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The Reliability and Validity of the Rhodes Index of Nausea, Vomiting and
Retching in Postoperative Nausea and Vomiting

Article  in  Korean Journal of Anesthesiology · January 2007

DOI: 10.4097/kjae.2007.52.6.S59

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대한마취과학회지 2007; 52: S 59～65
□ 영문논문 □
Korean J Anesthesiol Vol. 52, No. 6, June, 2007

The Reliability and Validity of the Rhodes Index of Nausea,

Vomiting and Retching in Postoperative Nausea and Vomiting
Departments of 1Anesthesiology and Pain Medicine, 2Clinical Pharmacology and Therapeutics and 3Preventive Medicine,
Asan Medical Center, University of Ulsan College of Medicine, Seoul; 4Department of Anesthesiology and Pain Medicine,
College of Medicine, Dankook University, Cheonan, Korea

1 1 1
Tae Hee Kim, M.D. , Byung Moon Choi, M.D. , Ji Hyun Chin, M.D. ,
3 4 1,2
Moo Song Lee, M.D. , Dong Hee Kim, M.D. , and Gyu Jeong Noh, M.D.

Background: The Rhodes index of nausea, vomiting and retching (RINVR) is a patient self-report instrument to assess the
objective and subjective factors of nausea and vomiting. The aim of this study is to evaluate the reliability and validity of the
RINVR in postoperative nausea and vomiting (PONV).
Methods: The RINVR, VAS for nausea and incidence of emetic episodes were administered to 150 patients approximately
30 minutes apart at 6 hours and 24 hours after surgery. The validity was evaluated by Spearman's correlation and internal
consistency of reliability was determined using Cronbach's alpha. To determine test-retest reliability, second administration of
the RINVR was done 2 hours after the first. The test-retest reliability was evaluated by Spearman's correlation and agreement.
Results: Cronbach's alpha of nausea, vomiting, retching and total experience scores of the RINVR ranged from 0.912 to 0.968.
Test-retest scores of all items were strongly correlated (Spearman's coefficients: 0.962-1.000, P ＜ 0.0001) and highly agreed
(weighted kappa: 0.932-1.000). Coefficients of construct validity for nausea components (vs VAS for nausea) and emetic
components (vs incidence of emetic episodes) of the RINVR were 0.860-0.928 and 0.724-0.811, respectively (P ＜ 0.0001).
The overall weighted kappa between the incidences of PONV assessed by the RINVR and by patient self-assessment of VAS
for nausea and incidence of emetic episodes was 0.917-0.945. The number of patients in “great” total experience category was
1.33% or less. There was no significant difference of VAS for nausea between “severe” and “great” nausea experience categories.
Conclusions: The RINVR was a reliable and valid instrument to assess PONV. (Korean J Anesthesiol 2007; 52: 59～65)
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
Key Words: postoperative nausea and vomiting, reliability, Rhodes index, validity.

Nausea and vomiting should be assessed independently and

INTRODUCTION
Although the need for common assessment criteria has been
raised for a long time, there is still no gold standard to assess
postoperative nausea and vomiting (PONV). Recently “Con-
sensus guidelines for managing postoperative nausea and vomi-
1)
ting” was published, but no comments or suggestions regar-
ding to the assessment of PONV could be found.
Received：October 19, 2006
Corresponding to：Gyu Jeong Noh, Departments of Anesthesiology and Pain
Medicine, Clinical Pharmacology and Therapeutics, Asan Medical
Center, University of Ulsan College of Medicine, 388-1, Poongap
2-dong, Songpa-gu, Seoul 138-736, Korea. Tel: 82-2-3010-3868,
Fax: 82-2-470-1363, E-mail: nohgj@amc.seoul.kr
This study was supported by a grant (2003-0709) from the Industry Trust
Research Service between University of Ulsan College of Medicine and
GlaxoSmithkline Korea, Seoul, Korea.
S 59
retching may be grouped together with vomiting under the
term of emetic episodes or assessed separately from vomiting,
thereby it is important to describe the definitions of nausea,
vomiting and retching in detail.2) Nausea should be evaluated
by the patient, and observer rated assessment is considered the
standard method for estimating the number of emetic episodes,
which require a great deal of time and dedication for the
observer involved.3)
In general, incidence of emetic episodes and the severity of
nausea based on a visual analog scale (VAS) or graded scale
has been assessed in anti-emetic trials of PONV.4) Additionally,
the need for rescue anti-emetics is used to evaluate the
anti-emetic efficacy.5) The subjective factor of vomiting and
retching such as distress, and objective factor of vomiting such
as amount, have been overlooked for the assessment of PONV.
Even though nausea is a subjective sensation, there must be
 Korean J Anesthesiol：Vol. 52. No. 6, 2007

