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The Relationship of Intravenous Dextrose
Administration During Emergence from Anesthesia
to Postoperative Nausea and Vomiting: A Randomized
Controlled Trial
Parul Patel, MD,* Minhthy N. Meineke, MD,* Thomas Rasmussen, MD,* Donald L. Anderson, MD,*
Jennifer Brown, MSN, CRNA,† Sam Siddighi, MD, MS,‡ and Richard L. Applegate II, MD*
BACKGROUND: Postoperative nausea and vomiting (PONV) may occur despite antiemetic prophylaxis and is associated with unanticipated hospital admission, financial impact, and patient
dissatisfaction. Previous studies have shown variable impact of IV dextrose on PONV. We sought
to determine the relationship of IV dextrose administered during emergence from anesthesia
to PONV.
METHODS: This was a prospective, double-blind randomized placebo-controlled trial. Adult
female ASA physical status I and II nondiabetic patients scheduled for outpatient gynecologic,
urologic, or breast surgery were randomly assigned to infusion of 250 mL lactated Ringer’s solution (group P; n = 75) or dextrose 5% in lactated Ringer’s solution (group D; n = 87) over 2 hours
beginning with surgical closing. Blood glucose was determined using a point-of-care device
before transfer to the operating room, in the operating room immediately before study fluid infusion, and in the recovery room after study fluid infusion. No antiemetics were given before arrival
in the recovery room. PONV scores were recorded at 0, 30, 60, and 120 minutes and 24 hours
after arrival in the recovery room. Medication administration was recorded.
RESULTS: Data from 162 patients with normal baseline blood glucose were analyzed. There
were no significant intergroup differences in demographics, history of PONV, or tobacco use.
There was no significant intergroup difference in PONV during the first 2 hours after anesthesia
(group D 52.9% vs group P 46.7%; difference, 6.2%; 95% confidence interval [CI], −9.2% to
21.6%; P = 0.43). Patients in groups D or P who developed PONV within 2 hours of anesthesia
had similar number of severity scores ≥1 during recovery stay (1.5 vs 1.0; difference, 0; 95% CI,
0%–0%; P = 0.93); and similar proportions of: PONV onset within 30 minutes of recovery room
arrival (65.2% vs 57.1%; difference, 8.1%; 95% CI, −13.1% to 28.8%; P = 0.46); more than 1
dose of antiemetic medication (56.5% vs 62.9%; difference, 6.3%; 95% CI, −26.9% to 15.1%;
P = 0.65); or more than 1 class of antiemetic medication (50.0% vs 54.3%; difference, 4.3%;
95% CI, −25.5% to 17.4%; P = 0.82).
CONCLUSIONS: The administration of dextrose during emergence from anesthesia was not
associated with a difference in the incidence of PONV exceeding 20% or in the severity of PONV
in the first 2 hours after anesthesia. The relationship between PONV and the optimal dose and
timing of IV dextrose administration remains unclear and may warrant further study. (Anesth
Analg 2013;XX:XX–XX)
T
he risk of developing postoperative nausea and vomiting (PONV) is at least 30% in general surgery patients1
and is up to 80% in high-risk surgical patients.2 In the
approximately 80 million outpatient and inpatient surgeries performed in the United States each year,3,4 PONV is a
From the *Department of Anesthesiology, Loma Linda University School
of Medicine; †Loma Linda University School of Nursing; and ‡Department
of Gynecology and Obstetrics, Loma Linda University School of Medicine,
Loma Linda, California.
Accepted for publication March 08, 2013
Funding: The sole source of funding for this study was the Department of
Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA.
The authors declare no conflict of interest.
An abstract based on part of this study was presented at the 2011 Annual
Meeting of the IARS, Vancouver, BC, Canada, May 2011; S-17.
Reprints will not be available from the authors.
Address correspondence to Richard L. Applegate II, MD, Department of
Anesthesiology, Loma Linda University School of Medicine, Room 2532
LLUMC, 11234 Anderson Street, Loma Linda, CA92354. Address e-mail to
[email protected].
