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Efficacy of Gastric Aspiration in Reducing Posttonsillectomy Vomiting
Jacqueline E. Jones, MD;
Abtin Tabaee, MD;
Robert Glasgold, MD;
Matthew C. Gomillion, MD
Arch Otolaryngol Head Neck Surg. 2001;127:980-984.
ABSTRACT
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Objective To determine the effectiveness of postoperative gastric decompression
in reducing the incidence and complications associated with vomiting following
tonsillectomy.
Design A prospective, randomized controlled study.
Setting Private office and clinic of a university teaching hospital and research
center.
Patients Eighty pediatric patients ranging in age from 22 months to 11 years,
American Society of Anesthesiologists class I or II, undergoing tonsillectomy
with or without adenoidectomy were enrolled in the study. Six were excluded
from the final analysis, 5 because of failure of the parents to complete and
return the data forms and 1 because of postoperative bleeding. Of the 74 patients
included in the study, 35 were in the control group and 39 were in the study
group.
Interventions The 39 patients in the study group underwent postoperative aspiration
of gastric contents with an orogastric tube placed under direct visualization
while the patient was still under general anesthesia. The 35 patients in the
control group did not undergo gastric aspiration following surgery.
Main Outcome Measures The incidence of vomiting, the number of episodes of vomiting before
and after hospital discharge, the total volume of emesis, the postoperative
length of stay, the need for rescue antiemetic prophylaxis, and the number
of readmissions to the hospital for persistent vomiting were noted.
Results No statistically significant difference (P<.05)
was noted between the control group and the study group for the percentage
of patients experiencing vomiting (74% vs 85%), the mean number of episodes
of vomiting before (2.6 vs 2.8) and after (0.8 vs 0.7) hospital discharge,
the mean volume of emesis (157 mL vs 222 mL), the postoperative length of
stay (394 minutes vs 334 minutes), the percentage of patients requiring rescue
antiemetics (34% [12 patients] vs 33% [13 patients]), and the percentage of
unplanned admissions because of vomiting (9% [3 patients] vs 15% [6 patients]).
Conclusion Our results indicate that gastric aspiration does not decrease the incidence
of vomiting following tonsillectomy.
INTRODUCTION
POSTOPERATIVE vomiting represents the most common complication of pediatric
tonsillectomy and adenoidectomy. Despite advances in anesthetic and surgical
technique, incidences as high as 75% have been reported.1-3
Persistent vomiting is costly both in terms of financial effect and potential
medical sequela.4-5 The cause
of postoperative vomiting in the pediatric population is thought to be multifactorial
with patient characteristics, anesthetic medications, surgical manipulation,
and postoperative care all hypothesized to contribute.2, 4-9
In response to this "Big ‘Little' Problem,"3
multiple studies have investigated the effects of newer anesthetic agents
and antiemetic prophylaxis on postoperative vomiting.10-18
In general, the results of these studies have been mixed. Marginal improvements,
unfavorable adverse effect profiles, and high costs have limited the universal
adoption of any single protocol. The use of gastric aspiration in reducing
postoperative vomiting has been advocated in the older medical literature
and several review articles.6, 19-20
However, recent studies have failed to demonstrate any benefit of gastric
aspiration in reducing postoperative vomiting in gynecologic or general surgical
patients.21-22 Further, a recent
literature search failed to find any prospective studies examining the effectiveness
of gastric aspiration in reducing postoperative vomiting following tonsillectomy,
adenoidectomy, or adenotonsillectomy. This study determined the efficacy of
gastric aspiration in reducing the incidence and complications associated
with posttonsillectomy vomiting in a pediatric population.
PATIENTS AND METHODS
The study was approved by the Institutional Review Board Committee on
Human Rights in Research, Weill College of Medicine at Cornell University,
New York, NY. Informed consent was obtained from the parents of 80 pediatric
patients, American Society of Anesthesiologists class I or II, who underwent
tonsillectomy with or without adenoidectomy at New York Hospital between July
9, 1997, and November 8, 1999. Patients were alternately randomized to the
control group (n = 35) or the study group (n = 39) at the time of enrollment.
Patients in the study group underwent gastric aspiration with an orogastric
tube prior to extubation following surgery. Those in the control group did
not undergo gastric aspiration. Patients with any remarkable history of gastrointestinal
disorders were ineligible for the study.
