Prevention of nausea,vomiting and reflux aspiration in two cases of painless hysteroscopy

Wan-Jun Zhou,Cheng-Yun Hu,Fei-Biao Dai,Zhe-Tao Zhang,Yan Yin,Chao-Liang Tang

1Department of Anesthesiology,The First Affiliated Hospital of USTC,Division of Life Sciences and Medicine,University of Science and Technology of China,Hefei 230001,China.2Department of Pharmacy,The First Affiliated Hospital of USTC,Division of Life Sciences and Medicine,University of Science and Technology of China,Hefei 230036,China.3Department of Operating room,The First Affiliated Hospital of USTC,Division of Life Sciences and Medicine,University of Science and Technology of China,Hefei 230001,China.

Abstract Objective: To investigate the prevention and management of perioperative nausea and vomiting and reflux aspiration in painless hysteroscopy patients.Methods: The clinical datum of one patient with reflux and postoperative vomiting and another one with a history of multiple postoperative nausea and vomiting during painless hysteroscopy were retrospectively analyzed.Results: In case 1,despite the occurrence of reflux,no significant aspiration or other serious consequences occurred through positive attraction,ondansetron,dexamethasone,droperidol and other drugs and candy treatment,then nausea and vomiting gradually eased.In case 2,due to the reduction of preoperative dosage of sufentanil,prophylactic application of ondansetron,psychological intervention and postoperative candy,no nausea and vomiting occurred during the painless hysteroscopy.The patient recovered quickly with high satisfaction.Conclusion: Patients with a high risk of nausea and vomiting may be ameliorated by positive psychological and drug intervention.Even if patients have intraoperative reflux and postoperative nausea and vomiting,it can be relieved by psychological and drug treatment,and the occurrence of serious complications such as aspiration can be prevented.

Keywords: nausea and vomiting;reflux aspiration;psychological and drug intervention;case report

Background

During the perioperative period of painless hysteroscopy,respiratory depression,falling tongue,decreased blood pressure,abortion syndrome,water poisoning,nausea and vomiting,reflux aspiration and other complications may occur to varying degrees.Appropriate airway management,gentle intrauterine operation,effective low-pressure irrigation,close monitoring of vital signs and prophylactic application of antiemetic drugs can reduce the occurrence of related complications significantly.However,severe postoperative nausea and vomiting (PONV) is not easy to predict,and the effect of routine prophylactic antiemetic drugs is not good.

Severe nausea and vomiting after anesthesia may also lead to reflux aspiration and serious complications such as aspiration pneumonia.Regurgitation refers to the phenomenon of reflux of gastric contents into the throat cavity due to relaxation of the cardia or excessive pressure in the stomach.Aspiration refers to the entry of gastric contents into the airway on account of losing of laryngeal reflex,which may cause airway obstruction and even aspiration pneumonia(Mendelson syndrome).Regurgitation is more common than vomiting under anesthesia.Female is currently considered to be the strongest independent predictor of PONV.History of PONV motion sickness,non-smoking,volatile anesthetics and the use of opioids are potentially susceptible to PONV [1].There are two cases of perioperative anesthesia management related to PONV and regurgitation in the outpatient department.

Patient data and perioperative anesthesia management

Case one:The patient was a 32-year-old female,1.62 m in height and 63 kg in weight.The patient had no previous history of chronic diseases,gastrointestinal diseases,smoking,or motion sickness,who was ASA I,cardiac function grade II,and the general examination was not special.Due to infertility,the patient is expected to undergo painless hysteroscopy,and routine fasting for 8 h and water restriction for 6 h before surgery.

The patient was placed in a lithotomy position,and a venous access was established.The standard monitoring consisted of five-lead electrocardiography and measurement of oxygen saturation and noninvasive blood pressure.The basic blood oxygen was about 97%,heart rate was 70 beats/min,and blood pressure was 122/77 mmHg.After nasal catheter oxygen inhalation to 98% blood oxygen,she was received intravenous sufentanil 5 µg,flurbiprofen 50 mg,and ondansetron 4 mg.Meanwhile,the surgeon prepared for surgery,and about 3 minutes later,95 mg of propofol was given.Soon afterwards,the patient fell asleep,eyelash reflection disappeared,and the operation began.About 1 minute after the operation,when the doctor pulled the cervix to dilate,the patient choked once and vomited the yellow-white stomach contents.At this time,the blood oxygen decreased to 95%.The anesthesiologist tilted the patient’s head to one side quickly,inhaled about 5-10 mL of oral reflux with an aspirator,and given 5 mg of dexamethasone.The patient was changed to lower head,raised the mandibular Angle,and blood oxygen was restored to 100%.When the operation continued for about 7 minutes,the patient choked again and vomited pale yellow stomach contents.The anesthesiologist repeated the same steps and sucked up about 5-10 mL of reflux in the oral cavity.However,at the moment,intraoperative B ultrasound showed no obvious residual fluid in the stomach.At this point,blood oxygen remained at 98% and surgery continued.Then,the patient vomited about 5 mL gastric contents for the third time.The anesthesiologist repeated the same steps.At this time,the blood oxygen was still maintained at 98%.Near the end of the operation,the patient woke up.