Copyright © 2013 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e318292ed5f
leading cause of unexpected admission to the hospital after
outpatient surgery, contributing to unanticipated admission
in 0.1% to 0.2%.5–8 Preventing PONV is reported to be economically beneficial.9 From the patient’s perspective, vomiting can be a worse experience than postoperative pain.10
Patients at the highest PONV risk include patients of female
gender, nonsmokers, and those with a history of PONV or
motion sickness.11,12
Previous investigations into the impact of IV fluid and
dextrose administration on the incidence of PONV and the
use of antiemetic medications have reported variable results.
Some investigators have reported that IV fluid or dextrose
administration in the perianesthetic period is associated
with decreased PONV frequency or severity.12–16 Adequate
hydration may contribute to prophylaxis and treatment of
PONV17 and allow earlier discharge from recovery after
elective surgery while decreasing overall health care cost
and improving patient satisfaction. Additionally, an oral
carbohydrate load before surgery was associated with less
PONV, perhaps by decreasing postoperative catabolism and
insulin resistance.18 However, there may be an optimal dose
XXX 2013 • Volume XX • Number XXwww.anesthesia-analgesia.org
1
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Relationship of IV Dextrose, Blood Glucose and PONV
of dextrose to obtain this favorable outcome because larger
amounts of supplementary IV dextrose do not prevent
PONV after outpatient surgery and may increase PONV.19
We hypothesized that individual differences in blood
glucose response, perhaps related to the timing of administration, may contribute to the inconsistent impact of IV
dextrose on PONV. It is possible that glucose administration during emergence from anesthesia could impact the
incidence of PONV. We sought to determine the relationship of IV dextrose administered in small amounts during
emergence from anesthesia to PONV.
METHODS
This prospective, double-blind randomized placebocontrolled trial was approved by the IRB of Loma
Linda University and registered with ClinicalTrials.gov
(NCT01123837). Written informed consent was obtained
from ASA physical status I and II female patients, 18 to 65
years of age, scheduled for outpatient gynecologic, urologic,
or breast surgery at Loma Linda University Medical Center.
A history of PONV risk factors was recorded. Patients were
excluded for severe hypertension, coagulopathy, significant
hepatic or renal disease, diabetes mellitus, abnormal blood
glucose on the morning of surgery, or withdrawal of consent. Patients were excluded from analysis for severe intraoperative hypotension requiring large volume intravascular
fluid treatment or protocol violations including nitrous
oxide administration.20
After consenting, patients were assigned by hospital
pharmacists using a computerized randomization function
to lactated Ringer’s solution (group P) or 5% dextrose in
lactated Ringer’s solution (group D). The study fluid was
delivered in opaque bags labeled “study fluid,” and infusion
controlled by infusion pumps at 125 mL/h IV for 2 hours
(250 mL) beginning with the start of surgical closure. This
volume was chosen to provide small glucose supplements,
and blood glucose increases after infusion. The anesthesia
providers, surgeons, perioperative nurses, postanesthesia
care unit (PACU) nurses, patients, and investigators were
blinded to group assignment throughout.
Subjects received general anesthesia using propofol (2–
2.5 mg/kg) for induction and sevoflurane in oxygen and air
for maintenance. Anesthesia depth was maintained at moderate general anesthesia based on processed electroencephalogram (Patient State Index between 30 and 50; SEDLine©;
Masimo, Irvine, CA). Intraoperative IV maintenance fluid
was standardized at 3 mL/kg/h with additional IV crystalloid given as needed at the discretion of the anesthesia
provider if arterial blood pressure decreased >20% from
baseline. Prophylactic administration of 1 antiemetic medication was reported to decrease PONV from nearly 60% to
approximately 35% with only small additional decreases in
PONV from prophylactic administration of 2 or more antiemetics in a subset of patients who received volatile anesthetics in air.1 Thus to decrease the possibility that treatment
effects of study fluid administration could be masked, no
prophylactic antiemetics were given. We anticipated that
3 risk factors for PONV21 would be present in our patients
(female, nonsmoker, postoperative opioids), with approximately 60% PONV risk.22 The increased PONV risk resulting from withholding antiemetic prophylaxis was discussed
2 www.anesthesia-analgesia.org
thoroughly with patients during informed consent, as was
the usual antiemetic prophylaxis given. Patients were
encouraged to seriously consider their risk for PONV and
their desire to limit that risk by antiemetic prophylaxis.
