Editor, Patients undergoing laparoscopic cholecystectomy have a 63 to 72% incidence of postoperative nausea and vomiting (PONV),1 requiring multi-modal antiemetic therapy. The use of adjunct non-pharmacological therapies minimises the cost and the potential side effects of the antiemetic drugs. Previous studies assessing the effects of perioperative carbohydrates on PONV have shown variable results.2,3 We hypothesised that the administration of dextrose in the immediate postoperative period might decrease the incidence of PONV by reducing postoperative catabolism and insulin resistance. Approval from the institutional ethics committee (9196-PG/2-Trg/12/19529-30, chairman Prof R. Singh), and written informed consents from 120 American Society of Anaesthesiologists (ASA) physical status I or II patients aged between 19 and 60 years undergoing laparoscopic cholecystectomy were obtained. Patients were excluded if they had diabetes mellitus; significant cardiac, hepatic or renal disease; gastrointestinal diseases; history of PONV or motion sickness; BMI more than 30; menstruating women; abnormal blood sugar on the morning of surgery; the surgical procedure was converted to laparotomy. The baseline risk for PONV was assessed using a simplified risk score.4 Patients were randomly allocated to receive either 5% dextrose (Group D) or Lactated Ringer solution (Group R) in the postanaesthesia care unit (PACU). General anaesthesia was induced with propofol 2 mg kg−1 and fentanyl 2 μg kg−1. Vecuronium 0.1 mg kg−1 intravenous (IV) was used to facilitate tracheal intubation, and anaesthesia was maintained with isoflurane 2 to 2.5% (minimum alveolar concentration 1.2) in 40% oxygen. Intra-operatively, lactated Ringer's solution (10 ml kg−1 h−1) was given as maintenance fluid to patients in both groups. Diclofenac 75 mg IV and surgical port site infiltration with 0.5% bupivacaine was given for postoperative pain relief. Ondansetron 4 mg IV was administered 30 min before emergence from anaesthesia. In the PACU, patients received either 1000 ml of 5% dextrose or 1000 ml of Lactated Ringer's solution of within 30 to 40 min, according to the group allocation. Blood glucose was measured using a portable glucometer (Free Style Optium; Abbott Diabetic Care Ltd, Whitney, UK) before induction of anaesthesia, and before and after completion of the study fluid infusion in the PACU. Metoclopramide 10 mg IV was given as rescue antiemetic for severe nausea, vomiting or retching. Paracetamol 1 gm IV was given for pain when the VAS score was more than 3. Post-operatively, all patients received 4 mg of ondansetron orally, and paracetamol (650 mg up to 6 hourly) and diclofenac (75 mg up to 8 hourly) were given if requested by the patient. The primary outcome was to measure the incidence of PONV (nausea, vomiting or retching) between 0 and 6 h. PONV between 6 to 24 and 0 to 24 h after surgery were also recorded. Complete response (defined as no PONV or no requirement for administration of rescue antiemetic), nausea, vomiting, requirement of rescue antiemetic, postoperative pain, hunger, thirst and fatigue in the first 24 h were evaluated as secondary outcomes. Nausea was assessed using the VAS scale. A score of more than 5 was considered severe, 5 = moderate, and less than 5 minimal. During the period of monitoring more than two vomiting episodes was considered severe, two as moderate and less than two as mild. The sample size was calculated on the basis of a previous study, reporting a 50% incidence of PONV with single-dose antiemetic in patients undergoing laparoscopic cholecystectomy.5 Assuming a 25% relative risk reduction in incidence of PONV after dextrose in the first 6 h, 58 patients per group were required with α = 0.05 and β = 0.80. To compensate for dropouts, we recruited 60 patients in each group. Normally distributed data were compared using t test, and the Mann–Whitney test was used for skewed data. Repeated measures ANOVA was used to investigate the difference between time-related variables. Proportions were compared using Fisher's exact test/Yate's corrected chi-square test, whichever was applicable. All statistical tests were two-sided, with a significance level set at α = 0.05. Three