When the patient was conscious fully,his medical history was asked.The patient complained about sleep disturbance,vague discomfort in the gastrointestinal tract,and occasional acid reflux in the days before surgery.After surgery,the patient still felt nausea and vomiting,which was mainly saliva and a little yellowish-green fluid.One mg of haloperidol was given,and the patient was ordered to lateral decubitus with head high and a candy was given.Then the patient's symptoms gradually disappeared.The patient was observed in PACU for 1 hour without other complaints.Blood oxygen remained at 97%,blood pressure 118/72 mmHg,heart rate 75 beats/min,meanwhile,the patient was escorted from the hospital by family members.During the telephone follow-up on the second day after the operation,the patient complained of nausea on the first day after the operation,but did not vomit anymore.After taking a small amount of semi-liquid diet at dinner,the patient gradually alleviated and slept well that night.

Summary:In case one,the patient did not a have history of nausea and vomiting.And the doctor was not fully aware of the stomach discomfort caused by anxiety and sleep disorder before surgery,so the drug was given in accordance with the conventional dose.When cough and regurgitation occurred during the operation,intervention psychological and drug treatment was given immediately.Thus aspiration and other more serious complications were prevented.Case two:The patient was a 41-year-old female,1.58 m in height and 58 kg in weight.The patient had no previous history of chronic diseases,gastrointestinal diseases,smoking,or motion sickness,who was ASA I,cardiac function grade II,and the general examination was not special.The patient self-reported that he had undergone general anesthesia for many times in the past (including laparotomy,laparoscopy and painless abortion,etc.),and severe vomiting lasted for 20 hours after surgery,which could not be relieved after antiemetics (specific medication unknown).The patient was scheduled to undergo painless hysteroscopy due to irregular menstruation,and routine fasting for 8 h and water restriction for 6 h before surgery.

The patient was placed in a lithotomy position,and a venous access was established.The standard monitoring consisted of five-lead electrocardiography and measurement of oxygen saturation and noninvasive blood pressure.The basic blood oxygen was about 96%,heart rate was 77 beats/min,and blood pressure was 118/76 mmHg.The patient was reassured preoperatively that the anesthesiologist would try to take measures to reduce PONV.After nasal catheter oxygen inhalation to 98% blood oxygen,she received intravenous sufentanil 2 µg,flurbiprofen 50 mg,and ondansetron 4 mg.About 3 minutes later,90 mg of propofol was given.Soon afterward,the patient fell asleep,eyelash reflection disappeared,and the operation began.Propofol was injected intermittently,the operation went smoothly,and the patient was diagnosed with diverticular incision after a cesarean section.After the operation,the patient woke up without complaining of obvious discomfort.After the patient was fully awake,a candy was given to the patient.After 20 min observation in PACU,the patient complained of no discomfort and left the hospital accompanied by his family members.During the telephone follow-up on the second day after surgery,the patient showed no nausea,vomiting,dizziness and other symptoms,and slept well that night.

Summary:In case one,the patient had a history of severe vomiting after surgery,and the anesthesia plan,which include reducing the use of opioids,increasing the need for antiemetic drugs,and giving positive psychological suggestions,was adjusted before surgery.And patients were given candy early after surgery to restore gastrointestinal function.Therefore,severe vomiting did not occur during this case.

Discussion

Under normal circumstances,the cardiac sphincter has a certain ability to increase gastric pressure.If the gastric pressure is too high(more than 80-100 mmHg) or the sphincter tension is too low (less than 100 mmHg),vomiting and regurgitation may occur.Risk factors predicting the incidence of PONV include sex,history of PONV,gynecologic (GYN) procedure,nonsmoker,and age younger than 40 years Nonsmoking female patients undergoing GYN procedures have up to 75% risk of experiencing PONV [2].During hysteroscopy,patients may have bradycardia,decreased blood pressure,sweating,nausea and vomiting,because intraoperative stimulation such as uterine traction,cervical dilation,suction and curettage,postoperative balloon placement and strong uterine contraction can cause vagus nerve excitation.In addition,preoperative fasting and water restriction resulted in low perfusion of the intestinal mucosa,which may also be related to the occurrence of PONV.At present,the relationship between PONV and gene polymorphism has gradually become the focus of public attention.Previous studies have proved that polymorphisms ofOprm15-HT3A/3B receptorChrm3(cholinergic receptor muscarinic 3),Kcnb2and other genes are correlated with the incidence of PONV and can be used as independent predictors of PONV [3,4].