Additionally, patients were informed they could request
prophylactic antiemetic treatment or withdraw consent
at any time before anesthesia induction, with subsequent
exclusion from the study but no negative impact on their
perioperative care.
Blood glucose was measured using a point-of-care
device (ACCU-CHEK©, Roche Pharmaceuticals, Basel,
Switzerland) at presurgical preparation area baseline (using
blood in the needle used for IV catheter placement), intraoperatively immediately before study fluid infusion (finger
stick sample), and immediately after study fluid infusion by
PACU nurses (finger stick sample).
The PACU nurses assessed and documented PONV
using a Verbal Descriptive Scale,23 which correlates to visual
analog nausea scores, with an objective measure of severity:
• 0 = no PONV: patient reports no nausea and has had
no emesis episodes;
• 1 = mild PONV: patient reports nausea but declines
antiemetic treatment;
• 2 = moderate PONV: patient reports nausea and
accepts antiemetic treatment; and
• 3 = severe PONV: nausea with any emesis episode
(retching or vomiting).
The score was obtained at 0, 30, 60, 90, and 120 minutes after PACU arrival; thus 5 scores were recorded during PACU stay. A 24-hour PONV assessment that elicited
any nausea and emesis episode since PACU discharge was
obtained by a blinded investigator by telephone or in person at the patient’s bedside. Initial antiemetic treatment was
4 mg IV ondansetron, with additional treatment at the discretion of the anesthesiologist caring for the patient. PONV
severity was further assessed by comparing the number
of antiemetic doses and drug classes given. Intraoperative
and PACU pain medications and doses were recorded and
converted to fentanyl equivalents (µg/kg/h) as few patients
received opioids other than fentanyl for these scheduled
outpatient procedures.
Statistical Analysis
Sample size was calculated using the incidence of PONV
within 2 hours after anesthesia (yes or no) assuming a 60%
prevalence of PONV associated with the expected number
of PONV risk factors. A sample size of 160 was needed to
detect an absolute 20% decrease in PONV, with power of 0.8
and P = 0.05 considered significant.
The primary outcome measure was the intergroup difference in PONV incidence within 2 hours after surgery,
expressed as mean and 95% confidence interval (CI) of the
intergroup difference. Secondary outcome measures were
intergroup differences of patient and perioperative characteristics; the occurrence and severity of PONV including
emesis episodes and PONV scores, the number of doses and
classes of antiemetic drugs needed to control PONV, and the
incidence of delayed PONV (onset after 2 hours). Further
secondary analysis was done to compare intraoperative
anesthesia & analgesia
Copyright © 2013 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
and patient characteristics, including changes in blood glucose after study fluid infusion, in patients with or without
PONV. Statistical analysis was performed using computerized software (JMP 10.0.0, SAS Institute, Cary, NC; Prism
6.0b, GraphPad Software, La Jolla, CA) with P < 0.05 considered significant. Continuous data were analyzed for
normal distribution by the Shapiro–Wilk test with P < 0.05
indicating data was not normally distributed. Normally distributed data were analyzed using the t test. Data that were
not normally distributed were analyzed using the Wilcoxon
test, and differences between medians analyzed using the
Hodges–Lehmann method as data were symmetrically distributed. Results of continuous data are shown as mean, 95%
CI for normally distributed data and median, 95% CI if not
normally distributed. Ordinal data were compared using
Pearson χ2 or Fisher exact test when bivariate. The association between the sum of severity scores and the number of
antiemetic medication doses given within 2 hours of anesthesia was assessed by Kendall τ and LOWESS (locally weighted
scatterplot smoothing) regression. Intergroup differences in
proportions were compared using the adjusted Wald test and
expressed as mean and 95% CI of the intergroup difference.
