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Short Communication

A Prospective Survey of Postoperative Nausea and Vomiting:

Its Prevalence and Risk Factors
N. Ahmed Abired, M. Hosam Elmahmoudi1, A. Nafisa Bkhait2, E. Ahmed Atia1
Department of Basic Medical Science, Tripoli Higher Institute for Medical Professions, 1Department of Anesthesia and Intensive Care, Faculty of Medical Technology,
University of Tripoli, 2Department of Pharmacy, University of Tripoli Alahlia, Tripoli, Libya

Abstract
Background: To improve the efforts that try to detect the common risk factors of postoperative nausea and vomiting (PONV), this epidemiologic
survey was designed to evaluate the present incidence of PONV for different types of common surgical procedures among patients of Tripoli
Medical Center, Tripoli, Libya. Methods: Over a period of 6 months, the prospective interview‑based survey included more than 170 elective
surgical inpatients aged between 18 and >65 years and received general or regional anesthesia was done by the authors. Results: Among the
170 patients surveyed in this study, the incidence of PONV at the recovery room was 28.2% and 22.3%, respectively. Over the whole 24 h
period, the incidence of PONV was gradually increased to 32.3% and 25.8%, respectively. The highest prevalence of PONV was observed in
the gynecology patients. Female patients were suffered from both nausea and vomiting more than male patients. Besides, PONV in patients
who received general anesthesia was much more common than those who received regional anesthesia in both observation periods (the recovery
room and the ward). Conclusion: Our study shows various risk factors of PONV. These factors could help to increase the possibility of
recognizing patients at risk for PONV.

Keywords: Nausea, postoperative, surgical, vomiting

Introduction or opioids), patient‑related factors (history of motion sickness

Globally, anesthesia is given to more than 75 million
surgical patients each year. One‑third of them will suffer
from postoperative nausea, vomiting, or both if they were
untreated.[1‑3] Postoperative nausea and vomiting (PONV) and
postoperative pain are among one of the most common and
disturbing complications following anesthesia and surgery.
Adult patients often rate PONV as worse than postoperative
pain.[4,5] Many studies reported that the incidence of PONV
ranges from 20% to 30% of patients, whereby the highest
occurrence can be found in the first 6 h after operation.[6,7]
It has been suggested that PONV may increase the risk of
unwarranted side effects, such as pulmonary aspiration,
esophageal rupture, bilateral pneumothoraxes, and
subcutaneous emphysema.[8,9] Furthermore, PONV is a leading
cause of unexpected hospital admission and increased total
health‑care costs.[10,11] Equally important is the high levels of
patient discomfort and dissatisfaction associated with PONV.
It is assumed that PONV has multifactorial origin, for instance,
esthetic factors (such as volatile anesthetics, mask ventilation,
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or female gender), and surgical factors.[12,13]
Because of the reduced attention to nausea and vomiting
occurring after surgical anesthesia, this epidemiologic survey
was designed to evaluate the present incidence of PONV
for different types of common surgical procedures at Tripoli
Medical Center, Tripoli, Libya.
Methods
This study was designated as a prospective interview‑based
investigation of the occurrence of PONV. To attain an
illustrative sample of everyday surgery, we collected records
from 170 patients attending several types of surgical procedures
in different operating theaters: general surgery, gynecological,
Address for correspondence: Dr. E. Ahmed Atia,
Department of Anesthesia and Intensive Care, Faculty of Medical
Technology, University of Tripoli, Tripoli, Libya.
E‑mail: elbadri83@yahoo.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Abired NA, Elmahmoudi MH, Bkhait AN, Atia EA.
10.4103/LJMS.LJMS_26_18 A prospective survey of postoperative nausea and vomiting: Its prevalence
and risk factors. Libyan J Med Sci 2019;3:18-21.

18 © 2019 Libyan Journal of Medical Sciences | Published by Wolters Kluwer ‑ Medknow

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Abired, et al.: Incidence and risk factors of postoperative nausea and vomiting

