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Review Article Anaesthesia and emesis II: Prevention and Mark G.A. Palazzo MB CHB MRCP FFARCS, Leo Strunin MD trFAItCS ~RCV(C) management

Many of the factors which influence the incidence offset by their other useful properties. However, if of , retching and (emesis) were opiate premedication is desirable it should be discussed in part one of this review. ~ Some, such as combined with a long acting . duration of anaesthesia and operative site are Prevention of emesis is paramount in patients predetermined and thus may bias a patient towards a with a full presenting for emergency high incidence of emetic symptoms. However, surgery. The problem is one of possible vomiting other factors, such as postoperative movements, during induction of anaesthesia, or aspiration of opiate premedication and gastric inflation, are more regurgitated stomach contents following muscle easily controlled by the anaesthetist. relaxation and attenuation of the laryngeal and This article discusses methods available for pharyngeal reflexes. Furthermore, a full stomach prevention and management of postoperative eme- preoperatively is likely to remain a full stomach sis under three main sub-headings: prophylactic postoperatively and might influence the incidence measures to help prevent emetic symptoms, specific of emesis during this period. Active vomiting (antiemetir agents for prophylaxis and treatment, during induction of anaesthesia is uncommon, but and general management after emesis has begun. regurgitation of stomach contents is more frequent. In an effort to avoid these complications, methods Prophylactic measures have been devised either to empty the stomach, or Most of the general measures to help prevent prevent its contents from reaching the laryngeal part postoperative emesis can be taken before or im- of the pharynx, thus reducing the risk of aspiration. mediately after anaesthesia. Although opiates may Allowing the stomach to empty naturally is nor- be avoided at premedieation, it is difficult to suggcst mat anaesthetic practice before routine operations that opiates used for maintenance of anaesthesia and most anaesthetists request that patients be should be omitted on the strength of their emetic fasting for four to six hours. However, even among potential, for this in our view is overwhelmingly non-surgical subjects gastric emptying time is variable and is more likely to be between six to eight hours ;2 unfortunately, in emergency operations this time period is not reliable. Howard's observation, Key words that stomach emptying was delayed for 24 hours ANAESTHESIA: general, regional', COMPLICATIONS: after major trauma during the Korean war, 3 sug- emesis, vomiting, nausea; VOMITING; . gests that it is prudent to treat all trauma patients as though they have a full stomach, regardless of the From the Departmem of Anaesthesia, Foothills Hospital, period of fasting. Stomach emptying is additionally at the University of Calgary, Calgary, Alberta. impaired by pain, anxiety, fear, , anal- Address correspondence to: Dr. Mark Palazzo, gesics, , labour, hypotension, intra- Nuffield Dept of Anaesthesia, John Radcliffe Hospital, abdominal conditions that lead to ileus or obstruc- Headington, Oxford, England. tion, and by large meals. The stomach empties at an

CAN ANAESTH SOC J 1984 t 31:4 / pp407-15 408 CANADIAN AblAESTUET|STS" SOCIETY JOURNAL exponential rate in relation to the size of the the apnoeic phase before tracheal intubation are meal; thus, within the same time span, large meals satisfactory solutions to this problem. will leave a larger residue than smaller ones. Solids After certain operations, such as rhinoplasty, it is and fats similarly will remain in the stomach common for the patient to have post-nasal bleeding. longer. 4 Careful and effective oropharyngeal packing with Techniques to actively empty the stomach in- gauze can prevent blood reaching the stomach clude passage of stomach tubes or administration of during surgery. Any blood that does the to induce vomiting, hut these methods stomach might act as a potent emetic stimulant and are both unpleasant and inefficient. Recently, drugs vomiting resulting from this can promote further such as have been used to speed bleeding from the nasal area, which is particularly gastric emptying; radiologists have been using undesirable postoperatively. metoclopramide to accelerate meals for a On emergence from anaesthesia there are two number of years, 5'6 Howarth7 showed, using potent causes for gagging with possible vomiting, barium meals, that after intravenous metoclo- namely pharyngeal suction and the presence of an pramide 20 mg the mean gastric emptying time was airway. As patients awaken, the gag reflex returns 83 minutes, as compared with a group of control and pharyngeal stimulation during this period might patients where the mean gastric emptying time was result in vomiting. Fortunately this period is not 142 minutes; in a further group of patients given an often remembered by patients; however, while intravenous injection of 2 ml