RESULTS
We enrolled 202 patients between June 7 and December 29,
2010, of whom 18 did not receive the allocated intervention.
As shown in Figure 1, this included 8 given prophylactic
antiemetics before anesthesia and 5 who withdrew consent.
The remaining 184 patients received the allocated intervention, of whom 22 were excluded from analysis, including 17
given nitrous oxide (group D n = 4; group P n = 13). Data
from 162 patients with normal baseline blood glucose were
analyzed. There were no significant intergroup differences
in demographics, history of PONV or tobacco use, perioperative characteristics, or unplanned admission (Table 1).
PONV occurred during the first 2 hours after anesthesia
in 81 of 162 (50%) patients, equally in group D (52.9%) and
group P (46.7%; P = 0.53; difference, 6.2%; 95% CI, −9.2%
to 21.6%). Emesis episodes within 2 hours after anesthesia occurred in 9 patients: 4 group D (4.6%) and 5 group P
(6.7%; P = 0.73; difference, −2.1%; 95% CI, −9.3% to 5.1%).
There were no significant intergroup differences in
time of onset of PONV, duration of PONV, or the number
of antiemetic doses or drug classes given to control PONV
(Table 2). PONV severity scores were not normally distributed but the data were symmetrical (Fig. 2), and analysis
showed no significant intergroup differences in severity
at any time the score was obtained (Table 1). The sum of
PONV severity scores was associated with the number of
antiemetic medication doses given within 2 hours of PACU
arrival (Kendall τ = 0.88; 95% CI, 0.84–0.92; Fig. 3). More
than 1 dose of antiemetic medication was used to treat
PONV in 48 of 81 (59.3%) patients who developed PONV
(intergroup difference, 5.5%; 95% CI, −13.5% to 14.6%), and
>1 antiemetic drug class in 42 of 81 (51.9%; intergroup difference, 1.1%; 95% CI, −12.4% to 14.6%). Ten patients had
unplanned admission (6.2%; intergroup difference, 1.6%;
95% CI, −5.8% to 8.9%). Six patients were admitted for pain
control, and 1 was admitted for each of PONV, oxygen
desaturation, dizziness, and ureteral obstruction. PONV
Figure 1. Consolidated Standards of Reporting Trials (CONSORT) diagram. MAC = monitored anesthesia care.
XXX 2013 • Volume XX • Number XX
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Copyright © 2013 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Relationship of IV Dextrose, Blood Glucose and PONV
Table 1. Demographic and Perioperative Characteristics of Placebo and Dextrose Groups
Patient characteristics
Categorical data, n (%)
ASA physical status II
History of PONV
History of smoking
3 PONV risk factors
2
3
4
Type of surgery
Gynecologic
Laparoscopic or hysteroscopic
Open
Urologic
Breast
Received opioids in recovery room
Unplanned admission
Reason for admission, n
Inadequate pain control
Dizziness
Ureteral obstruction
Oxygen desaturation
Nausea/vomiting
PONV within 2 h of anesthesia
Any emesis episodes within 2 h of anesthesia
Continuous data (median, 95% CI except age)
PONV severity score in PACU
On arrival
30 min after arrival
60 min after arrival
90 min after arrival
120 min after arrival
24 h after arrival
Age (y; mean, 95% CI)
Body mass index (kg/m2)
Estimated blood loss (mL)
Length of surgery (min)
Total intraoperative fentanyl dose (µg/kg/h)
