Sustained hypotension during shoulder arthroscopy is associated with postoperative nausea and vomiting

Rili Yu; Xia Yang; Juan Chen; Fan Zhang

doi:10.1371/journal.pone.0357794

Abstract

Background

Postoperative nausea and vomiting (PONV) is a common and distressing complication following shoulder arthroscopy. Although hypotension is known to trigger nausea, the specific association between sustained intraoperative hypotension (SIH) during shoulder arthroscopic surgery and PONV has not been well characterized. This retrospective study aimed to investigate whether SIH is independently associated with PONV.

Methods

We retrospectively analyzed data from 306 patients who underwent shoulder arthroscopy between March 2018 and January 2024. SIH was defined as a ≥ 20% decrease in mean arterial pressure (MAP) from baseline persisting for at least 60 minutes during the controlled hypotension phase. Univariate logistic regression analysis and multivariate exact logistic regression analysis were performed to identify factors associated with the occurrence of PONV. PONV severity was compared between the SIH and non-SIH groups using the chi-square test.

Results

PONV occurred in 96 patients (31.37%). Univariate logistic regression analysis revealed that females, smoking, history of motion sickness and/or PONV, and SIH were related to the occurrence of PONV (all p < 0.05). Multivariate logistic regression analysis revealed that females (adjusted OR: 3.966, 95% CI: 2.149–7.317, p < 0.001), smoking (adjusted OR: 0.232, 95% CI: 0.107–0.501, p < 0.001), history of motion sickness and/or PONV (adjusted OR: 32.393, 95% CI: 3.801–276.051, p = 0.001), and SIH (adjusted OR: 2.198, 95% CI: 1.289–3.749, p = 0.004) were independently associated with the occurrence of PONV. Additionally, patients with SIH exhibited significantly higher severity grades for both nausea (p = 0.002) and vomiting (p = 0.007).

Conclusion

SIH due to controlled hypotension during shoulder arthroscopic surgery was independently associated with PONV. SIH may serve as a clinically relevant predictor for PONV.

Citation: Yu R, Yang X, Chen J, Zhang F (2026) Sustained hypotension during shoulder arthroscopy is associated with postoperative nausea and vomiting. PLoS One 21(9): e0357794. https://doi.org/10.1371/journal.pone.0357794

Editor: Helen Howard, No institution, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND

Received: March 13, 2026; Accepted: August 22, 2026; Published: September 8, 2026

Copyright: © 2026 Yu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The relevant data are available from Dataverse at doi:10.7910/DVN/FELDJC (https://doi.org/10.7910/DVN/FELDJC).

Funding: This research was funded by the Nature Science Foundation of Hunan Province (#2025JJ80482 and #2025JJ60698) http://kjt.hunan.gov.cn/kjt/zxgz/zkjj/zzjg/202502/t20250212_33602215.html. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Postoperative nausea and vomiting (PONV) is the most common complication following surgical anesthesia, with an incidence rate of about 30% in the general population, rising to as high as 80% in high-risk groups [1]. PONV is a very distressing experience that can lead to wound dehiscence, electrolyte imbalance, and aspiration, significantly impacting patients’ satisfaction [2]. Furthermore, PONV is associated with delayed postoperative recovery, prolonged hospital stays, and increased healthcare costs [3]. Therefore, effective prevention and treatment of PONV is a critical component in the practice of enhanced recovery after surgery. The clear identification of the risk factors for PONV is a prerequisite for effective prevention and treatment. Patient-related factors include young females, non-smokers, a history of motion sickness, and/or a history of PONV [4–6]. Surgical factors encompass laparoscopic surgery, cesarean section, and otolaryngology procedures [7–9]. Anesthetic factors include volatile anesthetics, opioid analgesics, tramadol, and other opioids [10–12]. However, despite active interventions and management of the aforementioned factors, a number of patients still suffer from relatively severe PONV. This suggests that we might have overlooked other potential risks for PONV during the perioperative period.

As is well known, hypotension can induce nausea and vomiting. Hypoperfusion of the brainstem and intestine is recognized as a possible mechanism for PONV in hypotensive patients [13]. Interestingly, studies have reported an association between a reduction in the absolute value of mean arterial pressure during surgery (< 50 mmHg) and an elevated occurrence of PONV [13,14]. However, an absolute mean arterial pressure of less than 50 mmHg during surgery is an infrequent event and poses a significant risk of inadequate perfusion to vital organs, including the heart and brain. Another study confirms that a decrease in systolic blood pressure of more than 35% from baseline during the induction of anesthesia is associated with PONV, but that hypotension during the maintenance phase is not significantly related to PONV, and the reason is unclear [15]. However, intraoperative hypotension is generally defined as a decrease in blood pressure of more than 20% from baseline [16], and the duration of the hypotensive episodes should also be taken into account. The relationship between controlled, sustained intraoperative hypotension (SIH) during shoulder arthroscopy—a procedure characterized by the beach-chair position and deliberately induced and maintained hypotension—and PONV has not been specifically investigated. This study aims to investigate the association between SIH during shoulder arthroscopy and PONV, with the goal of informing more effective management strategies for PONV.