objective factors such as duration and frequency of nausea. vomiting due to telephone method of data collection.
These can provide us more additional information of anti- However, the reliability and validity of the RINVR,
emetic efficacy. In anti-emetic trials of chemotherapy, objective translated into Korean language, has not been evaluated in
and subjective factors of nausea and vomiting have been PONV. Thus, the aim of this study is to assess the reliability
6)
commonly assessed at the same time. and validity of the Korean version of the RINVR in PONV.
The Rhodes index of nausea, vomiting and retching
(RINVR) is an instrument consisting of eight 5-point self- MATERIALS AND METHODS
report items (Fig. 1) designed to assess subjective and ob-
Sample
jective factors of nausea, vomiting and retching in various
situations including surgical patients.7) The authors thought that After obtaining the approval of the Institutional Review
the RINVR is compatible with the criteria below mentioned. 1) Board of Asan medical center and Dankook University Hospital,
a simple, reliable and valid instrument in one sheet of paper, and the written informed consent of each patient at a
2) nausea, vomiting and retching should be defined in detail preoperative visit, one hundred fifty patients classified as
and assessed independently 3) patient self-report form to reduce American Society of Anesthesiologists physical status 1 or 2
time and dedication for the investigator involved, 4) objective were enrolled from these two institutes.
and subjective factors of nausea, vomiting and retching can be Inclusion criteria were postoperative patients underwent
assessed by the same instrument. A recent study demonstrated elective surgery known to cause PONV at high incidence, such
the reliability of the RINV (Rhodes index of nausea and as gynecologic surgery (gynecologic laparoscopic surgery, total
8)
vomiting) for ambulatory surgery patients. The instrument abdominal hysterectomy, radical hysterectomy, vaginal hy-
used to this article was modified Rhodes index of nausea and sterectomy, salphingo-oophorectomy),9,10) breast surgery (simple

Post-operative assessment
□ Nausea & vomiting sheet (6 hours after surgery)
Date Time
□□ □□ □□ □□ □□ □□
Year Month Day A.M/P.M Hour Minute
Rhodes index of nausea, vomiting and retching (6 hours after surgery)
1. In the last 6 hours, I threw up ( ) I did not
7 or more □ 5-6 times □ 3-4 times □ 1-2 times □ □
times. throw up
2. In the last 6 hours, from reteching or dry
No □ Mild □ Moderate □ Great □ Severe □
heaves have felt ( ) distress.
3. In the last 6 hours, from vomiting or
Severe □ Great □ Moderate □ Mild □ No □
throwing up, I have felt ( ) distress.
4. In the last 6 hours, I have felt nauseated 1 hour or More than
Not at all □ □ 2－3 hours □ 4-6 hours □ □
or sick at my stomach ( ). less 6 hours
5. In the last 6 hours, from nausea/sickness
No □ Mild □ Moderate □ Great □ Severe □
at my stomch, I have felt ( ) distress.
Very large
6. In the last 6 hours, each time I threw up Large Moderate Small (up I did not
(3 cups or □ □ □ □ □
I produced a ( ) amount. (2-3 cups) (1/2-2 cups) to 1/2 cup) throw up
more)
7. In the last 6 hours, I have felt nauseated
7 or more □ 5-6 times □ 3-4 times □ 1-2 times □ No □
or sick at my stomach ( ) times.
8. In the last 6 hours, I have had periods of
reteching or dry heaves without bringing No □ 1-2 times □ 3-4 times □ 5-6 times □ 7 or more □
anything up ( ) times.

Fig. 1. A questionnaire of the RINVR at 6 hours after surgery.