orthopedics, and ophthalmological at Tripoli Medical Center,

Table 1: Number (%) of different types of procedures by
Tripoli, Libya. Enrollment and interviewing of patients were
gender
conducted from the beginning from November 2017 to April
2018. This study was approved by the Committee of Faculty Department Procedure Male, Female, Total,
of Medical technology, Tripoli University, Libya. n (%) n (%) n (%)
General surgery Hemorrhoid 4 (6.5) ‑ 4 (2.4)
Inpatients arranged to undergo elective surgery from one Laparoscopy 8 (12.9) 36 (33.4) 44 (25.9)
of the surgical procedures requiring anesthesia (general or Hernia surgery 20 (32.2) 12 (11.1) 32 (18.8)
regional) and follow‑up for the first 2 h in the recovery room Laparotomy 8 (12.9) 24 (22.2) 32 (18.8)
were enrolled in this study. Patients from both genders but Otolaryngology Tonsillectomy 4 (6.5) 8 (7.4) 12 (7)
pregnant patients and those requiring management in the Nose and sinus ‑ 4 (3.7) 4 (2.4)
intensive care unit were not included in the study. All patients surgery
during the study who met the inclusion criteria entered Orthopedic Upper limb 6 (9.6) ‑ 6 (3.5)
the study, and patient consent was obtained. Anesthesia surgery
Lower limb 12 (19.4) 8 (7.4) 20 (11.8)
staff instructed to use the usual anesthesia technique and
surgery
postanesthetic care. Gynecology Laparotomy ‑ 4 (3.7) 4 (2.4)
All relevant data recorded in the data collection were analyzed Vaginal ‑ 12 (11.1) 12 (7)
surgery
using Microsoft Excel 2013 and SPSS version 22. 0 (SPSS Inc.,
Total ‑ 62 (36.5) 108 (63.5) 170 (100)
Chicago, IL). Descriptive statistics (such as frequencies and
percentages) were used to analyze the data. Comparing the
incidences of PONV with different surgical procedures were Emetic outcomes related to surgery
analyzed using the ANOVA test. Data comparison between During the first 2  h after surgery, nausea was experienced
PONV prevalence and anesthesia techniques was done using by 28.2% of all patients and 22.3% vomited. Significantly,
Student’s t‑test. the highest incidence of nausea was reported in gynecology
patients, of whom 62.5% were treated with antiemetic
Results medication [Table 3] (P < 0.05).
Patient characteristics During the second observation period from 2 to 24  h
Questioners and interviews were completed for 170 patients, postoperatively, the proportions of patients with nausea and
of whom, 108 (63.5%) were female. The distribution of the vomiting in the whole population were 32.3% and 25.8%,
inpatient within the four surgical departments and different respectively. Again, the rates were significantly higher in the
procedures is shown in Table 1. gynecology patients (nausea – 68.7% and vomiting – 50%),
followed by orthopedic surgery patients [Table 3]. Vomiting
Table  2 presents demographic characteristics of the patients
was treated with antiemetics more often than nausea only.
for different types of surgery and anesthesia. The anesthetic
technique was general in 152 (89.4%) patients and 18 (10.6%) Emetic outcomes by anesthesia
was regional anesthesia  (RA). In RA groups, the proportion Nausea, in the recovery room, was more common after
of female was greater than general anesthesia  (GA) group GA compared with RA  (36.8% and 27.7%, respectively,
(134 vs. 94), in which the patients were generally younger. Other P < 0.05) [Table 3]. Similarly, in the ward, the incidence of
characteristics in both anesthesia groups were quite similar. nausea was higher in GA than regional technique  (40.7%
Male and female patients were equally similar with regard to and 22%, respectively). Female patients suffered more from
age and preoperative condition, apart from some difference nausea than male patients. The incidence of vomiting both, in
in the following assumed prognostic factors for PONV; the the recovery room and on the ward, was higher in GA than
proportions of female with PONV after the previous general regional one (24.3% and 26.3% in GA and 11% and 16.6% in
and RA were 47% and 12%, respectively, and those of male RA, respectively, P < 0.05) [Table 4]. Again, female patients
26% and 8%, respectively; 23% of males were regular were suffered from vomiting more than male patients.
smokers.
Each patient received intraoperative opioids  (fentanyl in Discussion
most cases). Enhancement boluses of fentanyl were given as This survey was conducted to examine the occurrence of PONV.
required. Postoperative pain was treated with intramuscular PONV remains one of the most frequent anesthesia‑related
or intravenous opioid (tramadol) in 60% of patients and with problems, touching about 30% of patients after surgery,
epidural opioids in 19% of patients. Opioids were used less and with an frequency reaching up to 80% in high‑risk
after otolaryngology operations than after other types of patients.[14,15] The main cause of PONV remains blurred but
surgery and less after regional than GA [Table 2]. Further, 31% includes anesthetic and surgical influences. In addition to
of all patients received only nonsteroidal anti‑inflammatory patient dissatisfaction, PONV may also lead to more serious
drugs for pain relief. complications, such as adverse surgical consequences.[14]

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Abired, et al.: Incidence and risk factors of postoperative nausea and vomiting

