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ORIGINAL ARTICLE
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Perioperative dextrose infusion for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy


 Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission30-Aug-2021
Date of Decision22-Nov-2021
Date of Acceptance27-Nov-2021

Correspondence Address:
Smita Prakash,
C 17 HUDCO Place, New Delhi - 110.049
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_713_21

  Abstract 


Background and Aims: The effect of intravenous dextrose on the prevention of postoperative nausea and vomiting (PONV) is inconclusive. We aimed to determine the role of perioperative IV dextrose in the prevention of PONV and to analyze factors affecting PONV. Methods: This randomized, double-blind study was conducted in a tertiary care hospital. Two-hundred-fifty-five nondiabetic adults undergoing laparoscopic cholecystectomy were randomized into three groups (n = 85): group NS, group D5, and group D10 to receive perioperatively 250 mL of study fluid infusion (normal saline, dextrose 5%, and dextrose 10%, respectively). Nausea visual analog scale and PONV score, early (0–2 h) and late (2–24 h) PONV and rescue antiemetic treatment were assessed postoperatively. Statistical calculations were done using SPSS 17 version program for Windows. Results: Incidence of early and late PONV was significantly less in Groups D10 (25.9% and 2.4%, respectively) and D5 (43.5% and 17.6%, respectively) compared with Group NS (61.2% and 27.1%, respectively); P < 0.001. Postoperative PONV scores and the need for rescue antiemetics were significantly less in Groups D5 and D10 compared with Group NS; P < 0.05. After study fluid infusion, blood sugar levels (mg%) were significantly higher in patients in Group D10 (242.9 ± 26.2) compared with those who received NS (129.2 ± 10.8) or dextrose 5% (197.1 ± 20.8); P < 0.001. Factors associated with PONV were age, body mass index, female gender, increased anxiety and Apfel score, postoperative opioids, previous PONV, and blood sugar. Conclusions: Perioperative intravenous dextrose 5% (250 mL) can be considered the optimal dose for reducing the incidence and severity of PONV and antiemetic requirement in adults undergoing laparoscopic cholecystectomy.

Keywords: Cholecystectomy, laparoscopic, nausea, postoperative nausea and vomiting, vomiting



How to cite this URL:
Tripathi P, Prakash S, Mullick P, Wason R. Perioperative dextrose infusion for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337098




  Introduction Top


The incidence of postoperative nausea and vomiting (PONV) after general anesthesia is 25%–30%[1] with a higher incidence (46%–75%) following laparoscopic cholecystectomy.[2] The role of perioperative intravenous dextrose infusion in reducing PONV has been investigated with mixed results.[3],[4],[5],[6] Perioperative administration of 5% dextrose reduced the incidence of PONV and antiemetic requirement in patients undergoing laparoscopic surgery.[3],[4] In contrast, there have been some reports of no impact or increased PONV with preoperative dextrose infusion.[5],[6]

The potential efficacy of intravenous dextrose in reducing PONV needs to be convincingly demonstrated. Hence, we conducted this study. We hypothesized that perioperative intravenous dextrose infusion would reduce PONV. The aim of our study was to determine the efficacy of perioperative intravenous dextrose infusion in reducing PONV in patients undergoing laparoscopic cholecystectomy under general anesthesia. The primary outcome was to determine the incidence of PONV following the administration of perioperative intravenous dextrose (5% and 10%) infusion. Secondary outcomes were to determine the optimal dose of dextrose for reducing PONV and to determine patient characteristics and perioperative factors associated with PONV.


  Methods Top


After obtaining Institute Ethics Committee approval and written informed consent from the patients, this randomized, interventional, double-blind study was conducted between April 2018 and August 2018. The study was registered with Clinical Trials Registry India. The study included 255 American Society of Anesthesiologists (ASA) physical status I/II adults, aged 18–65 years, of either gender, scheduled for elective laparoscopic cholecystectomy under general anesthesia. Patients with diabetes, cardiovascular, hepatic or renal disease, increased intracranial tension, those currently receiving opioids, steroids, antiemetic drugs or chemotherapy, pregnant females, and those with abnormal blood glucose on the morning of surgery were excluded.

Patients were randomized into three groups (n = 85) by computer generated random number sequence in blocks of fifteen. Allocation concealment was done by sealed opaque envelopes.

Group NS: received 250 mL of normal saline 0.9%; Group D5: received 250 mL of dextrose 5%; Group D10: received 250 mL of dextrose 10%. The study fluid infusion commenced at the time of gall bladder removal at 100 mL/h as per group allocation.

Preoperatively, patients were familiarized with the visual analog scale (VAS) for PONV, pain, and patient satisfaction. Patient demographics and Apfel score were noted.[7] All patients fasted overnight and received oral alprazolam the night before and on the morning of surgery. Anxiety scores were assessed using the State-Trait Anxiety Index (STAI).[8]

In the operating room, standard monitoring was established. Preoperative blood glucose level was obtained during IV placement using a portable glucometer to confirm baseline normoglycemia.

Anesthesia was induced with IV fentanyl (2 μg/kg) and IV propofol (2–2.5 mg/kg), tracheal intubation was facilitated with IV vecuronium (0.1mg/kg) and maintained using isoflurane 0.6%–1% in oxygen and nitrous oxide (33%: 66%). All patients received dexamethasone 4 mg IV after induction. An orogastric tube was inserted, gastric contents were suctioned and left on continuous drainage. Intraoperatively, if narcotic supplementation was required, IV fentanyl (0.5 μg/kg) was administered. All patients received Ringer's lactate solution IV (2 mL/kg/h) as maintenance fluid. At the time of gallbladder removal, the study fluid was administered at 100 mL/h and continued into the postoperative period. The study fluid label (D5, D10, or NS) was removed by an anesthesiologist not involved in the study. The investigator responsible for data collection was unaware of group allocation. All patients received paracetamol IV (15 mg/kg) at the end of surgery and then 8-hourly postoperatively. Surgical wounds were infiltrated with bupivacaine 0.25%. At the end of surgery, neuromuscular block was antagonized (neostigmine 0.05 mg/kg, glycopyrrolate 0.01mg/kg). The orogastric tube was removed after suctioning gastric contents prior to extubation. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, mean arterial pressure, oxygen saturation, end-tidal carbon dioxide, and airway pressure (Paw) were noted at time points of induction, intubation, and every 10 min till extubation. Hypotension and hypertension were defined as a decrease or increase in SBP ≤ or ≥80% of baseline, respectively. Occurrence of bradycardia (HR <60 beats/min) and tachycardia (HR >100 beats/min) was noted. Total intravenous fluid administered was recorded. Blood glucose was measured at baseline, immediately before and after completion of study fluid infusion by finger stick sample. The duration of anesthesia and surgery was recorded. All patients received supplemental oxygen (5 L/min) and IV Ringer's lactate (2 ml/kg/h) postoperatively.

In the postanesthesia care unit (PACU), patients' nausea levels were assessed using a VAS score 0–10: 0 = no nausea; 10 = the worst nausea ever, or any episode of retching or vomiting. Early PONV was defined as PONV from 0 to 2h and late PONV as that between 2 and 24 h. Rescue antiemetic was given when the VAS score was ≥4 after excluding other causes of PONV (hypovolemia, hypotension, hypoxia). Severity of nausea was graded: none (VAS 0), mild (VAS 1–3), moderate (VAS 4–6), and severe (VAS 7–10). Patients with a VAS score of ≥4 received ondansetron 4 mg IV as first-line antiemetic treatment. If PONV persisted >30 min, metoclopramide 10 mg IV was administered. If these rescue antiemetic medications failed, promethazine 12.5 mg IV was administered. Rescue antiemetic medication requirement was noted.

Patient's pain was rated by a VAS score 0–10: 0 = no pain; 10 = most intense pain imaginable. Patients with a pain score ≥4 (despite paracetamol IV) received IM diclofenac 1mg/kg. In the PACU, if the pain was still unrelieved (VAS score ≥4 at the time of assessment or the patient complained of pain), IV fentanyl 25 μg for pain score 4–6, and 50 μg for pain score 7–10 was given. In the ward, the rescue analgesic was tramadol 1mg/kg IM if the pain was unrelieved with paracetamol and diclofenac. The analgesic requirement in 24 h was noted.

PONV and pain VAS scores were assessed at 0, 30, 60, 90, 120 min in the PACU, and at 6 h and 24 h postoperatively in the ward. Patients were kept in the PACU for 2 h (or more, if required) and then shifted to the ward. The duration of PACU stay was noted. At 24 h postoperatively, patients were asked about fatigue, hunger or thirst experienced. Patient satisfaction concerning postoperative physical comfort and wellbeing was recorded at 24 h with VAS 0–10: 0 = complete dissatisfaction; 10 = complete satisfaction.

Based on a previous study,[1] we took the baseline incidence of PONV in laparoscopic surgery as 40%. To detect a difference of 20% in the incidence of PONV between the study groups with 80% power and a two-sided α = 0.05, a sample size of 81 patients in each group would be required. Assuming a 5% dropout rate, we included 85 patients in each group.

Statistical analysis was performed by the Statistical Package for the Social Sciences program for Windows, version 17.0 (SPSS, Chicago, Illinois). Continuous variables are presented as mean ± standard deviation or median (interquartile range), and categorical variables are expressed as frequency and percentage. Data were checked for normality before statistical analysis using Shapiro–Wilk test. Normally distributed continuous variables were compared between groups using analysis of variance. If the F value was significant, Tukey or Tamhane's T2 multiple comparison tests were used to assess the differences between the individual groups. Nominal categorical data were analyzed using the Chi-square test or Fisher's exact test, as appropriate. Nonnormal distribution continuous variables were compared using the Kruskal Wallis test, and further paired comparisons were done using Mann–Whitney U-test. For all statistical tests, P < 0.05 indicated a significant difference.


  Results Top


The study included 255 patients [Figure 1]. Gender distribution, ASA physical status and APFEL scores, duration of anesthesia, surgery, and PACU stay were comparable between the groups [Table 1]. A significant difference was observed in age between groups NS and D10 (P = 0.026) and between Groups D5 and D10 (P = 0.015), and in body mass index (BMI) between groups NS and D5 (P = 0.032). STAI scores were significantly higher in Groups D5 and D10 compared with group NS; P = 0.001.
Figure 1: Consolidated standards of reporting trials diagram

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Table 1: Patient characteristics, State trait anxiety index, apfel scores, and duration of anesthesia, surgery, and postanesthesia care unit stay

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A significant difference was observed in the blood sugar level after study fluid administration between all three groups; P < 0.001 [Table 2]. The incidence of intraoperative hypotension (P = 0.664), hypertension (P = 0.731), bradycardia (P = 0.724), tachycardia (P = 0.510), intraoperative and postoperative analgesic (P = 0.166), and fluid requirements (P = 0.578) were comparable between the groups. The volume of intraoperative fluid (mL) administered in Group NS (1145 ± 133), group D5 (1102 ± 159) and Group D10 (1129 ± 132) was comparable; P = 0.138.
Table 2: Blood sugar levels

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A significant difference was observed in the PONV VAS scores at 0, 30, 60, 90 min, 2 h, 6 h, 24 h between Groups NS and D10; at 60 min and 6h between Groups D5 and D10; and at 60 min and 24 h between groups NS and D5 [Figure 2]. There was a significant difference between the incidence of early and late PONV between the groups. The odds ratio (OR) and 95% confidence interval (95% confidence interval [CI]) for early PONV between groups NS and D5 was 2.04 (1.101 to 3.77), between groups NS and D10 were 4.51 (2.35 to 8.67), and between groups, D5 and D10 was 2.21 (1.16 to 4.22). The OR (95%CI) for late PONV between Groups NS and D5 was 1.06 (0.54 to 2.10, between Groups NS and D10 was 15.39 (3.50 to 67.76), and between Groups D5 and D10 was 8.89 (1.97 to 40.23). Nausea severity was significantly different between the three groups [P < 0.001; [Table 3].
Figure 2: Postoperative nausea and vomiting visual analog scale scores

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Table 3: Early and late postoperative nausea and vomiting, nausea severity and incidence of vomiting and antiemetic requirement in 24 h

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Risk factors associated with PONV were older age (P = 0.021), female gender (P = 0.010), higher BMI (P = 0.001), higher STAI score (P < 0.001) and Apfel score (P < 0.001), postoperative opioids (P < 0.001), previous PONV (P = 0.012) and lower blood sugar level [P < 0.001; [Table 4].
Table 4: Patient characteristics and perioperative factors in patients with or without postoperative nausea and vomiting

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Patients in group NS had a significantly higher incidence of fatigue (P = 0.006) and hunger (P = 0.001) compared with Groups D5 and D10. Thirst (P = 0.029) and patient satisfaction VAS score at 24 h (median [range]) were significantly lower in Group NS (8 [7–10]) compared with Groups D5 (9 [7–10]) and D10 (9 [7–10]); P = 0.001.


  Discussion Top


Our results indicate that the administration of dextrose 5% and 10% decreased the incidence and severity of PONV and postoperative antiemetic requirement. It also reduced fatigue and hunger, and improved patient satisfaction. The factors associated with PONV were age, BMI, lower STAI score, high APFEL score, female gender, use of postoperative opioids, past PONV, and lower blood sugar levels.

The incidence of early PONV was significantly less in patients receiving dextrose 5% and 10% compared with those receiving normal saline. Administration of dextrose 5% and 10% decreased the incidence of early PONV by 17.7% and 35.3%, respectively and that of late PONV by 9.5% and 24.7%, respectively. Similar to our results, a reduction in PONV by 38% was reported in patients receiving dextrose 5% compared with normal saline with a 66% incidence of PONV in the saline group and 28% incidence in the dextrose group.[4] Likewise, 5% dextrose administered in the immediate postoperative period significantly decreased the PONV incidence compared with Ringer lactate (30% and 54%, respectively) between 0-6 h.[9] The beneficial effect of dextrose infusion on PONV has also been reported by other investigators.[7],[10],[11] However, some studies have not found dextrose administration to be effective in reducing PONV.[5],[6],[12] No significant difference in PONV was found during the first two hours after anesthesia in the dextrose group (52.9%) compared with the Ringer lactate group (46.7%) in patients undergoing varied surgeries.[5] Similarly, Dabu-Bondoc et al. reported no difference in nausea and vomiting episodes and PONV scores in patients receiving dextrose 5% with Ringer lactate or Ringer lactate alone, although IV dextrose administration reduced rescue antiemetic requirement and PACU length of stay.[3] The administration of dextrose has been associated with nausea and late thirst after elective gynecological laparoscopy.[6] A meta-analysis showed that perioperative dextrose administration decreased the risk of PONV in patients undergoing laparoscopic cholecystectomy but not in other types of surgeries.[13]

We found that the severity of nausea was significantly less in patients receiving dextrose 5% and 10% compared with those receiving normal saline. Likewise, a greater number of patients in the lactated Ringer group had mild nausea (score <5) than in the dextrose group though no difference was found in the incidence of moderate and severe nausea.[9] Administration of dextrose 5% was associated with a lower severity of PONV compared with administration of Ringer lactate.[11] Contrary to our results, Patel et al. reported no impact of dextrose administration during emergence from anesthesia on the onset or severity of PONV.[5]

Need for rescue antiemetic treatment was significantly less in patients receiving dextrose 5% and 10% compared with patients receiving normal saline. Previous studies have also reported decreased antiemetic requirements in patients receiving dextrose,[3],[4],[11],[12],[13] while others have not found a reduced requirement for antiemetic medication.[5],[9] In accordance with the results of previous studies, patients receiving dextrose in our study reported significantly less fatigue and hunger and a higher incidence of thirst and greater patient satisfaction compared to those receiving saline.[6],[9]

It is recognized that preoperative anxiety is associated with increased PONV.[14] Patients receiving normal saline had the least STAI scores but had a higher incidence of PONV compared with patients receiving dextrose. Perhaps dextrose administration reduced PONV, so even though patients in the dextrose groups were more anxious, they experienced less PONV compared to the saline group patients who suffered more PONV despite being less anxious.

Blood sugar levels following study fluid administration were well above the normal range in patients receiving dextrose 10%, compared with those receiving normal saline and dextrose 5%. Previous investigators have reported higher blood sugar levels following administration of dextrose solutions, while others have not found significant differences in blood sugar levels.[5],[6],[10],[11] Interestingly, no significant difference in perioperative blood sugar levels were reported following administration of a higher 0.5 g/kg dextrose dose compared with 12.5g and 25g dextrose dose used in our study.[11]

Analysis of patient and perioperative factors showed a positive association of PONV with age, BMI, female gender, STAI score, APFEL score, postoperative opioids, previous PONV, and blood sugar. Patients who experienced no PONV had higher blood sugar level after study fluid administration than those who had PONV. Similar to our results, Patel et al. found that patients with PONV had a positive relationship between the length of surgery, postoperative fentanyl doses, and a negative relationship with blood sugar levels after study fluid infusion.[5] Firouzian et al. also found a negative correlation between blood sugar levels and nausea scores at PACU arrival.[10] The use of postoperative opioids was associated with PONV in our study. Postoperative opioid administration affects the incidence of PONV in a dose-related manner.[15] Consensus guidelines for the management of PONV recommend the minimization of intraoperative and postoperative opioid use as a strategy to reduce PONV.[16] The sum of the extraocular muscles manipulated and the use of nalbuphine were found to be risk factors for PONV after strabismus study.[17]

A recent meta-analysis reported that perioperative dextrose infusion was associated with a reduction in antiemetic administration within the first 24 h but not a reduction in PONV.[18] However, this meta-analysis has limitations. There was a high degree of heterogeneity in their results, inability to perform meta-analysis of some secondary variables, and a small sample size. The authors of this meta-analysis have suggested further randomized controlled trials to determine if perioperative dextrose has a role in the prevention of PONV.[18] Our randomized controlled study has provided evidence of the beneficial role of dextrose infusion in decreasing PONV and has identified the use of 12.5 g dextrose (250 mL dextrose 5%) as the optimal dose for reducing PONV. In addition, our study confirms the known modifiable and nonmodifiable factors that affect PONV.

Our study has some limitations. This was a single-center study conducted in the Indian population. A recent meta-analysis reported that the prevalence of PONV during the first 24 h is higher in the European countries.[19] Therefore, our results cannot be generalized to other population groups. High-risk patients were not included. There is a need to study the effect of dextrose on the prevention of PONV in high-risk patients and in the elderly population. Our study groups were not comparable with respect of age and BMI. This was due to chance as this was a randomized study.


  Conclusions Top


Perioperative administration of dextrose 5% and 10% significantly reduced the incidence and severity of PONV and requirement for rescue antiemetics in patients undergoing laparoscopic cholecystectomy under general anesthesia. Administration of dextrose 10% resulted in hyperglycemia which precludes its use. Dextrose 5% (250 mL) can be considered the optimal dose for reducing PONV and requirement for antiemetics in patients undergoing laparoscopic cholecystectomy in view of its low-risk potential, universal availability, and benefit to patient care and satisfaction.

Acknowledgements

We would like to acknowledge Ms Parul Chugh, M.Sc. Statistics, Senior Statistician, Sir Ganga Ram Hospital, New Delhi, India, for her immense contribution to the study in data analysis and interpretation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  
11.
Atashkhoei S, Naghipour B, Marandi PH, Dehghani A, Pourfathi H. Effect of intraoperative dextrose infusion for prevention of postoperative nausea and vomiting in diagnostic gynecologic laparoscopy. Crescent J Med Bio Sci 2018;5:45-9  Back to cited text no. 11
    
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Laufenberg-Feldmann R, Müller M, Ferner M, Engelhard K, Kappis B. Is “anxiety sensitivity” predictive of postoperative nausea and vomiting? A prospective observational study. Eur J Anaesthesiol 2019;36:369-74.  Back to cited text no. 14
    
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