Methods

Study design and participants

This was a retrospective, observational, single-center cohort study. The study population consisted of patients who had exclusively undergone shoulder arthroscopic surgery at the Third Xiangya Hospital of Central South University between March 20, 2018, and January 31, 2024. The inclusion criteria were as follows: patients aged between 18 and 75 years, those who received general anesthesia, those with complete blood pressure recordings throughout the surgical procedure, those who used patient-controlled intravenous analgesia (PCIA) pumps following surgery, and those with detailed postoperative follow-up records regarding nausea and vomiting. The exclusion criteria were patients who underwent a composite surgery involving shoulder arthroscopy and those with incomplete clinical data.

This study was performed according to the guidelines of the Helsinki Declaration and approved by the Institutional Review Board of the Third Xiangya Hospital of Central South University (Date: 28/04/2024, Approval No.: K24371). The requirement for informed consent was waived for retrospectively collected data, in compliance with both national legislation and institutional guidelines. To protect the privacy of participants in this study, the personal identification data of the enrolled individuals was anonymized and replaced with a coding system.

Data collection

The data access date for this research was set as June 26th, 2024. Intraoperative blood pressure and anesthesia-related variables were extracted by a researcher blinded to PONV outcomes, while PONV data were extracted by another researcher blinded to blood pressure data and SIH classification. Thus, exposure and outcome data were collected independently. However, owing to the retrospective design, clinicians who originally documented PONV during routine postoperative care were not blinded to the study hypothesis. In addition, a third researcher carried out data monitoring and source-data verification in strict accordance with a pre-established plan.

We collected baseline data of all selected patients including demographic data: age, gender, height, weight, smoking history, history of motion sickness and/or PONV. Intraoperatively, we considered factors such as inhalation anesthetics and opioid dosage, the duration of procedure and controlled hypotension, MAP and liquid intake. Postoperative follow-up included assessment of PONV and pain, and postoperative opioid dosage. Among them, postoperative pain was considered a potential post-outcome variable. It was considered only for univariate descriptive analysis, and was excluded from the primary multivariate regression model to prevent timing-related bias.

Anesthesia management

Anesthesia was managed by experienced and specialized anesthesiologists. All participants received combined intravenous and sevoflurane inhalation anesthesia. They underwent shoulder arthroscopic procedures in the beach‑chair position, and received an interscalene block. The opioid analgesics used during the operation, including sufentanil, oxycodone, dezocine, and other opioids were converted to equivalent doses of sufentanil. Controlled hypotension, which involves maintaining the systolic blood pressure within a range of 90–100 mmHg, is essential for minimizing intraoperative blood loss and enhancing visualization of shoulder arthroscopy. Under the premise of maintaining appropriate sedation and analgesia, if the systolic blood pressure was still above 100 mmHg, nitroglycerin was employed to maintain the patient's systolic blood pressure within a targeted range of 90–100 mmHg through intravenous infusion. Vasoactive drugs (such as norepinephrine or ephedrine) were primarily used to correct hypotension that fell below the target or caused hemodynamic instability. All patients received 8 mg of ondansetron intravenously thirty minutes before the end of surgery to prevent PONV, without any other antiemetics during the procedure. For postoperative analgesia, all patients were equipped with PCIA pumps delivering sufentanil.

Blood pressure assessment

Baseline blood pressure was defined as the average of three readings recorded upon patient admission. Intraoperatively, invasive arterial blood pressure monitoring was employed, with periodic recordings every five minutes. A 20% decrease in MAP from baseline is a widely accepted threshold [16]. In addition, previous literature has reported that the duration of hypotension is associated with PONV [20]. The duration of controlled hypotension during shoulder arthroscopy ranges from 60 to 80 minutes based on the retrospective data from this study. A ≥ 60-minute duration captured sustained hypotension relevant to this specific surgery. Thus, SIH was defined as a decrease in MAP of at least 20% below baseline that persisted for 60 minutes or more during the controlled hypotension phase. To assess the robustness of the results to variations in SIH definition, we conducted sensitivity analyses using different MAP reduction thresholds and duration cutoffs: (1) Model A: MAP drop ≥20% from baseline lasting for ≥30 minutes. (2) Model B: MAP drop ≥30% from baseline lasting for ≥60 minutes.