physiological saline, consciousness is still dulled, vomiting remains the mean gastric emptying time was 195 minutes, hazardous. Pharyngeal suction is best done before the increased duration was attributed to possible reversal of muscle relaxation; any further secretions inhibition of peristalsis following a vene puncture. that might accumulate after reversal are easily dealt On the strength of these findings, Davies and with by turning the patient onto one side to en- Howells gave 20mg of metoclopramide inzra- courage free drainage. Similarly, early removal of venously to patients who had sustained a recent the airway and positioning should reduce pharyn- injury, s These patients had received small barium geal. stimulation without jeopardising the patient's meals (15 ml) before the administration of meto- airway. Nasogastric tubes may help reduce post- elopmmide and then the barium studies were operative vomiting in those cases where an upper repeated; although only a small number of patients gastrointestinal operation is done; however, the were studied, the results were encouraging. How- continuing presence of a tube in the postoperative ever, one cannot always rely on metoclopramide to period might increase retching. 9 empty the stomach. During the postoperative period, excessive The most common method for avoiding vomiting movement of the patient, especially after the admin- or regurgitation during induction of anaesthesia is a isn'ation of opiates might provoke nausea. It is not rapid sequence technique following a period of uncommon to hear that a patient, who had been reoxygenation. This combination along with Sel- trouble-free in the recovery room, began to vomit lick's manoeuvre (cricoid pressure) has proved on return to the ward. One answer to this problem is popular and efficient. However, it should be holed the use of a 24-hour recovery area near the operating that, if increasing cricoid pressure is applied before rooms; not only does this reduce repeated post- the onset of sleep, a feeling of nausea and a desire to operative movement but might also improve gener- gag is easily elicited. Although we have not seen a al postoperative care. Attention to other factors, patient vomit from this manoeuvre, it would be such as adequate pain relief, hydration and main- more pleasant to apply the cricoid pressure as the tenance of blood pressure, contributes to the pre- patient loses consciousness. vention of postoperative emesis. In part I of this review it was suggested that gastric inflation, after induction of anaesthesia, by Specific methods vigorous manual ventilation with a face mask, in- creases the incidence of emesis in the immediate post- Prophylactic and therapeutic use of antiemetics operative period, l Preoxygenation before muscle In the early part of this century several agents were relaxation and avoidance of gastric inflation during used to prevent postoperative vomiting; they in- Palazzo and Strunia: ANAESTHESIA AND EMESIS I1 '*09

TABLE Activityof drugs at neurotransmitterreceptor sites DtuRg Oopamine4. t~illz (adapted from Peroutka and Snyder)"

Dopamine Muscarinic Histamine Drug (D2) cholinergic (l-tjJ A ntlcholinergtcs H;~tam;ne+ Choli~erBir(MI'§ Cho~11~ ~i.e rgi~+ Hyoscine negligible + + -- + + negligible + ~tl..llt,, negligible + + + + + negligible -- I..,b~t. GIT. Glyeopyrrolate negligible + + = + + negligible 9r tmJ o M.....l~l* t flit . ~ibhOl*[lllbl. I tl4r H t FIGURE Probable neurotransmittcr and receptor sites for Promcthazinc + + + - + + + + + + + + + + vomiting. negligible ++++ +++++ + + + + + + + + + eluded preoperative administration of chloretone, Phenothiazlne~' perfumed gauzes during the later stages of the +++++ ++++ +++++ ProeMo~erazine +++++ ++-- ++++ operation, or of potassium +++++ ++-+ +*+++ bromide, and glucose, lO However, the great impetus to the study of antiemetics came during the second World War. Sea sickness was a known Dmperido[ + + + - + t~egligible + handicap to military personnel, and both British and + + + + + t~egligible + American workers tested a number of agents in a Miscellaneous series of unpopular trials (for both the subjects and Metoclopramide + + + + negligible + investigators). Among the agents tested, hyoscine Dompendone + + + + negligible negligible proved to he the most effective against motion sickness. Since then several types of agents have been found to have antiemeticrproperties, including Some situations might merit prophylactic anti- , antihistamines, , emetics, for instance, oral surgery patients who sedatives, and the antidopaminergics have their jaws occluded by wires. Such patients are metoclopramide and domperidone. Many of these at high risk for aspiration due to an inability to rid antiemeties have more than one mechanism of the mouth rapidly of vomitus. Patients undergoing action. The Figure and Table show the probable ear, eye or plastic operations should also he neurotransmitters, their sites of action, and the considered for prophylaxis because of the possible activity of a number of antiemetic agents at the detrimental consequences to delicate