Total recovery room fentanyl dose (µg/kg/h)
Recovery room length of stay (min)
Dextrose (n = 87)
Placebo (n = 75)
Difference, 95% CI
P value
67 (77%)
25 (28.7%)
12 (13.8%)
60 (69.0%)
7 (8.0%)
60 (69.0%)
20 (23.0%)
61 (81.3%)
28 (36.0%)
11 (14.7%)
43 (57.3%)
8 (10.7%)
43 (57.3%)
24 (32.0%)
−4.3%, −16.6% to 8.4%
−7.3%, −21.5% to 7.2%
−0.9%, −11.9% to 10.0%
11.6%, −3.3% to 26.1%
0.56
0.40
1.0
0.14
0.06
51
16
3
17
76
6
(58.6%)
(18.4%)
(3.5%)
(19.5%)
(87.4%)
(6.9%)
40 (53.3%)
17 (22.7%)
10 (13.3%)
8 (10.7%)
65 (86.7%)
4 (5.3%)
0.7%, −9.8% to 11.4%
1.6%, −6.5% to 9.2%
1.0
0.75
4
1
0
1
0
47 (52.9%)
4 (4.6%)
2
0
1
0
1
35 (46.7%)
5 (5.6%)
6.2%, −9.2% to 21.3%
−2.1%, −9.8% to 5.5%
0.53
0.73
0, 0–0
0, 0–0
0, 0–0
0, 0–0
0, 0–0
0, 0–0
−0.9, −4.4 to 2.7
0.4, −1.5 to 2.4
0, −10 to 20
−6, −34 to 20
0.1, −0.2 to 0.1
0.1, −0.1 to 0.3
−3, −12 to 5
0.90
0.38
0.81
0.19
0.95
0.16
0.63
0.65
0.65
0.64
0.57
0.37
0.43
0, 0–0
0, 0–0
0, 0–0
0, 0–0
0, 0–0
0, 0–0
46.3, 43.7 to 48.9
27.0, 25.0 to 29.0
50, 30 to 100
156, 133 to 176
1.2, 1.0 to 1.4
0.5, 0.4 to 0.7
133, 127 to 140
0, 0–0
0, 0–0
0, 0–0
0, 0–0
0, 0–0
0, 0–0
45.5, 43.0 to 47.9
27.0, 24.4 to 30.1
50, 30 to 75
151, 148 to 204
1.1, 1.0 to 1.4
0.7, 0.5 to 0.9
127, 121 to 136
Data were analyzed by t test if normally distributed and reported as mean, 95% confidence interval (CI). Data that were not normally distributed (Shapiro–Wilk,
all P < 0.01) were analyzed using Wilcoxon test and reported as median, 95% CI, and differences between medians analyzed using the Hodges–Lehmann
method. Analysis of ordinal data was by Fisher exact test if bivariate and by Pearson χ2 if not. Postoperative nausea or vomiting (PONV) episodes occurred during
postanesthesia recovery unit (PACU) stay within 2 hours after anesthesia in 50% of all patients, including emesis episodes in 5.6%. There were no significant
intergroup differences in patient or perioperative characteristics.
was present >2 hours after PACU arrival in 9 group D
(10.3%) patients and 13 group P (17.3%; P = 0.33) patients,
including 4 patients (group D n = 1; group P n = 3) in whom
the first episode of PONV was >2 hours after PACU arrival.
In total, 47 group D (54.0%) patients and 38 group P (50.7%)
patients experienced nausea or an emesis episode at some
point during the 24 hours after surgery (intergroup difference, 3.4%; 95% CI, −12.1% to 18.8%). As expected, infusion
of dextrose was associated with a larger increase in blood
glucose after study fluid infusion (Table 3).
Secondary analysis of PONV regardless of study group
revealed similarly increased PONV risk scores in those who
had PONV within 2 hours after anesthesia compared with
those who did not. PONV was neither correlated to demographic characteristics nor to history of PONV or smoking.
Further comparisons of patients with and without PONV
are shown in Table 4. Of interest, only 3 of 15 patients (20%)
in whom surgery was <1 hour experienced PONV within 2
hours after anesthesia, compared with 45% when surgery
4 www.anesthesia-analgesia.org
duration was 1 to 2 hours and 57% when surgery duration
was >2 hours. Eight of 81 patients who had PONV within 2
hours after anesthesia had unplanned admission, but only 1
admission was for PONV.