patients in Group D and one patient in Group R were excluded because of conversion to laparotomy, and one patient in Group D was excluded because of being given postoperative opioids. The data for the remaining 115 patients were analysed. Groups D and R did not differ in age [mean (SD), 44 (11) vs. 43 (13) years], BMI [mean (SD), 25 (2.8) vs. 24 (2.9), men/women (11/45 vs. 10/49)] or ASA classification (I/II) (47/9 vs. 51/8). Duration of surgery [mean (SD), 74 (9.3) vs. 71 (9.9) min], CO2 insufflation [mean (SD), 63 (9) vs. 60 (9.8) min] and the volume of fluids given [mean (SD), 1350 (200) vs. 1215 (176) ml, respectively] were also similar in both groups. Between 0 and 6 h, 17 (30%) patients in Group D and 32 (54%) patients in Group R complained of PONV (P < 0.001) (Table 1). The number of patients having mild nausea was higher in Group R than in Group D (18 vs. 8, P = 0.013). However, there was no significant difference in patients having moderate (P = 0.79) and severe nausea (P = 0.29). Eight (14%) patients in Group D and 10 (17%) patients in Group R experienced mild vomiting (P = 0.69). The time to first emetic episode (P = 0.87) and the need for rescue antiemetics (P = 0.83) were similar between the groups at all time points.Table 1: Patients who presented with postoperative nausea and vomiting, nausea, vomiting, complete response, who asked for antiemetics, analgesics and reported thirst, fatigue and hunger in the dextrose and the Ringer Lactated groupsBefore starting the study, blood sugar values were comparable in Groups D and R [mean (SD), 92 (12) vs. 91 (11) mg dl−1]. After the end of study infusions, Group D had higher blood sugar levels compared with Group R [mean (SD), 282 (32) vs. 92 (8) mg dl−1, respectively, P < 0.001]. Between 0 and 24 h after surgery, more patients in Group D reported thirst compared with Group R (P = 0.021). On the other hand, during the first 0 to 6 h, more patients in Group R complained of fatigue (P < 0.001) and hunger (P < 0.001) (Table 1). Patients in Group D were more satisfied with the management of their PONV [8 (8 to 9) vs. (7 to 8), P < 0.001]. Our results demonstrate a decreased incidence of PONV, an increased incidence of complete response achievement, and a decreased incidence of patients asking for analgesics or reporting fatigue or hunger after administration of IV dextrose in patients undergoing laparoscopic cholecystectomy. In our study, the incidence of antiemetic requirements was similar in the two groups at all time points (Table 1). In contrast to our data, Dabu-Bondoc et al.5 reported significant reduction in antiemetic requirement with IV dextrose. This could be attributed to the different criteria used for administering rescue antiemetic by the latter group. Patel et al.6 did not observe any benefit of dextrose on PONV, but that could be due the omission of prophylactic antiemetics in their trial. Stimulation of the mechanoreceptors in the gastrointestinal tract due to CO2 pneumoperitoneum leads to the release of serotonin and other neurotransmitters, resulting in a higher incidence of PONV in laparoscopic cholecystectomy. The use of a single antiemetic leads to relative risk reduction of approximately 20%. By adding IV dextrose, the relative risk reduction was 47% between 0 and 6 h and 41% between 0 and 24 h. We investigated relatively healthy patients undergoing laparoscopic cholecystectomy, therefore, these results cannot be extrapolated to patients with major comorbidities or undergoing major surgery. In conclusion, in patients undergoing laparoscopic cholecystectomy, postoperative administration of 5% dextrose solution after emergence from general anaesthesia reduces the incidence of PONV and the requirement for rescue analgesics as well as improving the wellbeing of the patients for the first 24 h postoperatively. Acknowledgements relating to this article Assistance with the study: we are grateful to the Journal's editorial team for their valuable comments and help. Financial support and sponsorship: none. Conflicts of interest: none.
No takes yet. Share an insight, caveat, or question.
Rao et al. (2017) studied this question.
Synapse has enriched 5 related papers. Consider them for comparative context: