Risk of postoperative nausea and vomiting in hip and knee arthroplasty: a prospective cohort study after spinal anaesthesia including intrathecal morphine

BACKGROUND: The overall risk of postoperative nausea and vomiting after general anaesthesia is approximately 30% even with prophylactic medications. Studies exploring the risk after regional anaesthesia including intrathecal morphine are limited but indicate that intrathecal morphine is highly emetogenic and is additive to the PONV risk associated with other forms of anaesthesia. The aim of this observational study was to investigate the risk of PONV after spinal blockade combined with intrathecal morphine and to explore associations with patient and perioperative factors, including given PONV-prophylaxis. We hypothesized that a large number of patients in a clinical setting receive less prophylaxis than the recommendations in guidelines (suboptimal prophylaxis), leading to a higher risk for PONV compared to those receiving adequate PONV prophylaxis. METHODS: The study was conducted as a prospective observational cohort study regarding PONV in patients undergoing hip/knee replacement under spinal anaesthesia including intrathecal morphine. Patients were included at a county hospital in Sweden during April-November 2013 (n = 59) and September 2014-June 2015 (n = 40). One hundred eight patients entered the study with 99 patients analysed in the final cohort. Patients were followed the first three postoperative days with a questionnaire regarding PONV and peri- and postoperative data was collected. PONV risk is presented as the proportion of patients (%) with PONV and was related to the level of perioperative PONV-prophylaxis (suboptimal/optimal). Univariate analysis was used to analyse factors associated with PONV. RESULTS: Forty-six patients (46%) experienced PONV during the 3-day study period whereof 36 patients (36%) until noon the first day after the procedure. 19/27 patients (70%) that received suboptimal PONV-prophylaxis experienced PONV compared to 27/72 (38%) that received optimal PONV-prophylaxis (p = 0.015). Further, female gender and/or a history of motion sickness were associated with an increased PONV-risk. CONCLUSIONS: There was a high risk for PONV after spinal anaesthesia including morphine. PONV risk was associated with the level of prophylaxis and with known risk factors for PONV. Our findings suggest that a more liberal use of PONV prophylaxis might be motivated.