The anesthetic protocol was standardized throughout the study and all
procedures were supervised by the same anesthesiologist (M.C.G.). Inhalational
anesthesia was achieved with 2% sevoflurane delivered in a combination of
30% oxygen and 70% nitrous oxide. Intravenous morphine sulfate (0. l mg/kg)
was administered at the time of induction. Intravenous mivacurium chloride
(0.25 mg/kg) was used for muscle paralysis to facilitate intubation. Intraoperative
steroids and antibiotic agents were not used. Patients were not given prophylactic
antiemetics or steroids.
The surgical technique was standardized and all procedures were supervised
by the same pediatric otolaryngologist (J.E.J.). Tonsillectomy was performed
using electrocautery; hemostasis was obtained by packing the tonsillar fossa
followed by suction electrocautery. Adenoidectomy was performed using adenoid
curettes and St Clair–Thompson forceps. Hemostasis was obtained with
nasopharyngeal packing followed by suction electrocautery.
In the study group (n = 39 patients), an orogastric tube was placed
postoperatively under direct visualization and the gastric contents were aspirated
prior to emergence from anesthesia. A mouth gag was in place at the time of
suctioning. The 35 patients in the control group emerged from anesthesia without
undergoing placement of an orogastric tube. The attending anesthesiologist
(M.C.G.) who followed up the patients postoperatively for emesis was not in
the operating room at the time of orogastric aspiration and was thus masked.
All 74 patients were transferred to the postanesthesia care unit following
extubation. Postoperative pain was addressed with a combined therapy of acetaminophen
(10 mg/kg) and codeine phosphate (0.5 mg/kg) given orally every 4 hours as
needed. Intravenous fluids were continued until oral liquids were tolerated.
Rescue prophylatic antiemetics were provided only in cases of persistent vomiting.
After the third episode of vomiting, the anesthesiologist (M.C.G.) administered
a single dose of intravenous metoclopramide hydrochloride (0.25 mg/kg).
The patients were observed in the ambulatory step down unit until the
following criteria for discharge were met: stable vital signs and airway,
stable wound, tolerant of oral fluids, alert, and ambulating. There was no
predetermined minimum postoperative length of stay. Emesis was defined as
the forceful expulsion of gastric contents from the mouth. The incidence and
volume of each episode of emesis was recorded in a log by the postanesthesia
care unit nurses and the parents for a 24-hour period following the patient's
arrival in the postanesthesia care unit. The anesthesiologist, nurses, and
parents were masked to the randomization of each patient. The parents were
instructed to send the completed record of postoperative vomiting to the senior
author (J.E.J.).
Data on the number of episodes of vomiting, total volume of emesis,
postoperative length of stay, administration of rescue prophylactic antiemetics,
and readmission to the hospital for persistent vomiting were collected from
the hospital medical record, parents' logs, and follow-up telephone calls
made by the research team. Mean (SD) or percentage was used to describe each
variable. The Wilcoxon rank sum test was used to compare the 2 study groups
and the Fisher exact test was used to examine categorical variables. P<.05 was considered statistically significant.
RESULTS
Eighty patients were initially enrolled in the study. Five patients
were excluded from the final analysis for failing to return the data forms;
1 was excluded for postoperative bleeding following extubation. Of the 74
patients included in the study, 35 were in the control group and 39 were in
the study group. The age of the patients ranged from 22 months to 11 years.
No statistically significant difference was noted between the 2 groups for
age, sex, weight, intraoperative blood loss, history of motion sickness, or
diagnosis (Table 1). Although
demographic factors were not strictly controlled, the 2 groups were considered
statistically similar enough for direct comparison. One patient in each group
underwent tonsillectomy; all of the other patients underwent adenotonsillectomy.
There was no statistically significant difference between the control
group and the study group in the overall incidence of vomiting (74% [26 patients]
vs 85% [33 patients]), mean number of episodes of vomiting before hospital
discharge (2.6 vs 2.8), or mean number of episodes of vomiting after hospital
discharge (0.8 vs 0.7). Further, the mean volume of emesis for the patients
who experienced postoperative vomiting was similar for the control group and
study group (157 mL vs 222 mL). Prophylactic antiemetic rescues were required
in 34% (12/35) of the control group patients and 33% (13/39) of the study
group patients (Table 2).