surgical work. neuroreceptor sites. It is difficult to suggest that all patients with known Adriani et al. Considered prophylactic adminis- increased risk of vomiting should be given prophy- tration of antiemetics unjustified 12 and with some lactic antiemetics, as this would result in all women exceptions we agree with this view. In their series, being so treated. However, if the operating room is only 3.5 per cent of patients had severe persistent a twenty-minute, uneven ride from the ward, and vomiting that needed treatment. A large percentage the patient is female, had an opiate premedicant, of the postoperative vomiting occurred at emer- and is to undergo upper abdominal surgery, prophy- gence from anaesthesia and did not recur; the laxis would not be unreasonable. incident, they suggested, is not usually remembered There are now several antiemetie drugs avail- by the patient, and does not call for treatment by able, but the difficulty is to decide which one to use. antiemetics. If antiemetics were innocuous, wide- Drugs that might be effective prophylactic agents spread prophylaxis would be acceptable. However, may be ineffective or unsuitable for treatment of the high incidence of side effects from these drugs active vomiting. Furthermore, the causes of post- should caution anaesthetists against indiscriminate operative emesis are multifaetorial so that no one use, reserving antiemetics for specific prophylactic single agent is appropriate. Combination antiemetic use when indicted, or for therapy when patients are therapy has not been investigated in relation to experiencing persistent symptoms. anaesthesia. One can speculate that combining 410 CANADIAN ANAESTHETISTS' SOCIETY JOURNAL

agents active at different sites might have advan- their actions. These differences are predictable tages; synergism between drugs might allow smaller from their chemical structure. The phenothiazines individual doses, and might reduce the incidence of share a common tricyelic nucleus; on the ten side effects. position in the tricyclic nucleus, the attached radical A review of some of the data on the commonly may be either an aliphatic (dimethylamino) chain or used antiemetics might help guide our decisions. a heterocyclic ring ( and piperidine)) 7 The clinical importance of these groups is that the Anticholinergics dimethylamino phenothiazines ( and Atropine, hyoscine and glycopyrrolate are familiar chlorpromazine) are less potent and have signifi- drugs in this group; they antagonise the muscarinic cantly more sedative action than the effects of acetylcholine. Hyoscine and atropine are (prochloperazine and ); the latter have tertiary ammonium compounds and differ from correspondingly greater antiemetic properties. The glycopyrrolate, a quaternary compound, in their phenothiazines are predominantly antidopaminer- central effects, it is perhaps for this reason gic agents with moderate antihistaminic and anti- that glycopyrrolate appears to have no antiemetic cholinergic activity. Because of this widespread properties) 3 Hyoscine and atropine act on the activity these agents are found to be effective and vomiting centre; however, hyoscine has the greater therefore popular for prophylaxis and treatment of sedative properties. Hyoscine is a very effective emesis. prophylaxis against sea sickness and is also effec- Chlorpromazine possesses significant prophylac- tive once symptoms of motion sickness are present. tic antiemetic properties; however, in effective Sympathomimetics given concurrently with hyo- doses, undue sedation and hypotension are frequent scine improve its effectiveness; dexamphetamine 5 side effects, ta Promethazine has been very popular to 10mg has been suggested but attention was as a premedicant; other than its antiemetic action it drawn to the abuse potential of this drug. J* has the advantage of and potent In a study by Clarke et al., ~5 hyoscine proved to antihistaminic properties which make it a useful be an effective prophylactic agent for pre- and premedicant for asthmatic patients. Promethazine is pestoperative nausea and vomiting when these were an effective prophylactic anticmetic but tends to induced by 10mg of morphine premedication. cause greater delay in awakening from anaesthesia Unfortunately the antiemetic effect of hyoscine is than the piperazines. 19 When promethazine is outlasted by the emetic properties of morphine. administered for treatment of active vomiting, an Atropine was also an effective prophylactic agent, intravenous dose of 12.5 mg has been shown to be but only for the postoperative period. Clarke et al. effective with little change in blood pressure, concluded that hyoscine was the superior drug for although with varying levels of subsequent seda- premedication, not only for its antiemetic proper- tion. 12 Chlorpromazine has no effect against mo- ties but also for its sedative qualities. However, tion sickness, and promethazine is the most potent there are more specific agents than atropine or of the phenothiazines for this problem. When hyoscine. Furthermore, the side effects of dry motion sickness is an important etiological factor in mouth, and sedation and occasional disorientation postoperative emesis, this drug would be preferable in the elderly after hyoscine, have contributed to the to hyoscine because of its longer duration of action. restriction of these drugs as premedicants. Similarly, promethazine is the prophylactic anti- emetic of choice for ear sugery. However, ehlor- Phenothiazines and promethazine administered after Although the drug was synthesised in anaesthesia have the capacity to induce sleep in 1883, it was not until the 1940s that the group of patients who are still recovering from other anaes- phenothiazine drugs was developed in France. thetic agents. This can be potentially hazardous Researchers were seeking an antiparasitic agent; while vomiting is still not effectively controlled. however, the antihistaminic and sedative effects of and perphenazine have justifi- promethazine were discovered and it was used as an ably been the most popular of the phenothiazines for adjuvant to anaesthesia. 16 The drugs in this group both prophylaxis and treatment of vomiting as- are qualitatively similar but differ quantitatively in sociated with anaesthesia. They both have potent Palazzo and Strunin: ANAESTHESIa. AND EMESIS II 411

antidopaminergic activity and are therefore well tions, intramuscular doses of prophylactic haloperi- suited to combat opiate-induced vomiting. Further- dol from 0.5-4 mg were effective antiemetics with more, prochlorperazine, unlike promethazine, in- no significant effect on the speed of emergence from creases lower oesophageal sphincter tone despite its anaesthesia.25 Haloperidol for treatment of vomit- minimal anticholenergic activity. 2~ Prochlorpera- ing was effective in intramuscular doses of 2 rag. It zinc and perphenazine are equally effective against had a rapid onset (within 30 minutes), but its vomiting, but perphenazine in clinical situations duration appeared to be as short as three hoursT' appears to have more sedative properties. Loeser Haloperidol is rarely used for emetic control in demonstrated that prochlorperazine was effective anaesthesia today; this is difficult to understand for treatment for vomiting, but that onset time follow- it is very similar to the piperazine phenothiazines in ing an of 10mg was be- action but seems to have less severe side effects. 26 tween 0.5-1 hour and was only effective for four is similar to haloperidol and has hours, zl Perphenazine in a dose of 5mg intra- received much attention as an antiemetic. In the muscularly has been shown to be effective prophy- comparative study conducted by Loeser the thera- laxis when administered with either morphine peutic cft'eet of dropcridol 5 mg intramuscularly had 10 mg or meperidine 100 rag. 22 However, the emet- a slower onset (2 hours) than haloperidol; however, ic effect of morphine will outlast the action of its action persisted for 24 hours.2J This is difficult to perphenazine. In order to reduce the high incidence explain in view of the shorter half life of droperidol. of restlessness seen with perphenazine, smaller The prophylactic efficacy of intravenous droperidol doses of only 2.5 mg have been used; they were less in doses of 0.005-0.07mg.kg -t is well docu- effective against emesis but the incidence of rest- mented, and its action seems to be longer (up to 24 lessness was reduced. 2z Unfortunately, although hours) than any other agent in common use. 27-3~ perphenazine and prochlorperazine are effective This long duration of activity, combined with its antiemetic agents, they frequently cause extrapy- efficacy, are significant enough to make droperidol ramidal side effects. 23 This can be manifest as our prophylactic drug of choice. Droperidol in the simple restlessness, which might be attributed to larger doses might cause disturbing mental effects another cause or, more rarely, as a frank oculogyric which are not apparent to the observer and it is best crisis. These effects may be seen after a single dose avoided in the awake patient unless given with a sometimes up to 24 hours after administration. long-acting opiate. However, recent work suggests Paradoxically, the most appropriate treatment for that it may be given alone in small doses of 1.25 mg extrapyramidal problems is the intravenous admin- to awake patients with few side effects. 29 Both istration of another phenothiazine, promethazine droperidol and haloperidol, in repeated doses, 10-25 rag, repeated if necessary. Alternative man- might produce cxtrapyramidal side effects, hypo- agement with an anti-Parkinsonian drug, such as tension, and postoperative sedation but these are benzotropine is effective. However, this drug is not less severe than with the phenothiazines, Droperi- an antiemetie, which under these circumstances dol 5 mg intravenously, although possessing alpha- would he desirable. adrenergic antagonist properties, does not appear to decrease lower oesophageal sphincter tone.2~ How- Butyrophenones ever, in the same study there was a suggestion that Haloperidol and droperidol are powerful anti- gastro-oesophageal reflux was increased. 2~ agents with neuroleptic properties. In a study by Shields et at. among volunteer inmates of Antihistamines a state penitentiary, haloperidol was found to be These drugs were first introduced by Bovet in 1944, a potent prophylactic antiemetic against apomor- and comprise a heterogenous group of agents, phine induced vomiting. Its action lasted for 12 among which the most familiar to the anaesthetist hours after intramuscular injection; also, it caused are , promethazine, cyclizine and less restlessness or drowsiness than prochlorpera- diphenhydramine. 3~ These preparations are excel- zinc and was less painful on injection than per- lent for motion sickness, their main action being at phenazine, z4 In a later study by Tornetta among the vomiting centre and on vestibular pathways; women undergoing minor gynaecological opera- however, all these agents can cause sedation. Other 412 CANADIAN ANAESTHETISTS ~ SOCIETY JOURNAL

than promethazine, which has been discussed, they either prophylaxis or treatment of postoperative have little activity at the chemoreceptor trigger zone vomiting, w In view of the evidence available, (CRTZ). Cyclizine is a widely used in metoclopramide can only be recommended for anaesthesia. It has proven efficacy equal to per- emetic control if administered at the end of anaes- phenazine as a prophylactic antiemetic and is also thesia; furthermore, in the event of it being ineffec- effective for treatment of established vomiting. 22'32 tive after a single dose we recommend another agent Cyclizine also increases the lower oesophageal such as cyclizine. Domperidone was specifically sphincter pressure and reduces gastro-oesophageal designed as an antiemetic with few central side reflux, z~ Although cyclizine has a short duration of effects. Studies so far suggest that domperidone action (4 hours), it is our first drug of choice for the appears to be better for treating postoperative treatment of postoperative vomiting because of its vomiting than for prevention. 41-43 Cooke found low incidence of side effects compared to the that 4mg of intramuscular domperidone given at phenothiazines. It has not been reported to cause induction to women undergoing short gynaecologi- but repeated doses can lead to cal procedures was not statistically better than rest]essness and drowsiness. placebo. ~ Among a similar group of patients, Wilson and Dundee administered either 10 or 15 mg Antidopaminergics doses of intramuscular domperidone at the time of Metoclopramide and dompcridone are specific anti- meperidine or morphine premedication. Their only dopaminergic drugs which are not phenothiazines positive finding was a reduction of preoperative and do not possess antihistaminic properties. Meto- nausea and vomiting associated with meperidine; clopramide has been available for some time, domperidone had no apparent effect on postopera- whereas domperidone has been introduced re- tive emetic sequelae. 42 Thus it would seem that any cently. These specific antiemetics have the advan- prophylactic effect of domperidone is short lived. tage of causing very little sedation in normal doses. Domperidone has been more effective in the Additionally domperidone, unlike metoclopramide, treatment of postoperative vomiting. Fragen and has difficulty in passing the blood brain harrier, thus Caldwell reported a significant reduction in post- its antidopaminergic activity is at peripheral sites operative nausea and vomiting in the first two hours only. This allows domperidone to influence the following an intravenous injection of 10mg of CRTZ which is outside the blood brain barrier domperidone compared to placebo. 43 Other studies without affecting the basal ganglia. Furthermore, have also confirmed the superiority of intravenous both drugs have effects on the gastro-intestinal domperidone over placebo for the treatment of tract which include increased lower oesophageal nausea and vomiting.44'45 In the two studies where sphincter pressure and faster gastric emptying. The domperidone 10 mg was given intramuscularly for extract mechanism for these gastro-intestinal ef- the treatment of vomiting it has been ineffective; fects is not clear. 33'34 Unlike the groups of drugs this might be dose related, z9'46 All studies report a that have been discussed so far, metoclopramide low incidence of side effects with both domperi- and domperidone have not proven to be effective in done and metoclopramide. Overall it appears that either prophylaxis or treatment of postoperative domperidone is more suited for treatment than for vomiting. Prophylaxis with metoclopramide ap- prophylaxis of emesis, whereas metoclopramide pears to have only been effective when the drug was should only be considered for immediate pro- administered at the end of the operation; it has phylaxis. shown poor antiemetic activity when administered with the premedication. 