S 60
 Tae Hee Kim, et al：Reliabilty and Validity of the RINVR in PONV

mastectomy, radical mastectomy),11) and major orthopedic sur-

Assessment
gery (spine surgery with instrumentation, total hip replacement,
total knee replacement and shoulder operation)12) and having Positive events of nausea, vomiting or retching within 6
postoperative intravenous patient-controlled analgesia (IV hours after surgery were designated as early PONV, while
PCA).13) The number of patients underwent three types of positive events of nausea, vomiting or retching between 6 and
surgery were equally distributed by randomization table created 24 hours after surgery were designated as late PONV. Instead
by SAS 8.0 (SAS Institute Inc, 1999). Exclusion criteria were of original measurement interval (12 hours) of the RINVR, the
smokers, subjects who had an active infection or a history of time period within which patients recalled their events of
HIV or a positive HIV antibody test, or a history of hepatitis PONV was modified to contain the phrase “within 6 hours
B or a positive test for hepatitis B or C surface antigen, after surgery” for the assessment of early PONV, and
subjects on average drink more than 4 units of alcohol per “between 6 and 24 hours after surgery” for late PONV. In the
day (1 unit = 235 ml of beer, 1 glass of wine) or subjects original RINVR, nausea, vomiting and retching were stated as
with a history of clinically significant abuse of alcohol, defined “nauseated or sickness at stomach”, “threw up or vomiting”,
as 1) patterns of alcohol intake consistent with disruption of and “retching or dry heaves”, respectively. We simply replaced
normal function in society, 2) history of or current impairment these phrases with nausea, vomiting and retching translated
of organ function reasonably related to alcohol intake, subjects into Korean language according to the English-Korean medical
who were less than 18 and more than 65 years of age, dictionary, respectively. Nausea was defined as the desire to
pregnant woman, subjects who had medication histories of vomit without indulging in expulsive muscular movements.
anti-emetics, steroid, antihistamine, psychoactive drugs within Vomiting was defined as the oral expulsion of gastrointestinal
24 hours before surgery, and subjects who had nasogastric tube contents, while retching was the attempt to vomit without
after surgery or could take meal except clear fluid within 8 expelling any material.
hours after surgery. The patient characteristics were presented Patients recorded VAS for nausea and incidence of emetic
in Table 1. episodes in a sheet other than the questionnaire of the RINVR
and were instructed to count the frequency of, not only
Anesthesia, prophylactic anti-emetics and IV PCA
vomiting but also retching.
Anesthesia was standardized as follows. All patients who Each of the RINVR and patient self-assessment of VAS for
were premedicated with midazolam 7.5 mg orally before nausea and incidence of emetic episodes was administered in
surgery were anesthetized using sevoflurane. They had random order to patients approximately 30 minutes apart by
postoperative IV PCA, in which 1,500μg of fentanyl and 180 the same study nurse at 6 hours and 24 h after surgery. To
mg of ketorolac were mixed in normal saline with total determine the test-retest reliability of the RINVR, second
volume being 100 ml. administration of the RINVR was done 2 hours after the first.
In the assessment by the RINVR, the PONV events were
determined by total experience score ＞ 0. When we converted
Table 1. Patient Characteristics twelve scores of the subscales of the RINVR to 5-point
󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚
categorical scales, the interval of each category was (maximum
Patients (n = 150)
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 possible score/4－1) with the score being zero in “none”
Sex (M/F) 28/122 category. For example, if the maximum possible score was 32,
Age (yr) 44.6 ± 10.0 then, none: 0, mild: 1-8, moderate: 9-16, severe: 17-24,
Weight (kg) 61.5 ± 9.6
great: 24-32.
Height (cm) 158.9 ± 7.3
PONV history (%) 33.9 The validity was evaluated by Spearman's correlation and
Menstruation (%) 7.7 internal consistency of reliability was determined using Cron-
Type of surgery* (%) 34.2/32.9/32.9 bach's alpha. To determine the stability of the RINVR, test-
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
retest procedure was used. The test-retest reliability was
Data are stated as mean ± SD, count or percentage as appropriate.
*: listed in the order of gynecologic, breast and major orthopedic evaluated by Spearman's correlation and agreement. To
surgery. determine the construct validity between the RINVR and VAS

S 61
 Korean J Anesthesiol：Vol. 52. No. 6, 2007

for nausea and incidence of emetic episodes, we divided the
RINVR to two components, that is, nausea and emetic epi-
sodes. Nausea components of the RINVR were nausea
experience, occurrence and distress score. The emetic com-
ponents of the RINVR included three summed values of
correspondent scores (experience, occurrence and distress score,
respectively) of vomiting and retching.
Analysis of data
Following data entry, the data file was checked for accuracy.
The data were analyzed using SAS 8.0 (SAS Institute Inc,
1999). Cronbach's alpha and Spearman's correlation coefficient
were assessed to determine the reliability and validity. Wei-
ghted Kappa was performed to reveal stability of the RINVR.
P values ＜ 0.05 were considered significant.
ting and retching while there were no patients who reported
vomiting and retching without nausea. The remainders (57 pa-
tients, 60%) reported nausea and retching or nausea and vomiting.
Reliability
Cronbach's alphas of nausea, vomiting, retching and total
experience of the RINVR were very high for both early and
late PONV (Table 2). Test-retest scores of all eight items of
the RINVR were strongly correlated and highly agreed (Table
3). The eight items of the RINVR for early and late PONV
were also strongly correlated (range of Spearman's correlation
coefficients: 0.962-1.000, P ＜ 0.0001) and highly agreed
(range of weighted kappa coefficients: 0.873-1.000) in test-
retest procedure of the RINVR.
Validity

RESULTS Spearman's correlation coefficients for nausea experience,

occurrence and distress (vs VAS for nausea) and for summed
By analyzing nausea, vomiting and retching experience experience, occurrence and distress scores of vomiting and
scores of the RINVR of 150 patients, 67 (44.7%), 26 (17.3%) retching (vs incidence of emetic episodes) were high for early
and 41 (27.3%) patients reported nausea, vomiting and retching and late PONV (Table 4). Spearman's correlation coefficients
within 6 hours after surgery, respectively. 64 of 148 (43.2%),
27 (18.1%) and 46 (30.9%) of 149 patients reported nausea,
vomiting and retching between 6 and 24 hours after surgery, Table 3. Test-Retest Reliability of the RINVR
󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚
respectively. Thus, during the first 24 hours after surgery, the Spearman's Weighted kappa
most frequent event of PONV was nausea, while retching was coefficient (95% CI)
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏｝ ｝󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
the second and vomiting was the least frequent event of PONV.
Early Late Early Late
Of 95 patients who reported PONV events throughout 24 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
hours after surgery, 17 (17.9%) patients reported only nausea, Frequency 0.970 1.000 0.949 1.000
21 (22.1%) patients reported the coexistence of nausea, vomi- of vomiting (0.877-1.000)
Distress 0.979 0.978 0.956 0.975
from retching (0.912-1.000) (0.948-1.000)
Table 2. Cronbach's Alpha to Determine Internal Consistency of the Distress 0.971 1.000 0.939 1.000
RINVR from vomiting (0.873-1.000)
󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚 Duration 0.985 0.998 0.980 0.993
Early Late of nausea (0.958-1.000) (0.980-1.000)
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Distress 0.978 0.990 0.932 0.974
Nausea experience 0.954 0.968
from nausea (0.895-0.970) (0.949-0.999)
Vomiting experience 0.918 0.919
Amount 0.979 1.000 1.000
Retching experience 0.914 0.912 0.981
of vomiting
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 (0.944-1.000)
Total experience 0.934 0.932 each time
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Frequency 0.979 0.990 0.938 0.974
RINVR: Rhodes index of nausea, vomiting and retching. Early: within of nausea (0.902-0.973) (0.949-0.999)
6 hours after surgery, Late: between 6 and 24 hours after surgery. Frequency 0.962 0.974 0.934 0.960
Nausea experience: duration of nausea, distress from nausea, frequency of retching (0.878-0.989) (0.923-0.998)
of nausea, Vomiting experience: frequency of vomiting, distress from 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
vomiting, amount of vomiting each time, Retching experience: distress RINVR: Rhodes index of nausea, vomiting and retching, CI:
from retching, frequency of retching, Total experience: sum of nausea, confidence interval. Early: within 6 hours after surgery, Late: between
vomiting and retching experiences. 6 and 24 hours after surgery.

S 62
 Tae Hee Kim, et al：Reliabilty and Validity of the RINVR in PONV

for summed occurrence of vomiting and retching were slightly
higher than those of summed experience and distress scores.
Agreement between PONV incidences assessed by the
RINVR and by VAS for nausea and incidence of
emetic episodes
In all patients (n = 150), the incidences of early PONV
assessed by total experience score of the RINVR, and by VAS
for nausea and incidence of emetic episodes were 46.7% and
44.7%, respectively, while 46.7% and 45.3% for the incidences
of late PONV, respectively.
The incidences of early and late PONV assessed by the
RINVR were highly agreed with those assessed by VAS for
nausea and incidence of emetic episodes (weighted kappa:
0.936 for early PONV, 0.922 for late PONV). The overall
weighted kappa between the incidences of PONV assessed by
the RINVR and by VAS for nausea and incidence of emetic
episodes, was 0.945 for early PONV and 0.917 for late
PONV. Thus, there was no difference in the incidences of
early and late PONV assessed by these two methods.

Experience categories based on experience scores of the

RINVR and relation of nausea experience score to
Table 4. Construct Validity of the RINVR VAS for nausea
󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚
Incidence of Nausea, vomiting, retching and total experience categories in
VAS for nausea
Subscales emetic episodes
(early/late) all patients were shown in Table 5. The number of patients
(early/late)
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 belonging to “great” total experience category was so small
Nausea
(1.33% for early PONV and none for late PONV). There were
Experience 0.928/0.860
no patients in the vomiting experience category of “great” for
Occurrence 0.875/0.862
Distress 0.884/0.861 early and late PONV. VAS for nausea in accordance with
Vomiting or retching* nausea experience categories was shown in Table 6. There was
Experience 0.795/0.739 no significant difference of VAS for nausea, especially,
Occurrence 0.811/0.760 between “severe” and “great” nausea experience categories for
Distress 0.787/0.724
early & late PONV, between “moderate” and “great” for early,
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
Values are stated as Spearman's correlation coefficient (P ＜ 0.0001 “mild” and “moderate” for late, “moderate” and “great” for
for all data). Early: within 6 hours after surgery, Late: between 6 and late.
24 hours after surgery. RINVR: Rhodes index of nausea, vomiting and
retching, VAS: visual analog scale. *: subscores of “vomiting or
retching” are the sums of each correspondent pair of subscales DISCUSSION
(experience, occurrence, distress, respectively) of vomiting and retching
of the RINVR, indicating emetic episodes. The overall incidence of PONV was assessed by total

Table 5. Number of Patients in accordance with Experience Categories Based on Nausea, Vomiting, Retching and Total Experience Scores in
all Patients
󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚
Experience categories
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
None Mild Moderate Severe Great
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏｝ 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏｝ 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏｝ 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏｝ 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
Early Late Early Late Early Late Early Late Early Late
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
Nausea (n = 150/148)* 83 (55.3) 84 (56.8) 19 (12.7) 21 (14.2) 29 (19.3) 28 (18.9) 15 (10.0) 12 (8.1) 4 (2.6) 3 (2.0)
Vomiting (n = 150/149)* 124 (82.7) 122 (81.9) 4 (2.7) 5 (3.4) 18 (12.0) 20 (13.4) 4 (2.7) 2 (1.3) 0 (0.0) 0 (0.0)
Retching (n = 150/149)* 109 (72.7) 103 (69.1) 17 (11.3) 19 (12.8) 16 (10.7) 20 (13.4) 5 (3.3) 6 (4.0) 3 (2.0) 1 (0.7)
Total (n = 150/148)* 80 (53.3) 79 (53.4) 36 (24.0) 37 (25.0) 26 (17.3) 25 (16.9) 6 (4.0) 7 (4.7) 2 (1.3) 0 (0.0)
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏
Data are stated as number of patients (percentage). Nausea and vomiting: none (experience score = 0), mild (1-3), moderate (4-6), severe (7-9),
great (10-12). Retching: none (experience score=0), mild (1-2), moderate (3-4), severe (5-6), great (7-8). Early: within 6 hours after surgery,
Late: between 6 and 24 hours after surgery. *: early/late.

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 Korean J Anesthesiol：Vol. 52. No. 6, 2007