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Table 2. Clinical Results
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The postoperative length of stay was defined as the time from extubation
to hospital discharge. There was no predetermined minimum postoperative length
of stay. In the control group, the mean postoperative length of stay for the
29 patients discharged on the day of the surgery was 394 minutes. This was
similar to the mean length of stay of 334 minutes for the 32 patients in the
study group (Table 2). In the
control group, 6 of the 35 patients were admitted overnight following surgery.
Three of these were because of persistent vomiting, 2 were planned based on
the patient being younger than 3 years, and 1 was planned based on a history
of mild factor VII deficiency. In the study group, 7 of the 39 patients were
admitted overnight following surgery. Six of these were because of persistent
vomiting and 1 was planned based on the patient being younger than 3 years.
No statistically significant difference was noted between the control group
and the study group for postoperative length of stay or unplanned admissions.
In the study group, there were no complications attributable to the placement
of the orogastric tube or gastric aspiration.
COMMENT
Tonsillectomy and adenoidectomy are among the most frequently performed
pediatric surgical procedures. Postoperative vomiting represents one of the
most common complications and the single most common reason for unplanned
hospital admission following adenotonsillectomy.2, 4, 9
In a study of 1476 pediatric patients undergoing general anesthesia, Kermode
et al9 found a 24% overall incidence of postoperative
vomiting and a 54% incidence of vomiting following tonsillectomy. Incidence
of posttonsillectomy vomiting as high as 75% has been reported in the literature.3, 9 In addition to the potentially fatal
complications of dehydration, electrolyte imbalance, and aspiration pneumonitis,
vomiting has been reported to result in a level of physical and psychological
distress exceeding that of the operation in 54% to 71% of patients surveyed
in an ambulatory setting.4-5 The
economic consequences of postoperative vomiting are likewise significant with
both direct costs such as medical staffing and medications as well as indirect
costs such as fewer surgical cases and slower patient recovery contributing
to this major financial sink.
The cause of posttonsillectomy vomiting is theorized to be multifactorial.
Patient characteristics associated with increased incidence include young
age (peak incidence during ages 6-16 years), female sex, history of postoperative
vomiting or motion sickness, history of gastroparesis, and obesity. Research
investigating the link between anesthetics and postoperative vomiting indicates
that inhalational anesthetics, nitrous oxide, and opioids all tend to be proemetogenic
while newer agents such as propofol tend to be less so. Postoperative factors
linked to emesis include pain, dizziness, ambulation, and oral intake. The
mechanism of these factors in triggering emesis varies and includes activation
of chemoreceptors and mechanoreceptors in the oropharynx and stomach by swallowed
blood and intraoperative manipulation, direct stimulation of the chemoreceptor
trigger zone in the area postrema, stimulation of the trigeminal nerve, and
vestibular input to the vomiting center.5, 7-9,17
Given the increasing insight into the pathophysiology of proemetic factors,
multiple studies have focused on methods to decrease posttonsillectomy vomiting.
The use of prophylactic antiemetics has been shown to be effective in reducing
posttonsillectomy emesis. Ondansetron hydrochloride, specifically, has received
a great deal of attention with some studies demonstrating a 40% to 50% reduction
in the incidence of posttonsillectomy vomiting.10-14
Although the use of antiemetics has been advocated by some authors, their
universal adoption has been precluded by insufficient prophylaxis, untoward
adverse effects, and high cost. Recent research in anesthesia has concluded
that the use of propofol in place of inhalational anesthetics results in a
34% decrease in posttonsillectomy vomiting.17
The anesthetic protocol used in our study was supplied in a standardized fashion
to minimize confounding variables. Steroids were also not given since studies
investigating their use in patients who undergo tonsillectomy have been conflicting.15-16
In a review article addressing anesthetic issues in outpatient otolaryngology
surgery, Pasternak6 states that gastric aspiration
with an orogastric tube prior to extubation is essential to decreasing nausea,
emesis, and pulmonary aspiration. Further, this practice has been advocated
in multiple review articles dating back several decades.19-20
However, in a recent review of the literature, we were unable to find any
prospective studies addressing the efficacy of gastric aspiration in reducing
posttonsillectomy vomiting. Regardless of its unproven efficacy and potential
complications, it remains a practice commonly performed by otolaryngologists
and anesthesiologists.
Postoperative gastric decompression with an orogastric tube is generally
considered to be a safe procedure. Most complications secondary to orogastric
and nasogastric tubes are associated with long-term placement.23
When used to aspirate gastric contents postoperatively, orogastric tubes have
been associated with inadvertent placement into the trachea, esophageal perforation,
uvular trauma with secondary edema, and gastric ulceration. Although these
complications are rare, they have the potential to result in significant morbidity.23-30
In our series, we did not detect any complications attributable to the use
of orogastric tubes.