PONV assessment

In our institution, postoperative assessments in the post-anesthesia care unit (PACU) and wards are conducted by nursing staff and anesthesiologists following strict standard operating procedures. Vital signs and subjective symptoms (including PONV) are required to be recorded at specific time points: upon admission to and discharge from the PACU, and in the ward at 24 and 48 hours after surgery. The assessment was based on the documentation provided by the attending healthcare professionals, which included the timing and severity of PONV symptoms. The postoperative nausea scale was categorized as follows: 0-absence of nausea; 1-no nausea at rest, experienced with movement; 2-infrequent nausea at rest; 3-persistent nausea at rest, with severe nausea upon movement. The postoperative vomiting scale was rated as: 0-no vomiting; 1-mild vomiting, occurring one to two times daily; 2-moderate vomiting, happening three to five times daily; 3-severe vomiting, more than six times daily. In cases where the nausea and vomiting scores were both zero, the patient was deemed to have no postoperative nausea and vomiting (n-PONV); otherwise, PONV was considered present. The administration of rescue antiemetics (such as metoclopramide or tropisetron) is rigorously documented in the electronic medical record. In this study, the administration of any rescue antiemetic was automatically categorized as a “PONV present” event, ensuring that patients who received treatment but whose detailed symptom scores might have been incompletely documented were still correctly identified.

Postoperative pain evaluation

The patient's level of pain was evaluated using the numeric rating scale (NRS) at 24 hours and 48 hours after surgery, wherein patients were prompted to select a numerical value that most closely corresponds to their pain level, both at rest and during movement. The NRS scores are classified as follows: 0: no pain; 1–3: mild pain; 4–6: moderate pain; 7–10: severe pain.

Statistical analysis

Statistical analyses were performed using SPSS 25.0 (SPSS Inc., Chicago, IL, USA) and SAS 9.4 (SAS Institute, Cary, NC, USA). The Kolmogorov–Smirnov test was utilized to determine whether the continuous variables conformed to a normal distribution. For continuous variables with a normal distribution, the data were presented as means±standard deviations; for non–normally distributed continuous variables, they were presented as medians and interquartile ranges; and for enumeration data, they were presented as frequencies. To assess the differences between two groups of continuous variables, the unpaired t test was employed for variables with a normal distribution, while the Mann–Whitney U test was utilized for those with a non-normal distribution. For enumeration data, the χ² test was used for comparison.

Univariate logistic regression analysis was employed to screen perioperative factors for their association with PONV. Variables with a p-value <0.10 in univariate analysis were considered for inclusion in the multivariate model. Multicollinearity was assessed using Variance Inflation Factor (VIF); all VIF values in the final model were below 2.0, indicating no concerning multicollinearity among the four independent variables (female sex, smoking, history of motion sickness/PONV, and SIH). The final model included 4 independent variables with 96 PONV events, yielding an EPV ratio of 24, which substantially exceeds both the conventional minimum threshold of 10 events per variable and the more stringent criterion of 20, ensuring stable parameter estimates and reliable confidence intervals. Given the sparse data observed for the history of motion sickness/PONV variable, which caused quasi-complete separation in standard logistic regression, multivariate exact logistic regression was employed to provide more reliable estimates in the presence of small cell sizes. The area under the receiver operating characteristic curve (AUC-ROC) was used to assess model discrimination, with AUC > 0.7 indicating adequate discrimination. Sensitivity analyses were performed using alternative definitions of SIH: Model A (≥20% MAP drop for ≥30 minutes) and Model B (≥30% MAP drop for ≥60 minutes). A p-value <0.05 was considered statistically significant.

Results

In our study, a total of 306 patients who underwent shoulder arthroscopic surgery were included. PONV was observed in 96 patients, whereas it was absent in 210 patients (Fig 1). The incidence rate of PONV was 31.37%. Although controlled hypotension was performed during the surgery, no adverse neurological sequelae, including sensory, motor, or cognitive impairments, were observed in any patient in this study.

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Fig 1. Flow chart for patient selection.

https://doi.org/10.1371/journal.pone.0357794.g001

Baseline demographic and clinical characteristics of patients

In the present study, patients with PONV exhibited a higher proportion of females (70 [72.92%] of 96 patients in the PONV group vs. 119 [56.67%] of 210 patients in the n-PONV group), a history of motion sickness and/or PONV (8 [8.33%] of 96 patients in the PONV group vs. 1 [0.48%] of 210 patients in the n-PONV group), and SIH (61 [63.54%] of 96 patients in the PONV group vs. 91 [43.33%] of 210 patients in the n-PONV group) (all p < 0.01), but a lower proportion of smokers (11 [11.46%] of 96 patients in the PONV group vs. 49 [23.33%] of 210 patients in the n-PONV group) (p < 0.05). There were no significant differences in other demographic and clinical parameters, including age, weight, height, duration of procedure, intraoperative sevoflurane and analgesic dosages, liquid intake, duration of controlled hypotension, postoperative analgesic dosage and pain (all p > 0.05) (Table 1).

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Table 1. Comparison of demographic characteristics and clinical data between groups.

https://doi.org/10.1371/journal.pone.0357794.t001

The relationship between the perioperative factors and the occurrence of PONV

Univariate logistic regression analysis was utilized to explore the association between perioperative factors and the occurrence of PONV among patients undergoing shoulder arthroscopy. It showed that females (OR: 2.059, 95% CI: 1.216–3.485), smokers (OR: 0.425, 95% CI: 0.210–0.860), history of motion sickness and/or PONV (OR: 19.000, 95% CI: 2.341–154.186), and SIH (OR: 2.279, 95% CI: 1.386–3.747) were related to the occurrence of PONV (Table 2). Other factors, including patient demographics (age, weight, height), procedural details (duration of procedure, intraoperative sevoflurane and analgesic dosages, Intraoperative use of nitroglycerin and vasopressors, liquid intake, and duration of controlled hypotension), as well as postoperative variables (postoperative analgesic dosage and pain), showed no significant association with the occurrence of PONV (all p > 0.05) (Table 2).

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Table 2. Univariate logistic regression analysis results of factors related to the occurrence of PONV.

https://doi.org/10.1371/journal.pone.0357794.t002

Multivariate exact logistic regression analysis revealed that females (OR: 3.966, 95% CI: 2.149–7.317, p < 0.001), smoking (OR: 0.232, 95% CI: 0.107–0.501, p < 0.001), history of motion sickness and/or PONV (OR: 32.393, 95% CI: 3.801–276.051, p = 0.001), and SIH (OR: 2.198, 95% CI: 1.289–3.749, p = 0.004) were independently associated with the occurrence of PONV in patients who underwent shoulder arthroscopy (Table 3). The AUC was 0.730 (95% CI: 0.667–0.793), indicating acceptable discrimination.

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Table 3. Multivariate logistic regression analysis results of the occurrence of PONV.

https://doi.org/10.1371/journal.pone.0357794.t003

Sensitivity analysis indicated that model A (MAP drop ≥20% from baseline lasting for ≥30 minutes) showed a weak association with the occurrence of PONV (OR: 1.710, 95% CI: 1.041–2.808, p = 0.034). Model B was similar to model A (OR: 1.763, 95% CI: 1.080–2.878, p = 0.023), but model B had limited statistical power due to a smaller sample size meeting the stricter threshold.

SIH and severity of PONV

There was a statistically significant difference in nausea severity between the two groups (χ² = 14.510, p = 0.002). In the n-SIH group, 119 patients reported absence of nausea (Grade 0), while 19 patients experienced nausea only with movement (Grade 1), 14 patients had infrequent nausea at rest (Grade 2), and only 2 patients had persistent nausea with severe nausea upon movement (Grade 3). In contrast, the SIH group showed a higher proportion of patients with more severe nausea: 91 patients had no nausea, 22 had Grade 1 nausea, 29 had Grade 2 nausea, and 10 had Grade 3 nausea (Table 4).

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Table 4. Comparison of PONV severity between the SIH and n-SIH groups.

https://doi.org/10.1371/journal.pone.0357794.t004

For postoperative vomiting grading: A statistically significant difference was also observed in vomiting severity between the two groups (χ² = 12.070, p = 0.007). In the n-SIH group, 122 patients reported no vomiting (Grade 0), 18 had mild vomiting (1–2 times daily, Grade 1), 13 had moderate vomiting (3–5 times daily, Grade 2), and only 1 patient had severe vomiting (>6 times daily, Grade 3). In the SIH group, 98 patients had no vomiting, 21 had Grade 1 vomiting, 25 had Grade 2 vomiting, and 8 patients had severe vomiting (Grade 3) (Table 4).

Furthermore, we performed a stratified analysis to differentiate early PONV (occurring in the PACU, 0–2 hours after surgery) from late PONV (occurring within 2–48 hours postoperatively). Our analysis showed that SIH was significantly associated with early PONV (OR: 2.079, 95% CI: 1.252–3.454, p = 0.005) and late PONV (OR: 2.448, 95% CI: 1.467–4.086, p = 0.001).

Discussion

In this study, we discovered that females, smoking, history of motion sickness and/or PONV, and SIH were independently associated with the occurrence of PONV in patients who underwent shoulder arthroscopy. Moreover, SIH showed a higher proportion of patients with more severe PONV.

PONV is one of the most common complications following surgical anesthesia, and its prevention and treatment have received high attention from anesthesiologists and surgeons. Medications used for the prevention and treatment of PONV include 5-HT3 receptor antagonists, dexamethasone, antihistamines, dopamine receptor antagonists, and NK1 receptor antagonists [1,17,18]. However, the prevention and treatment effects of PONV are not ideal. The occurrence of PONV is often predicted using the Apfel scores [19], which include risk factors such as females, history of motion sickness and/or PONV, and non-smoking, which is consistent with our findings. However, SIH is not included in the traditional Apfel score. The relationship between SIH and PONV is not entirely clear.

Previous limited studies have found that hypotension during general anesthesia is associated with PONV [14,15,20], but there is controversy [21], and the definition of intraoperative hypotension varies. Pusch et al. confirm that a decrease in systolic blood pressure of more than 35% from baseline during the induction of anesthesia is associated with PONV, but that hypotension during the maintenance phase is not significantly related to PONV [15]. Nakatani et al. discover that the cumulative duration of hypotension during thyroidectomy is associated with PONV [20]. Maleczek et al. through retrospective analysis, identify that intraoperative MAP below 50 mmHg for more than 1.8 minutes is a predictor for PONV [14]. Unlike these studies, our research uniquely revealed that MAP dropping below 20% of the baseline value and lasting for at least 60 minutes during shoulder arthroscopy was associated with an increased occurrence of PONV. To minimize intraoperative bleeding and enhance the visibility of the surgical field, patients are required to undergo controlled hypotension while in the beach-chair position during shoulder arthroscopy. In this position, due to the effect of gravity, cerebral perfusion pressure is significantly lower than the systemic pressure measured at arm level. This treatment can also significantly decrease local cerebral oxygen saturation in patients [22]. The above factors can directly cause relative ischemia in brainstem-related regions [14,15], reduce intestinal perfusion [22], and lead to excessive excitement of the vagus nerve and subsequent symptoms of nausea and vomiting. Our study is the first time to specifically examine PONV in the context of sustained hypotension during shoulder arthroscopy, and link both the threshold and duration of hypotension to PONV in this surgical setting. The novelty lies in the specific clinical scenario (controlled hypotension + beach-chair position), not in the general concept of hypotension causing PONV.

Our findings have several practical implications for perioperative care. Anesthesiologists should be aware that sustained hypotension during shoulder arthroscopy is not merely a hemodynamic consideration but may also be associated with clinically meaningful consequences for PONV. In particular, prolonged reductions in MAP of ≥20% from baseline lasting 60 minutes or more warrant careful attention. However, our findings do not suggest that controlled hypotension should be abandoned during shoulder arthroscopy, as it remains an important technique for reducing intraoperative bleeding and improving surgical visualization. Rather, unnecessary prolongation or excessive depth of hypotension should be avoided whenever possible. In patients with established PONV risk factors, particularly those identified by the Apfel score, closer hemodynamic monitoring and more aggressive multimodal PONV prophylaxis may be warranted. Any modification of hypotension strategies must be balanced against surgical field quality, bleeding control, cerebral perfusion, and overall patient safety. Future prospective studies are needed to determine whether optimizing hypotension management, or reducing the need for sustained controlled hypotension through strategies such as epinephrine-containing irrigation fluid, can decrease PONV without compromising surgical outcomes.

There are the following confounding factors in this study. All patients routinely received 8 mg of ondansetron intravenously thirty minutes before the end of surgery. This standardized prophylaxis may have masked the true pathophysiological effect of SIH on PONV, potentially leading to an underestimation of the association. All patients used opioid-based PCIA pumps postoperatively. Opioids are a well-known cause of PONV, and this uniform exposure may have acted as a confounder. However, the total postoperative opioid dosage did not differ significantly between the PONV and n-PONV groups (p = 0.758), suggesting that opioid use did not drive the observed association in our cohort. While we adjusted for several anesthesia-related variables (e.g., sevoflurane dosage, intraoperative opioid dosage, use of nitroglycerin and vasopressors), residual confounding from unmeasured factors (e.g., depth of anesthesia, or use of other adjunct medications) cannot be excluded.

It should be pointed out that this study has certain limitations. First, due to the retrospective nature of this study, we cannot establish causality between SIH and PONV. Our findings demonstrate an association only, and prospective randomized controlled trials are needed to confirm these results. Second, this study was conducted at a single tertiary medical center, which may limit the generalizability of our findings to other institutions or patient populations with different perioperative management protocols. Third, selection bias may be present, as only patients with complete blood pressure recordings and detailed postoperative follow-up records were included. Patients with incomplete records were excluded, and no data imputation was performed. Therefore, the potential influence of missing data on the study findings cannot be completely ruled out. In addition, outcome assessment was based on retrospective medical record review, which may have introduced information bias. Fourth, the small number of patients with a history of motion sickness and/or PONV (n = 9) led to wide confidence intervals for this predictor in the multivariate analysis, indicating model instability. Although multivariate exact logistic regression was used to address this issue, the results for this variable should be interpreted with caution. Fifth, all patients uniformly received 8 mg of ondansetron as prophylaxis. This universal intervention may have suppressed the true incidence and severity of PONV, potentially underestimating the association between SIH and PONV. Finally, neurological outcomes were not prospectively assessed; therefore, the absence of documented neurological sequelae in our retrospective data does not preclude the possibility of subclinical events.

Conclusion

SIH due to controlled hypotension during shoulder arthroscopic surgery was independently associated with PONV.

Acknowledgments

We are grateful to the Third Xiangya Hospital of Central South University for providing all necessary assistance.

References

1. Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020;131(2):411–48. pmid:32467512
- View Article
- PubMed/NCBI
- Google Scholar
2. Khanna SS, Mohammed Abdul MS, Fatima U, Garlapati H, Qayyum MA, Gulia SK. Role of general anesthetic agents in postoperative nausea and vomiting: A review of literature. Natl J Maxillofac Surg. 2022;13(2):190–4. pmid:36051800
- View Article
- PubMed/NCBI
- Google Scholar
3. Meyer TA, Habib AS, Wagner D, Gan TJ. Neurokinin-1 receptor antagonists for the prevention of postoperative nausea and vomiting. Pharmacotherapy. 2023;43(9):922–34. pmid:37166582
- View Article
- PubMed/NCBI
- Google Scholar
4. Darvall J, Handscombe M, Maat B, So K, Suganthirakumar A, Leslie K. Interpretation of the four risk factors for postoperative nausea and vomiting in the Apfel simplified risk score: an analysis of published studies. Can J Anaesth. 2021;68(7):1057–63. pmid:33721198
- View Article
- PubMed/NCBI
- Google Scholar
5. Rajan N, Joshi GP. Management of postoperative nausea and vomiting in adults: current controversies. Curr Opin Anaesthesiol. 2021;34(6):695–702. pmid:34560688
- View Article
- PubMed/NCBI
- Google Scholar
6. Echeverria-Villalobos M, Fiorda-Diaz J, Uribe A, Bergese SD. Postoperative Nausea and Vomiting in Female Patients Undergoing Breast and Gynecological Surgery: A Narrative Review of Risk Factors and Prophylaxis. Front Med (Lausanne). 2022;9:909982. pmid:35847822
- View Article
- PubMed/NCBI
- Google Scholar
7. Wolk RL, Lalwani AK, Pagano PP. Is dexamethasone effective in preventing nausea and vomiting after common otolaryngology procedures? Laryngoscope. 2017;127(7):1493–5. pmid:28271536
- View Article
- PubMed/NCBI
- Google Scholar
8. Tan HS, Habib AS. The optimum management of nausea and vomiting during and after cesarean delivery. Best Pract Res Clin Anaesthesiol. 2020;34(4):735–47. pmid:33288123
- View Article
- PubMed/NCBI
- Google Scholar
9. Salamah HM, Elsayed E, Brakat AM, Abualkhair KA, Hussein MA, Saber SM, et al. The effects of acupressure on postoperative nausea and vomiting among patients undergoing laparoscopic surgery: A meta-analysis of randomized controlled trials. Explore (NY). 2023;19(3):300–9. pmid:36319586
- View Article
- PubMed/NCBI
- Google Scholar
10. Sriganesh K, Bharadwaj S, Shanthanna H, Rao GSU, Kramer BW, Sathyaprabha TN. Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials. Eur Spine J. 2023;32(1):289–300. pmid:36437435
- View Article
- PubMed/NCBI
- Google Scholar
11. Schaefer MS, Kranke P, Weibel S, Kreysing R, Kienbaum P. Total intravenous anaesthesia versus single-drug pharmacological antiemetic prophylaxis in adults: A systematic review and meta-analysis. Eur J Anaesthesiol. 2016;33(10):750–60. pmid:27454663
- View Article
- PubMed/NCBI
- Google Scholar
12. Derry S, Cooper TE, Phillips T. Single fixed-dose oral dexketoprofen plus tramadol for acute postoperative pain in adults. Cochrane Database Syst Rev. 2016;9(9):CD012232. pmid:27654994
- View Article
- PubMed/NCBI
- Google Scholar
13. Goss S, Jedlicka J, Strinitz E, Niedermayer S, Chappell D, Hofmann-Kiefer K, et al. Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective cohort study. Curr Med Res Opin. 2024;40(8):1439–48. pmid:38946490
- View Article
- PubMed/NCBI
- Google Scholar
14. Maleczek M, Laxar D, Geroldinger A, Kimberger O. Intraoperative Hypotension Is Associated with Postoperative Nausea and Vomiting in the PACU: A Retrospective Database Analysis. J Clin Med. 2023;12(5):2009. pmid:36902796
- View Article
- PubMed/NCBI
- Google Scholar
15. Pusch F, Berger A, Wildling E, Tiefenthaler W, Krafft P. The effects of systolic arterial blood pressure variations on postoperative nausea and vomiting. Anesth Analg. 2002;94(6):1652–5, table of contents. pmid:12032046
- View Article
- PubMed/NCBI
- Google Scholar
16. Gregory A, Stapelfeldt WH, Khanna AK, Smischney NJ, Boero IJ, Chen Q, et al. Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery. Anesth Analg. 2021;132(6):1654–65. pmid:33177322
- View Article
- PubMed/NCBI
- Google Scholar
17. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693–700. pmid:10485781
- View Article
- PubMed/NCBI
- Google Scholar
18. Williams BA, Holder-Murray JM, Nettrour JF, Ibinson JW, DeRenzo JS, Dalessandro C, et al. Aim for zero: prevention of postoperative nausea and vomiting using an off-patent five-drug multimodal approach. Br J Anaesth. 2023;131(1):e1–4. pmid:36737386
- View Article
- PubMed/NCBI
- Google Scholar
19. Sakanoue H, Yamaji H, Okamoto S, Okano K, Fujita Y, Higashiya S, et al. Incidence of nausea/vomiting following propofol sedation with adaptive servo-ventilation for atrial fibrillation ablation. J Arrhythm. 2024;40(2):289–96. pmid:38586848
- View Article
- PubMed/NCBI
- Google Scholar
20. Nakatani H, Naito Y, Ida M, Sato M, Okamoto N, Nishiwada T, et al. Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective analysis of 247 thyroidectomy cases. Braz J Anesthesiol. 2023;73(5):635–40. pmid:33766682
- View Article
- PubMed/NCBI
- Google Scholar
21. Kranke P, Roewer N, Rüsch D, Piper SN. Arterial hypotension during induction of anesthesia may not be a risk factor for postoperative nausea and vomiting. Anesth Analg. 2003;96(1):302–3; author reply 303. pmid:12505973
- View Article
- PubMed/NCBI
- Google Scholar
22. Gan TJ, Mythen MG, Glass PS. Intraoperative gut hypoperfusion may be a risk factor for postoperative nausea and vomiting. Br J Anaesth. 1997;78(4):476. pmid:9135331
- View Article
- PubMed/NCBI
- Google Scholar

[ref1] 1. Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020;131(2):411–48. pmid:32467512
View Article
PubMed/NCBI
Google Scholar

[2] View Article

[3] PubMed/NCBI

[4] Google Scholar

[ref2] 2. Khanna SS, Mohammed Abdul MS, Fatima U, Garlapati H, Qayyum MA, Gulia SK. Role of general anesthetic agents in postoperative nausea and vomiting: A review of literature. Natl J Maxillofac Surg. 2022;13(2):190–4. pmid:36051800
View Article
PubMed/NCBI
Google Scholar

[6] View Article

[7] PubMed/NCBI

[8] Google Scholar

[ref3] 3. Meyer TA, Habib AS, Wagner D, Gan TJ. Neurokinin-1 receptor antagonists for the prevention of postoperative nausea and vomiting. Pharmacotherapy. 2023;43(9):922–34. pmid:37166582
View Article
PubMed/NCBI
Google Scholar

[10] View Article

[11] PubMed/NCBI

[12] Google Scholar

[ref4] 4. Darvall J, Handscombe M, Maat B, So K, Suganthirakumar A, Leslie K. Interpretation of the four risk factors for postoperative nausea and vomiting in the Apfel simplified risk score: an analysis of published studies. Can J Anaesth. 2021;68(7):1057–63. pmid:33721198
View Article
PubMed/NCBI
Google Scholar

[14] View Article

[15] PubMed/NCBI

[16] Google Scholar

[ref5] 5. Rajan N, Joshi GP. Management of postoperative nausea and vomiting in adults: current controversies. Curr Opin Anaesthesiol. 2021;34(6):695–702. pmid:34560688
View Article
PubMed/NCBI
Google Scholar

[18] View Article

[19] PubMed/NCBI

[20] Google Scholar

[ref6] 6. Echeverria-Villalobos M, Fiorda-Diaz J, Uribe A, Bergese SD. Postoperative Nausea and Vomiting in Female Patients Undergoing Breast and Gynecological Surgery: A Narrative Review of Risk Factors and Prophylaxis. Front Med (Lausanne). 2022;9:909982. pmid:35847822
View Article
PubMed/NCBI
Google Scholar

[22] View Article

[23] PubMed/NCBI

[24] Google Scholar

[ref7] 7. Wolk RL, Lalwani AK, Pagano PP. Is dexamethasone effective in preventing nausea and vomiting after common otolaryngology procedures? Laryngoscope. 2017;127(7):1493–5. pmid:28271536
View Article
PubMed/NCBI
Google Scholar

[26] View Article

[27] PubMed/NCBI

[28] Google Scholar

[ref8] 8. Tan HS, Habib AS. The optimum management of nausea and vomiting during and after cesarean delivery. Best Pract Res Clin Anaesthesiol. 2020;34(4):735–47. pmid:33288123
View Article
PubMed/NCBI
Google Scholar

[30] View Article

[31] PubMed/NCBI

[32] Google Scholar

[ref9] 9. Salamah HM, Elsayed E, Brakat AM, Abualkhair KA, Hussein MA, Saber SM, et al. The effects of acupressure on postoperative nausea and vomiting among patients undergoing laparoscopic surgery: A meta-analysis of randomized controlled trials. Explore (NY). 2023;19(3):300–9. pmid:36319586
View Article
PubMed/NCBI
Google Scholar

[34] View Article

[35] PubMed/NCBI

[36] Google Scholar

[ref10] 10. Sriganesh K, Bharadwaj S, Shanthanna H, Rao GSU, Kramer BW, Sathyaprabha TN. Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials. Eur Spine J. 2023;32(1):289–300. pmid:36437435
View Article
PubMed/NCBI
Google Scholar