Table 6. The Mean VAS for Nausea in accordance with Nausea effect on outcome.18) But such a possibility seems insignificant
Experience Categories to our results. Because nausea, vomiting, and retching are
󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚󰠚
Nausea experience Nausea experience categories universal symptoms, the universal conceptual equivalence re-
categories (VAS for Nusea [cm]) garding the 3 symptoms lead to less confusion in the process
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 of translating.
None Early (n = 83) 0.07 ± 0.39
Late (n = 84) 0.27 ± 1.29 Even though the underlying mechanism of vomiting and
Mild Early (n = 19) 2.55 ± 1.87 retching may not be different, retching is distinguished from
Late (n = 21) 2.51 ± 1.68 vomiting by the fact that no materials are expelled. In our
Moderate Early (n = 29) 4.34 ± 1.35 study, retching occurred approximately 1.7-fold more frequently
Late (n = 28) 3.32 ± 1.36
than vomiting, indicating that the main component of emetic
Severe Early (n = 15) 6.11 ± 1.78
episodes in PONV was retching. Thus, we propose assessing
Late (n = 12) 5.72 ± 1.48
Great Early (n = 4) 5.95 ± 2.04 retching and vomiting separately for the accurate evaluation of
Late (n = 3) 5.17 ± 3.33 the anti-emetic efficacy other than anti-nausea efficacy, which
󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 was reflected in the summed experience score of vomiting and
Data are stated as mean ± SD. VAS: visual analog scale. Early:
within 6 hours after surgery, Late: between 6 and 24 hours after
retching. The complexities of nausea, vomiting and retching
surgery. require accurate assessment of the individual patients as an
ongoing process over time. It is required to assess them by an
instrument whose responsiveness (sensitivity to detect change
experience score of the RINVR, which was the sum of nausea, over time) was evaluated. Although various scores can be
vomiting and retching experience scores. Experience consisted resulted in with the RINVR, three-factor model consisted of
of occurrence and distress, which reflected the objective and nausea, vomiting and retching experience, was reported as the
subjective factors of PONV, respectively. This seemed to be best responsive instrument.19) Nausea experience score was
reasonable because the events of PONV were the sum of highly reliable and valid (vs VAS for nausea). Vomiting and
nausea, vomiting or retching assessed objectively and retching experience scores were highly reliable, too and the
subjectively. If individual incidence of nausea, vomiting and summed experience score of vomiting and retching was
retching should be known, nausea, vomiting and retching significantly valid (vs incidence of emetic episodes). Thus, we
experience scores could be used separately. propose using nausea, vomiting and retching experience scores
Previously, the severity of PONV was assessed by several for the assessment of the severity of PONV. If we need the
methods whose validity was in question; for example, the need definition of complete response to prophylactic anti-emetics, it
for rescue anti-emetics and its duration,14) numeric scoring can be defined as total experience score of the RINVR = 0
system in which nausea was assessed together with vomiting, and no need for rescue anti-emetics, instead of using the
and described as less severe symptom than vomiting,15) or a definition of “no nausea or emetic episodes and no need for
grading system in which nausea, vomiting and need for rescue rescue anti-emetics”.20)
anti-emetics was compressed into one code and the severity Patient self-assessment of VAS for nausea and incidence of
16)
was in the order of nausea, vomiting and requiring therapy. emetic episodes and the RINVR were administered appro-
The different outcome variables of nausea, emetic episodes and ximately 30 minutes apart. Test-retest procedures of the
17)
rescue anti-emetics should be assessed independently. And RINVR were administered 2 hours apart. These time lapses
the assessment tools should be reliable and valid. In our study, were reported to be sufficient to avert participants' recall of
the RINVR was proved to be reliable and valid. The incidence their previous response.7,21) The itemized lists of response to
of emetic episodes may not be sufficient to explain the questions of the RINVR were so complex that they were
severity of vomiting and retching. Frequency of vomiting and arranged from “no symptom” to “severe symptom” or vice
retching, distress from vomiting and retching, and amount of versa for each item.
vomiting each time could be analyzed comprehensively by The weighted kappa coefficients of item 1, 3 and 6 for late
vomiting and retching experience scores of the RINVR. PONV at Table 3 showed complete agreement in test-retest
There is a possibility that translation process may have an procedures of the RINVR. The reason was considered that

S 64
 Tae Hee Kim, et al：Reliabilty and Validity of the RINVR in PONV
81% or more of patients replied as “no symptom” to these
items for late PONV.
Twelve 5-point categorical scales were converted from
twelve scores of the RINVR because categorical scales could
make us more easily understand the severity of PONV than
unfamiliar numerical values. Nausea experience categories
showed stepwise increase of mean VAS for nausea from
“none” to “severe”. But by the fact that there were no patients
in “great” vomiting experience category and there was no
significant difference of VAS for nausea between “severe” and
“great” nausea experience categories, “severe” and “great”
categories of each item could be united to “severe” category
so that 4-point categorical scale based on scores of the
RINVR would be used in PONV setting.
In conclusion, the RINVR was a reliable and valid
instrument to assess subjective and objective factors of nausea,
vomiting and retching in surgical patient.
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