Post operative nausea and vomiting : The big little problem impact on recovery

<p dir="ltr">Postoperative nausea and vomiting (PONV) remain a common and distressing complication following anaesthesia, affecting approximately 30 % of unselected patients and up to 70 % of individuals at high risk within the first 24 hours postoperatively. Women, particularly young non-smokers, are consistently identified as a high-risk group. Multidimensional instruments, such as the Quality of Recovery 15 (QoR-15) scale, provide valuable insight into recovery and the impact of PONV and post-discharge nausea and vomiting (PDNV) on overall patient wellbeing.</p><p dir="ltr">This thesis aimed to enhance the prediction and management of PONV in female patients undergoing high-risk surgical procedures. Four interconnected studies explored incidence, risk stratification, non-pharmacological interventions, and patient-reported recovery outcomes.</p><p dir="ltr">In Study I, 275 women scheduled for breast cancer surgery were included; 33 % experienced PONV and 67% did not. Sixty-one of these patients later received adjuvant chemotherapy. In the non-PONV group, 95 % did not experience chemotherapy-induced nausea and vomiting (CINV), compared with only 38 % among those who had previously suffered from PONV. This suggests that certain individuals may possess an intrinsic resistance to nausea and vomiting.</p><p dir="ltr">Study II included 183 women from the same cohort. PONV occurred in 35 % and incidence increased in line with the Apfel risk score. Preoperative platelet parameters-including count, mean platelet volume and platelet mass-did not differ significantly between groups, indicating that static platelet measurements are insufficient to predict PONV risk.</p><p dir="ltr">In Study III, 73 ASA 1-2 women undergoing elective laparoscopic surgery were included. The intervention group received a 200 mL nutritional drink two hours pre-operatively and chewed gum post-operatively. Quality of recovery, measured by QoR-15, sum score was significantly higher in the intervention group at 24 hours (113 + 20 vs 101 + 25, p = 0.026) and 48 hours (123 + 13 vs 111 + 13, p = 0.006), demonstrating the potential of simple non-pharmacological measures to enhance early recovery.</p><p dir="ltr">In Study IV, 98 women undergoing day-case laparoscopic cholecystectomy were followed for one week. All patients were assessed preoperatively with a modified Apfel score and received prophylaxis according to their risk level.</p><p dir="ltr">Preoperative median QoR-15 score was 129 (95 % CI 128-132). It declined to 123 (95 % Cl 119-129) immediately post-operatively and to 109 (95 % CI 104-114) on day 1, with no significant differences between Apfel risk score groups. Scores increased on day 2 (median 123; 95 % CI 119-128). On day 2, Apfel risk 1 patients scored 131 (95 % CI 130-137) while risk 4 patients scored 118 (95 % CI 108-126; p= 0.019). QoR-15 continued to increase on day 3 and at one week reaching 129 (95 % CI 125-132) and 135 (95 % CI 132-138) respectively, with no significant risk-group differences. These findings confirm that risk-based prophylaxis combined with multimodal opioid-sparing analgesia supports comparable recovery trajectories across risk categories when applied in female day-case surgery.</p><p dir="ltr">In conclusion, this work provides insights into the multifactorial nature of PONV in women, emphasising the importance of validated risk assessment, tailored prophylaxis, and the value of simple supportive interventions such as nutritional drinks and chewing gum. It underscores the utility of multidimensional patient-reported outcome measures in assessing postoperative recovery, and highlights the potential influence of genetic and individual variability in susceptibility to nausea. The findings support a patient-centred, evidence-based strategy to reduce the incidence and impact of PONV, improve recovery and guide future research on predictive markers and optimised care pathways in female surgical populations.</p><h3>List of scientific papers</h3><p dir="ltr">I. Is there an association between PONV and chemotherapy- induced nausea and vomiting? Oddby-Muhrbeck E, <b>Öbrink E,</b> Eksborg S, Rotstein S, Lönnqvist PA. Acta Anaesthesiol Scand. 2013 Jul;57(6):749-53. Epub 2013 Jan 3. PMID: 23281590 <a href="https://doi.org/10.1111/aas.12053">https://doi.org/10.1111/aas.12053</a></p><p dir="ltr">II. Preoperative platelet count and volume could not help predict PONV in women undergoing breast cancer surgery: A prospective cohort study <b>Öbrink E,</b> Eksborg S, Lönnqvist PA, Oddby-Muhrbeck E, Jakobsson JG. Int J Surg. 2015 Jun;18:128-31. Epub 2015 Apr 16. PMID: 25889881 <a href="https://doi.org/10.1016/j.ijsu.2015.03.006">https://doi.org/10.1016/j.ijsu.2015.03.006</a></p><p dir="ltr">III. Can simple perioperative measures improve quality of recovery following ambulatory laparoscopic surgery in females? An open prospective randomised cohort study, comparing nutritional preoperative drink and chewing gum during recovery to standard care <b>Öbrink E,</b> Lerstrom J, Hillström C, Oddby E, Jakobsson JG Ann Med Surg (Lond). 2019 Jun 8;44:20-25. PMID: 31289670; PMCID: PMC6593201 <a href="https://doi.org/10.1016/j.amsu.2019.05.010" rel="noreferrer" target="_blank">https://doi.org/10.1016/j.amsu.2019.05.010</a></p><p dir="ltr">IV. Quality of Recovery 15 (QoR15) after cholecystectomy in females receiving Apfel risk score based PONV-prophylaxis is similar between high and low risk score. <b>Öbrink E,</b> Jakobsson JG [Manuscript]</p>