[38] View Article

[39] PubMed/NCBI

[40] Google Scholar

[ref11] 11. Schaefer MS, Kranke P, Weibel S, Kreysing R, Kienbaum P. Total intravenous anaesthesia versus single-drug pharmacological antiemetic prophylaxis in adults: A systematic review and meta-analysis. Eur J Anaesthesiol. 2016;33(10):750–60. pmid:27454663
View Article
PubMed/NCBI
Google Scholar

[42] View Article

[43] PubMed/NCBI

[44] Google Scholar

[ref12] 12. Derry S, Cooper TE, Phillips T. Single fixed-dose oral dexketoprofen plus tramadol for acute postoperative pain in adults. Cochrane Database Syst Rev. 2016;9(9):CD012232. pmid:27654994
View Article
PubMed/NCBI
Google Scholar

[46] View Article

[47] PubMed/NCBI

[48] Google Scholar

[ref13] 13. Goss S, Jedlicka J, Strinitz E, Niedermayer S, Chappell D, Hofmann-Kiefer K, et al. Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective cohort study. Curr Med Res Opin. 2024;40(8):1439–48. pmid:38946490
View Article
PubMed/NCBI
Google Scholar

[50] View Article

[51] PubMed/NCBI

[52] Google Scholar

[ref14] 14. Maleczek M, Laxar D, Geroldinger A, Kimberger O. Intraoperative Hypotension Is Associated with Postoperative Nausea and Vomiting in the PACU: A Retrospective Database Analysis. J Clin Med. 2023;12(5):2009. pmid:36902796
View Article
PubMed/NCBI
Google Scholar

[54] View Article

[55] PubMed/NCBI

[56] Google Scholar

[ref15] 15. Pusch F, Berger A, Wildling E, Tiefenthaler W, Krafft P. The effects of systolic arterial blood pressure variations on postoperative nausea and vomiting. Anesth Analg. 2002;94(6):1652–5, table of contents. pmid:12032046
View Article
PubMed/NCBI
Google Scholar

[58] View Article

[59] PubMed/NCBI

[60] Google Scholar

[ref16] 16. Gregory A, Stapelfeldt WH, Khanna AK, Smischney NJ, Boero IJ, Chen Q, et al. Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery. Anesth Analg. 2021;132(6):1654–65. pmid:33177322
View Article
PubMed/NCBI
Google Scholar

[62] View Article

[63] PubMed/NCBI

[64] Google Scholar

[ref17] 17. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693–700. pmid:10485781
View Article
PubMed/NCBI
Google Scholar

[66] View Article

[67] PubMed/NCBI

[68] Google Scholar

[ref18] 18. Williams BA, Holder-Murray JM, Nettrour JF, Ibinson JW, DeRenzo JS, Dalessandro C, et al. Aim for zero: prevention of postoperative nausea and vomiting using an off-patent five-drug multimodal approach. Br J Anaesth. 2023;131(1):e1–4. pmid:36737386
View Article
PubMed/NCBI
Google Scholar

[70] View Article

[71] PubMed/NCBI

[72] Google Scholar

[ref19] 19. Sakanoue H, Yamaji H, Okamoto S, Okano K, Fujita Y, Higashiya S, et al. Incidence of nausea/vomiting following propofol sedation with adaptive servo-ventilation for atrial fibrillation ablation. J Arrhythm. 2024;40(2):289–96. pmid:38586848
View Article
PubMed/NCBI
Google Scholar

[74] View Article

[75] PubMed/NCBI

[76] Google Scholar

[ref20] 20. Nakatani H, Naito Y, Ida M, Sato M, Okamoto N, Nishiwada T, et al. Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective analysis of 247 thyroidectomy cases. Braz J Anesthesiol. 2023;73(5):635–40. pmid:33766682
View Article
PubMed/NCBI
Google Scholar

[78] View Article

[79] PubMed/NCBI

[80] Google Scholar

[ref21] 21. Kranke P, Roewer N, Rüsch D, Piper SN. Arterial hypotension during induction of anesthesia may not be a risk factor for postoperative nausea and vomiting. Anesth Analg. 2003;96(1):302–3; author reply 303. pmid:12505973
View Article
PubMed/NCBI
Google Scholar

[82] View Article

[83] PubMed/NCBI

[84] Google Scholar

[ref22] 22. Gan TJ, Mythen MG, Glass PS. Intraoperative gut hypoperfusion may be a risk factor for postoperative nausea and vomiting. Br J Anaesth. 1997;78(4):476. pmid:9135331
View Article
PubMed/NCBI
Google Scholar

[86] View Article

[87] PubMed/NCBI

[88] Google Scholar

Figures

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Study design and participants

Data collection

Anesthesia management

Blood pressure assessment

PONV assessment

Postoperative pain evaluation

Statistical analysis

Results

Baseline demographic and clinical characteristics of patients

The relationship between the perioperative factors and the occurrence of PONV

SIH and severity of PONV

Discussion

Conclusion

Acknowledgments

References