The efficacy of gastric aspiration in reducing postsurgical vomiting
has been addressed in 2 recent prospective studies. In a study of 201 patients
who underwent hysterectomy, Hovorka et al22
showed no statistically significant difference in the incidence of vomiting
between patients who underwent postoperative gastric aspiration and patients
who did not (79% vs 70%, respectively). Trepanier and Isabel21
actually demonstrated a higher incidence of vomiting in patients who underwent
postoperative gastric aspiration with an orogastric tube (17% vs 6.8%) in
a study of 256 ambulatory general surgical patients. These studies seem to
indicate that reducing gastric distention with an orogastric tube does not
reduce postoperative vomiting.These studies cannot be directly correlated
with pediatric otolaryngology because patients who undergo tonsillectomy experience
additional proemetic stimuli including intragastric blood, manipulation of
the posterior pharynx, and stimulation of the trigeminal nerve. Therefore,
addressing gastric aspiration in patients who undergo tonsillectomy remains
a critical next step.
Indirect evidence concerning the efficacy of gastric aspiration in reducing
posttonsillectomy vomiting is available from recent studies. In their investigation
of the role of prophylatic antiemetics in reducing posttonsillectomy vomiting,
Ferrari and Donlon10 and Furst and Rodarte11 required all patients, including the control groups,
to undergo gastric aspiration. The incidence of vomiting in these control
groups was high (62% and 70%, respectively). In comparison, 3 similar studies
evaluating prophylactic antiemetics were designed so that no patients underwent
gastric aspiration. The control groups of these studies also had high incidences
of posttonsillectomy vomiting (54%-73%).12-14
Although experimental and surgical variables preclude the direct statistical
comparison of these studies, they seem to indicate that gastric aspiration
may not significantly affect the incidence of posttonsillectomy vomiting.
The goal of this study was to determine the efficacy of gastric aspiration
in reducing posttonsillectomy vomiting in a pediatric population. Our data
showed no statistically significant reduction in the incidence of vomiting,
the number of episodes of vomiting, or total volume of emesis. Further, there
was no difference in the need for rescue prophylatic antiemetics or the number
of readmissions for persistent vomiting. This is consistent with the results
of the studies noted earlier. The incidence of vomiting in our study groups
and control groups (85% and 74%, respectively) are high compared with previous
studies. However, other studies defined postoperative vomiting as 3 or more
episodes, whereas our protocol included all cases of vomiting. The limited
sample size of our study may also be a factor in the high incidence.
With the increasing emphasis placed on financial efficiency in health
care, the issue of postoperative length of stay in ambulatory surgery has
taken on greater significance. Postoperative emesis represents a major factor
in delaying the time of hospital discharge for patients who undergo tonsillectomies,
as described earlier. One of the major goals of decreasing the incidence of
postoperative vomiting is to decrease the postoperative length of stay and,
therefore, improve efficiency. In our study, there was no minimum observation
period following surgery and patients were discharged after meeting discharge
criteria. In addition to having no detectable effect on the incidence of vomiting,
gastric aspiration also failed to result in any significant reduction in the
postoperative length of stay.
CONCLUSIONS
Our data do not support the routine use of orogastric tube placement
for gastric aspiration following pediatric tonsillectomy. There was no reduction
in the incidence of postoperative vomiting, number of episodes of vomiting,
postoperative length of stay, or unplanned hospital admissions. Our results
are consistent with the results of previous studies in other surgical fields.
Therefore, the routine use of gastric aspiration requires reassessment. Further
studies are needed to evaluate the role of gastric aspiration in select cases
in which significant bleeding or gastric distention is a concern.
AUTHOR INFORMATION
Accepted for publication March 27, 2001.
Corresponding author: Jacqueline E. Jones, MD, Department of Otorhinolaryngology,
Weill College of Medicine at Cornell University, Starr Bldg, Suite 541, 520
E 70th St, New York, NY 10021 (e-mail: jjones{at}mail.med.cornell.edu).
From the Departments of Otorhinolaryngology (Drs Jones, Tabaee, and
Glasgold) and Anesthesiology (Dr Gomillion), Weill College of Medicine at
Cornell University, New York, NY.
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