Acta Anaesthesiologica Taiwanica xxx (2016) 1e2 Contents lists available at ScienceDirect Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com Editorial view Postoperative nausea and vomiting free for all: A solution from propofol? Postoperative nausea and/or vomiting (PONV) is an annoyance, particular during anesthesia emergence1, and its influence on the cost of medical care is significant It is estimated that more than 230 million major surgeries are performed annually around the globe2, and about 30% of the patients, with an incidence of 80% in high-risk group, suffered from PONV3,4; it sums up to more than 69 million people in the world every year Furthermore, about 1% of ambulatory surgical patients are admitted overnight because of intractable PONV3 Treatment of PONV and associated complications, and time lost from related works are estimated about millions of US dollars annually5 Yet, since it is self limiting in nature, seldom chronic, and almost non-lethal, it rarely becomes a big issue for anesthesiologists; and its impact is usually underestimated, however, it matters to patients Sometimes, patients would rather suffer from pain than PONV, and are willing to pay substantial amounts of money for effective prevention and treatment1 No wonder Kapur described postoperative nausea and vomiting-the “big little problem”6 The prevalence of PONV has stayed unchanged over past decades, regardless of the introduction of new antiemetic drugs, short-acting anesthetics, and minimally invasive surgeries7 The “big little problem” PONV depicted by Kapur is still a truth nowadays despite the hard works of anesthesiologists and pharmaceutical companies As an editorial aiming at the prevention of PONV, when PONV and its annihilation are addressed, doctors have in mind the mental attitude: “we're tired of waiting”8 Although the persisted high incidence of PONV has been partly due to the remarkable increase in ambulatory surgery and the growing emphasis on earlier mobilization and discharge postoperatively9, a key barrier to the development of an effective treatment for PONV has been the lack of a suitable animal model Consequently, anesthesiologists have to count on the results of numberless clinical trials, most of which are small-sized and even some with suspicious power1 In this issue of Acta Anaesthesiologica Taiwanica (AAT), Bhakta and colleagues report the results of a randomized controlled trial determining the safety, efficacy and feasibility of propofol-basedanesthesia in gynecological laparoscopies in reducing incidences of PONV compared to a standard anesthesia using thiopentone/isoflurane10 Surprisingly, with a sample size of 30 patients in each groups, the authors demonstrated that propofol-based-anesthesia was associated with significantly less PONV, implying a strong preventive potential for this strategy Also in this issue of AAT, to overcome the aforementioned doubtful validity associated with small sample sizes, Matsuura and colleagues compared the incidence and duration of PONV between propofol anesthesia and sevoflurane anesthesia utilizing a retrospective analysis of an institutional registry11 Interestingly, with a large original sample size of 21,606 general anesthesia cases, a higher incidence of PONV received propofol anesthesia compared to sevoflurane anesthesia, however less PONV occurred after propofol anesthesia in propensity score matched 2,554 patient pairs This result supported the preventive potential of propofol-based anesthesia, and also demonstrated a good model for PONV research As patients are more satisfied with PONV prophylaxis than with the treatment of symptoms after their occurrences, prophylactic strategy has become the customary approach to curtail postoperative emetic symptoms7 However, the mechanisms underlying PONV are complex that a general cure-all is almost implausible, therefore a multimodal approach serves better prevention and treatment9 To accomplish this objective, there is more than one option to consider The first approach would be to wait and see, and to treat PONV once the symptoms arise However, this idea obviously requires a vigilant clinical setting, and quick and aggressive management Such approach is incompatible with busy environments, at least 24 h after anesthesia, when emetic symptoms, especially nausea, are frequently missed It makes this approach impossible12 The second major option would be the so called ‘stratified medicine’, i.e to tailor the remedial decisions based on the patients' risks estimated by validated prognostic models However, the results on whether use of PONV risk scores can significantly decrease the rate of PONV remains controversy13, and there has been a strong dispute and discussion whether this approach truly works in a busy clinical scenario14,15 A third approach would be that all patients are given one or more antiemetics during the course of surgery to reduce the incidence of PONV as possible Given the fact that the easy accesses are safe and low-priced, there is little indication to deny these strategies for fear of side effects16 We believe, with the new support from the articles in this issue of AAT, patients might be benefit from incorporation of propofol into regular anesthesia practice Conflicts of interest All contributing authors declare no conflicts of interest References r MR Treatment of postoperative nausea and vomiting BMJ 2003 Oct Trame 4;327(7418):762e3 http://dx.doi.org/10.1016/j.aat.2016.12.002 1875-4597/Copyright © 2017, Taiwan Society of Anesthesiologists Published by Elsevier Taiwan LLC This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article in press as: Chang C-C, Wong C-SPostoperative nausea and vomiting free for all: A solution from propofol?, Acta Anaesthesiologica Taiwanica (2016), http://dx.doi.org/10.1016/j.aat.2016.12.002 C.-C Chang, C.-S Wong Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA An estimation of the global volume of surgery: a modelling strategy based on available data Lancet 2008 Jul 12;372(9633):139e44 r MR A rational approach to the control of postoperative nausea and Trame vomiting: evidence from systematic reviews Part I Efficacy and harm of antiemetic interventions, and methodological issues Acta Anaesthesiol Scand 2001 Jan;45(1):4e13 Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, Watcha M, Chung F, Angus S, Apfel CC, Bergese SD, Candiotti KA, Chan MT, Davis PJ, r MR, Hooper VD, Lagoo-Deenadayalan S, Myles P, Nezat G, Philip BK, Trame Society for Ambulatory Anesthesia Consensus guidelines for the management of postoperative nausea and vomiting Anesth Analg 2014 Jan;118(1):85e113 Hooper VD PONV/PDNV: why is it still the “big little problem?” J Perianesth Nurs 2015 Oct;30(5):375e6 Kapur PA The big “little problem” Anesth Analg 1991 Sep;73(3):243e5 White PF Prevention of postoperative nausea and vomitingea multimodal solution to a persistent problem N Engl J Med 2004 Jun 10;350(24):2511e2 Lichtor JL, Glass PS We're tired of waiting Anesth Analg 2008 Aug;107(2): 353e5 Sweeney B Postoperative nausea and vomiting BMJ 2006 Aug 12;333(7563): 313e4 10 Bhakta P, Ghosh BR, Singh U, Preeti S, Govind PS, Gupta A, Kapoor KS, Jain RK, Nag T, Mitra D, Ray M, Singh V, Mukherjee G Incidence of postoperative nausea and vomiting following gynaecological laparoscopy: a compassion of standard anesthetic technique and propofol infusion 11 Matsuura H, Inoue S, Kawaguchi M The risk of postoperative nausea and vomiting between surgical patients received propofol and sevoflurane anesthesia: a matched study Acta Anaesthesiol Taiwan 2016 Nov http:// dx.doi.org/10.1016/j.aat.2016.09.002 pii: S1875e4597(16)30004-2 12 Franck M, Radtke FM, Apfel CC, Kuhly R, Baumeyer A, Brandt C, Wernecke KD, Spies CD Documentation of post-operative nausea and vomiting in routine clinical practice J Int Med Res 2010 May-Jun;38(3):1034e41 13 Kappen TH, Moons KG, van Wolfswinkel L, Kalkman CJ, Vergouwe Y, van Klei WA Impact of risk assessments on prophylactic antiemetic prescription and the incidence of postoperative nausea and vomiting: a clusterrandomized trial Anesthesiology 2014 Feb;120(2):343e54 14 Eberhart LH, Morin AM Risk scores for predicting postoperative nausea and vomiting are clinically useful tools and should be used in every patient: cone‘life is really simple, but we insist on making it complicated’ Eur J Anaesthesiol 2011 Mar;28(3):155e9 15 Kranke P Effective management of postoperative nausea and vomiting: let us practise what we preach! Eur J Anaesthesiol 2011 Mar;28(3):152e4 16 Scuderi PE PRO: anatomical classification of surgical procedures improves our understanding of the mechanisms of postoperative nausea and vomiting Anesth Analg 2010 Feb 1;110(2):410e1 Chuen-Chau Chang, Section Editor* Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 250 Wuxing St., Taipei, 11031, Taiwan Chih-Shung Wong Department of Anesthesiology, Cathay General Hospital, #280, Renai Road, Section 4, Taipei, 10630, Taiwan * Corresponding author E-mail address: nekota@tmu.edu.tw (C.-C Chang) Please cite this article in press as: Chang C-C, Wong C-SPostoperative nausea and vomiting free for all: A solution from propofol?, Acta Anaesthesiologica Taiwanica (2016), http://dx.doi.org/10.1016/j.aat.2016.12.002 ... 11 Matsuura H, Inoue S, Kawaguchi M The risk of postoperative nausea and vomiting between surgical patients received propofol and sevoflurane anesthesia: a matched study Acta Anaesthesiol Taiwan... Corresponding author E-mail address: nekota@tmu.edu.tw (C.-C Chang) Please cite this article in press as: Chang C-C, Wong C-SPostoperative nausea and vomiting free for all: A solution from propofol? , Acta... KS, Jain RK, Nag T, Mitra D, Ray M, Singh V, Mukherjee G Incidence of postoperative nausea and vomiting following gynaecological laparoscopy: a compassion of standard anesthetic technique and propofol