3~-4~ Miscellaneous The value of metoclopramide for the treatment Two other groups of agents, benzodiazepines and of vomiting after anaesthesia has not been exten- cannabinoids, are being investigated for their anti- sively studied. In the best controlled of the studies, emetic effect against cytotoxic agents. The former Korttila etal. compared the prophylactic and thera- have been successfully used as an adjunct to peutic efficacies of droperidol, metoclopramide and conventional antiemetic therapy. Benzodiazepines domperidone. They observed that metoclopramide appear to remove the anxiety associated with the and domperidone were no better than placebo for "threat of vomiting," that often leads patients to Palazzo and Strunin: ANAES'IHESIA AND EMESIS II 413 refuse chemotherapy. Furthermore, they help re- the recovery room have vomited a number of times, duce the frequency of vomiting. 47'48 Patients who it would be unkind to send them back to the ward on might be anxious about postoperative sickness can the strength of their being alert. These patients are benefit from these preparations, but it would be best held back, perhaps for a further hour or more. difficult to prove their antiemetic effectiveness This does not guarantee reduced vomiting, but it under these circumstances. does allow the attendants to observe the patients' In 1975, young cancer patients at the Sidney progress and then perhaps administer a second Farber Institute reported that they experienced antiemetic if the first one was ineffective. Finally, less emetic side effects from their therapy while we would recommend that patients about to enter smoking marijuana. 49 Much interest was aroused in the postoperative recovery room not be placed close this substance and its derivatives. The active com- to a vomiting patient. Any patienl, put beside ponent delta-9-tetrahydrocannahinol and a syn- another actively vomiting one, might be sufficiently thetic , , have been shown to stimulated by psychic, visual, olfactory and audi- have antiemetic properties, so,s' The mechanism of tory inputs to feel nauseated themselves. action of these agents is uncertain, although mari- juana is known to possess adrenergic activity, s2 Conclusion However, it is unlikely that cannabinoids wi]l find a The causes of emesis associated with anaesthesia place in routine anaesthetic antiemetic practice, are varied and in any one patient are likely to be since there is a high incidence of side effects multifactorial. Our approach has been to emphasise including sedation, hypotension, dysphoria, un- those areas which can be controlled. However, steadiness, dry mouth and feelings of intense panic general prophylactic measures, such as reduced or fear. gastric inflation, avoidance of opiate premedication and pharyngeal stimulation, might not be sufficient General therapeutic measures to prevent emesis. Although we do not recommend Once a patient has started vomiting, there is a routine preoperative use of antiemetics because of tendency among anaesthetists to rely heavily on the their relatively high incidence of side effects, we do efficacy of antiemetic drugs. However, there are feel there is a place for prophylaxis under certain some simple measures which help reduce the circumstances. Our drug of choice for prophylaxis patient's discomfort. The vomiting patient will would be droperidol 0.175 mg-kg -* intravenously, need increased intravenous fluids. These should be given peroperatively, although a smaller dose can sufficient to offset hypotension caused by both fluid be effective. For operations involving the ear we loss and antiemetic drugs; hypotension is thought to would prefer promethazine given with the premedi- make vomiting more likely. If patients have pain, it cation or peroperatively. Once nausea and vomiting is better to treat this with opiates than to withhold have begun, cyclizine 25-50 mg intramuscularly, treatment for fear of further opiate induced vomit- or one of the pipcrazine phenothiazines (prochlor- ing, although local and regional analgesic tech- perazinc or perphenazine), would be appropriate. In niques should not be forgotten. In addition, pain the event of the first choice drug being ineffective, itself can be one of the causes of vomiting, and any we would encourage the use of a second agent, patient who is retching can only be expected to preferably one with a different site of action. We suffer more pain from the further stress on incision feel that familiarity with a few drugs and more sites. attention to the controllable factors mentioned Insisting that patients keep their oxygen masks in should help reduce postoperative emesis. place while nauseated may only increase the un- pleasant feeling of stuffiness that some patients Acknowledgments experience. It is common to hear the nursing staff The authors wish to thank Dr. Jan Davies for her encourage patients to take deep breaths while the help with preparation of the manuscript and Mrs. latter are feeling nauseated. Although poorly ex- Janet Beyer for secretarial assistance. plained, this is a well-reeognised and effective way of decreasing nausea, thus "buying" time while antiemetie drugs are being prepared. If patients in 414 CANADIAN ANAESTHETISTS ~ fiOCIEI'Y JOURNAL

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