsteroidal anti-inflammatory drug and
paracetamol were used for postoperative analgesia instead of opi-
oids to minimize the concern of emesis further.3,8,15 Laparoscopic
surgery was chosen for our study as it is considered as a model for
the study of PONV, similar to squint surgery. Furthermore, gyne-
cological laparoscopy is better suited in this regard because of the
higher PONV rate.10e13 Female patients between ages 20 and 60
years were selected for our study as this age range and sex group
are seen to be associated with the highest incidence of PONV.9,19,22
Nonpregnant patients were selected to eliminate the influence of
pregnancy on PONV and gastric emptying.23
Surgeries consisted mainly of laparoscopic procedures for
infertility and pelvic inflammatory diseases. Although proper care
was taken to avoid user bias, total elimination was not possible
because of the distinct milk-like color of propofol. Thus, anesthetic
technique was single blinded. However, postoperative assessment
was double blinded as neither the observer nor the patient knew
anything about the anesthesia techniques used. A single person
undertook postoperative observations to avoid interpersonal bias.
Aspiration of the stomach was done routinely in all cases after
intubation as there is a theoretical possibility of gastric regurgita-
tion because of pneumoperitoneum and to avoid trocar-induced
surgical trauma to the stomach.24
Intraoperative heart rate in all patients decreased compared to
their preinduction value. This represents the negative chronotropic
effect of propofol as well as adequate anesthetic plane. However, no
patient developed any significant bradycardia or hypotension. Also,
there was no significant difference in perioperative vital parame-
ters between the two groups. This explains the safety of propofol-
based anesthesia like standard anesthesia.17
It is evident from postoperative recovery parameters that
propofol-based anesthesia had favorable outcome in regard to
PONV.6,11,17 Results in the current study match those of other
similar studies.6,16,17,25,26 Klockgether-Radhke et al,17 in a similar
study involving laparoscopic cholecystectomy or herniotomy,
observed 20% incidence of postoperative vomiting in the thio-
pentoneehalothane group and 0% in the propofol group. In that
study, the overall incidence of emesis was 43% and 23% in the
control and propofol groups, respectively.12 The higher overall
incidence of emesis in both groups combined in the current study
in emetic incidence can be explained by female patients and gy-
necological laparoscopy, both of which are reported to have higher
incidence rates of PONV.9,12,13,22
The exact mechanism for the lower incidence of emesis with
propofol-based anesthesia is not yet known. Still, propofol is not
known to have any receptor-specific antiemetic effect including
effects on chemoreceptor trigger zone, 5-HT3, and dopamine 2
P. Bhakta et al.
receptor.17,27 Rather, it increases the dopamine concentration in the
nucleus accumbens.28 It has been propounded that this antiemetic
activity may be attributable to the decrease in serotonin level in
area prostema, probably mediated through its action via the
gamma aminobutyric acid receptor.29 Propofol has been used in
subhypnotic dose as an antiemetic and is known to be superior to
ondansetron.19 Whether the antemetic effect of propofol is because
of its true antiemetic property or depressant effect on the central
nervous system, remains to be resolved. However, this study-
dsimilar to previous other studiesdproved that propofol-based
anesthesia is associated with significantly reduced emetic sequel.
Patients in Group B also experienced significantly faster recov-
ery compared to those in Group A similar to previous
studies.16,17,26,30,31 In addition, the recovery times for all post-
operative variables were much shorter in Group B patients, thus
demonstrating a better recovery profile with propofol-based
anesthesia compared to a standard anesthesia.
In our study, all patients were discharged in the 2nd post-
operative day in order to facilitate the recording of the parameters
over 24 hours. Worldwide, gynecological laparoscopies are usually
managed as day cases and discharged on the same day. However,
discharge may be delayed because of higher incidences of post-
operative emesis and associated complications leading to delayed
recovery. Thus, propofol-based anesthesia has an advantage over
standard anesthesia because of its significantly lower incidence of
PONV and faster recovery profile. One disadvantage is that
propofol-based anesthesia is more expensive than standard tech-
niques.31 However, considering the value-added effect of better
patient experience and faster recovery through prevention of the
stressful effects and complication of PONV as well as reduced
hospital stay, propofol is more cost-effective and therefore a better
choice in day case surgeries such as gynecological laparoscopies.31
4.1. Limitations
There are several limitations in our study that we could not
avoid.
1. We could not completely avoid perioperative opioids in our
patients. This may have increased the overall incidences as
opioid is a well-known cause of PONV. But then again in such
procedures complete avoidance of opioids was not possible
because of the nature of the surgery. Also, it is very well known
that untreated perioperative pain can lead to PONV. We thus
decided to use short-acting fentanyl for both intra- and post-
operative rescue analgesia. We also added paracetamol and
diclofenac to reduce overall fentanyl consumption and thus the
incidence of PONV. However, whatever the incidence may be, it
was equal in both groups and thus was nullified in the statistical
analysis.
2. Similarly, we should have avoided the use of nitrous oxide in our
cases, knowing that it increases the incidence of PONV. How-
ever, this was not possible in our setup; we do not have the
necessary facilities to use air in all cases. The issue of PONV and
nitrous oxide is not as severe as was thought previously, and the
problem can be solved with the mere use of antiemetics.
Moreover, it adds to analgesia and thereby reduces intra-
operative opioid consumption, and thus also reduces some
amount of impact on overall PONV. At any rate, whatever the
effect may be, it was equal in both groups and thus again got
nullified in the statistical analysis.
3. The use of neostigmine for the reversal of residual neuromus-
cular block could not be avoided in our setup even knowing that
it was previously thought to increase incidences of PONV.
However, in our setup, mivacurium is not available and our
Incidence of PONV in gynecological laparoscopy
PACU as well as ward staffing were not particularly well
equipped to tackle any postreversal residual paralysis, which
could have been a major threat to our patient than accepting a
slightly higher incidence of PONV, which is easily manageable.
Moreover, recently the role of neostigmine in the overall rate of
PONV has become a subject of debate.
4. A major risk of total intravenous anaesthesia (TIVA) is a higher
risk of intraoperative awareness. Thus, it is highly recommended
that bispectral index equipment be used to monitor the depth of
anesthesia. Unfortunately, this was not available in our setup.
We used the well-tested infusion protocol that is known to
maintain a proper level of anesthesia. In addition, we used
nitrous oxide and monitored the vital parameters as well as the
patient's movement. Thus, to our consideration, awareness was
not an issue and no patient reported about intraoperative
awareness of any sort afterward.
5. Conclusion
Propofol-based anesthesia is associated with significantly lower
incidences of PONV and faster recovery compared to standard
anesthesia using thiopentone and isoflurane. Therefore, in day case
surgeries such as gynecological laparoscopy, where reduced PONV
and faster recovery profile are of prime importance, propofol is a
better choice.
Conflicts of interest
The authors report no conflicts of interest.
Acknowledgments
No funding other than personal was used in conducting the
audit as well as writing the manuscript. We declare that we have no
financial and/or personal relationships with other people or orga-
nizations that could inappropriately influence (bias) our work.
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Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.aat.2016.10.002.