For patients with PONV,the first thing to do is to comfort the patients and inform them that nausea and vomiting are common postoperative reactions.Then relieve the patient’s fear and impatience,clean up vomit in time to keep the environment comfortable.At present,the following drugs are commonly used to prevent PONV in the clinic.(1) Serotonin receptor antagonists,ondansetron,granisetron.(2) Cortisol,dexamethasone.(3) Butane Dione,droperidol.(4) Neurokinin receptor antagonist.(5)Anticholinergic,hyoscine.(6) dopamine receptor antagonists,metoclopramide.In addition,dexmedetomidine can also be used as a treatment for PONV [5].The most recent clinical guidelines indicate that combination prophylaxis with PONV is superior to monotherapy prophylaxis [6].Among them,ondansetron combined with dexamethasone or droperidol was effective.

However,pharmacologic PONV treatment comes with financial costs and side effects.The effect of non-drug treatment is better for mild patients.Darvall,et al.showed that gum chewing was not inferior to ondansetron in the preliminary trial of 94 female patients who underwent laparoscopic or breast surgery after general anesthesia[7].One mechanism may be that chewing activity may stimulate the vagus nerve in the head,leading to increased gastrointestinal activity.On the other hand,gastrointestinal motility may be affected by the mint smell of the gum.Similarly,studies have found that aromatherapy is effective in the treatment of PONV.For example,ginger has a clear antiemetic effect without any adverse reactions,and its mechanism may be related to the adjustment of gastrointestinal function [8].Similarly,Oral D glucose has been used through the ages for the symptomatic relief of nausea and vomiting.One possible explanation has been thought to be due to a direct local action on the wall of the gastrointestinal tract that reduces muscle contraction because of the high osmotic pressure exerted by the simple sugar [9].Appropriate fluid therapy is also effective in preventing and relieving PONV.Chappell,et al.concluded that IV fluid therapy in liberal doses might reduce PONV in outpatients undergoing minor surgery [10].Susan,et al.concluded that perioperative administration of dextrose-containing IV fluids reduced the number of antiemetics required and shortened the Length of Stay in the PACU in healthy female patients undergoing gynecologic hysteroscopic and laparoscopic procedures [11].

In addition,non-drug therapy,such as stimulating neiguan point can promote the release of cerebrospinal fluid β-endorphin,and increase the activity of endogenous mu-opioid receptors against vomiting,which can also play a role in preventing PONV.Gan TJ,et al.found that acupoint stimulation had a similar effect on prevention of PONV as ondansetron,a commonly used 5-HT3antagonist [12].

In case one,the patient was a young female,who was scheduled to undergo hysteroscopy,with no smoking history and a low dose of opioids induced by anesthesia.She had high-risk factors for nausea and vomiting.Although the patient had not been diagnosed with gastrointestinal diseases,the patient had symptoms of acid reflux and stomach discomfort,and may have the risk of gastroesophageal reflux.Even if water is strictly forbidden before surgery,the cardiac sphincter is relaxed after anesthesia induction,it is necessary to prevent reflux and aspiration.In case two,the patient was a female,who was scheduled to undergo hysteroscopy,and had no smoking history.She used a small dose of opioids induced by anesthesia.She had a history of severe PONV and was a high-risk patient with PONV.

For these two patients,detailed medical history and fasting time should be paid attention to during preoperative screening.If necessary,B-ultrasound should be used to evaluate gastric volume before surgery.For high-risk patients with more than two risk factors,aromatherapy such as ginger,gums,candies and proper liquid management can be used preventively.If necessary,single or combined antiemetic drugs can also be used preventively [13].Try to reduce the amount of opioid drugs,which can be supplemented by non-steroidal analgesics.During and after anesthesia,it is necessary to guard against the occurrence of reflux aspiration and prepare suction device in advance.When reflux occurs,immediately adjust the patient’s head low side position,keeping the respiratory tract smooth,inhaling pure oxygen,and attracting the patient’s oral secretions timely.The cricoid is pressurized when necessary and prevents laryngeal spasm and bronchospasm.If aspiration is possible or hypoxemia persists,intubate the endotracheal tube for bronchial aspiration or flushing if necessary.

In conclusion,for patients with PONV and high-risk factors for reflux,it is necessary to carefully understand the medical history before surgery and take intervention measures to prevent PONV.Comprehensive measures should be taken when PONV occurs,and the occurrence of reflux aspiration should be actively prevented.