Table 2: Demographic data of the patients for the different types of surgery and anesthesia
Characteristics Type of surgery Type of anesthesia
GEN (n=112) OTO (n=16) ORTHO (n=26) GYN (n=16) GA (n=152) RA (n=18) Total (n=170)
Age
18-34 38 12 8 10 56 12 68
35-49 64 ‑ 12 6 76 6 82
50-64 8 4 6 ‑ 18 ‑ 18
≥65 2 ‑ ‑ ‑ 2 ‑ 2
Female (%) 65 43 59 100 47 67 64
Current daily smokers (%) 23 27 12 ‑ 22 20 23
Previous GA NV (%) 15 12 16 11 12 15 13
Previous RA NV (%) 11 13 9 13 14 11 12
Duration of operation/min 52 39 73 45 74 48 67
(median)
Use of postoperative opioids 67 65 76 71 72 68 70
(%)
GEN: General surgery, OTO: Otolaryngology, ORTHO: Orthopedic, GYN: Gynecology, GA: General anesthesia, RA: Regional anesthesia, NV: Nausea
and vomiting

Table 3: The percentage of patients with nausea and vomiting and administration of antiemetics in different type of
surgery
Outcomes Type of surgery Total (n=170),n (%) df P
GEN (n=112), OTO (n=16), ORTHO (n=26), GYN (n=16),
n (%) n (%) n (%) n (%)
0-2 h in recovery room
Nausea 30 (26.7) 4 (25) 6 (23) 8 (50) 48 (28.2) 3 <0.00001
Vomiting 26 (23.2) 2 (12.5) 6 (23) 4 (25) 38 (22.3)
Antiemetics 46 (41) 4 (25) 8 (30.7) 10 (62.5) 68 (40)
2-24 h in the ward
Nausea 34 (30.3) 2 (12.5) 8 (30.7) 11 (68.7) 55 (32.3) 3 0.0001
Vomiting 24 (21.4) 2 (12.5) 10 (38.4) 8 (50) 44 (25.8)
Antiemetics 36 (32.1) 3 (18.7) 14 (53.8) 12 (75) 65 (38.2)
GEN: General surgery, OTO: Otolaryngology, ORTHO: Orthopedic, GYN: Gynecology. Data were analyzed using one‑way ANOVA

might be induced by the involvement of high‑risk patients

Table 4: The percentage of patients with nausea and
(e.g., in gynecologic laparotomies, the patients are females
vomiting and administration of antiemetics in different
and are also probably receive postoperative opioids).[6,16] In
type of anesthesia
our survey, the highest incidence of nausea and vomiting
Outcomes Type of anesthesia P was in gynecology cases and the lowest incidence stated
GA (n=152), RA (n=18), in otolaryngology patients, which is consistent with other
n (%) n (%) previous studies.[5,7]
0-2 h in recovery room
Nausea 56 (36.8) 5 (27.7) 0.001
The importance of female gender is well established and
Vomiting 37 (24.3) 2 (11) appears as the most significant factor of PONV.[13,17,18] Our
Antiemetics 44 (28.9) 4 (22) results approved that, nausea and vomiting in female patients
2-24 h in the ward were higher than male patients, this is in occurrence with
Nausea 62 (40.7) 4 (22) 0.001 previous surveys.[5,18] Moreover, our findings showed that
Vomiting 40 (26.3) 3 (16.6) 152(89.4%) of patients were anesthetized by GA techniques,
Antiemetics 50 (32.8) 6 (33) which known to trigger more emetic reaction than RA does.
GA: General anesthesia, RA: Regional anesthesia. Data were analyzed This may have raised the overall prevalence of PONV even
using t‑test at a statistical significance of P<0.05
though the anesthetic technique used was illustrative of existing
practice elsewhere.[13,19]
Particular attention was given to the type of surgery. Certainly,
there is a connection between PONV and the operation type. In the present study, the occurrence of nausea and vomiting
However, its fundamental impact on PONV is still questionable after RA was similar to that reported by Carpenter et  al.[20]
because a high occurrence of PONV next certain procedures However, our sample size in this study was too small to dismiss

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Abired, et al.: Incidence and risk factors of postoperative nausea and vomiting
the chance difference. The practice of using opioids and other
sedatives in association with some regional blocks may also
have contributed to the high rate of nausea in these patients.
The incidence of PONV can be reduced by giving prophylaxis
medicines, less emetogenic anesthetic techniques, appropriate
pain control, good antiemetic drugs, and less invasive surgical
processes.[6,21]
Conclusion
Our survey is upgraded our awareness of postoperative
complication and increased the possibility of recognizing
patients at risk for PONV, using a small number of simple
individual characteristics. Furthermore, this survey is clinically
important for prophylaxis and treatment of the two symptoms
and possibly will influence how upcoming efforts in this area
are done.
Acknowledgment
We are grateful for all the anesthesiologist, anesthesia
technician, and students elaborated in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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