DISCUSSION
Fifty percent of patients experienced PONV during the 2
hours after surgery, somewhat less than predicted based
on the average number of PONV risk factors present.
Patients who received the small amount of IV glucose had
higher blood glucose after study fluid infusion and larger
increases in blood glucose between baseline and the end of
the study fluid infusion, despite normal baseline blood glucose. Dextrose administration during emergence was not
associated with any difference in either the time of onset
or severity of PONV. The need for >1 dose or >1 drug class
of antiemetic treatment was not affected by study fluid
administration. Delayed onset (>120 minutes after anesthesia) PONV and emesis episodes were found equally in
anesthesia & analgesia
Copyright © 2013 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Table 2. Comparison of PONV Severity in Study Group Patients Who Had Postoperative Nausea and
Vomiting Episodes in the First 2 Hours After Anesthesia While in the PACU
Patients who had nausea or emesis episodes in the first 2 h after anesthesia
Group D (n = 46)
Group P (n = 35)
Difference, 95% CI
First nausea or emesis episode within 30 min of
30 (65.2%)
20 (57.1%)
8.1%, −13.1% to 28.8%
arrival in recovery room, n (%)
Onset recorded
On arrival
9 (19.6%)
8 (22.2%)
21 (45.6%)
12 (33.3%)
1–30 min after arrival
31–60 min after arrival
6 (13.0%)
8 (22.2%)
61–120 min after arrival
10 (21.7%)
7 (19.4%)
Duration of PONV >30 min, n (%)
23 (50.0%)
16 (45.7%)
4.3%, −17.3% to 25.5%
Duration up to 30 min
23 (50.0%)
19 (54.3%)
Duration 31 to 60 min
15 (32.6%)
7 (31.8%)
Duration over 60 min
8 (17.4%)
9 (15.7%)
No. of scores ≥1 during recovery stay
1.5,1–2
1.0, 1–2
0, 0–0
Antiemetic treatment given while in recovery room
No. of antiemetic doses given
2, 1–2
2, 1–2
0, 0–1
No. 0; 1; 2; 3 or more
1; 22; 17; 6
1; 15; 10; 9
Patients given >1 dose of antiemetic, n (%)
26 (56.5%)
22 (62.9%)
−6.3%, −26.9% to 15.1%
No. of antiemetic drug classes given
2, 1–2
2,1–2
0, 0–1
No. 0; 1; 2; 3 or more
1; 22; 17; 6
1; 15; 10; 9
No. (%) of patients given:
45 (97.8%)
34 (97.1%)
0.7%, −8.0 to 10.5%
Ondansetron
Promethazine
14 (30.4%)
9 (25.7%)
4.7%, −15.2% to 23.6%
9 (19.6%)
12 (34.3%)
−14.7%, −33.5% to 4.9%
Metoclopramide
Dexamethasone
7 (15.2%)
8 (22.9%)
−7.6%, −25.0% to 9.7%
1 (2.2%)
0
2.2%, −6.2% to 9.2%
Hydroxazine
Scopolamine
1 (2.2%)
0
2.2%, −6.2% to 9.2%
Patient declined treatment
1 (2.2%)
1 (2.9%)
−0.7%, −10.5% to 8.0%
No. (%) given >1 class of antiemetic
23 (50.0%)
19 (54.3%)
−4.3%, −25.5 to 17.4%
P value
0.46
0.82
0.93
0.38
0.65
0.46
1.0
0.80
0.20
0.40
1.0
1.0
1.0
0.82
Ordinal data was analyzed by Fisher exact test if bivariate and by Pearson χ2 if not. Differences in proportions were analyzed by the adjusted Wald test. Continuous
data were not normally distributed (Shapiro–Wilk, all P < 0.01) and were analyzed by the Wilcoxon test, expressed as median and 95% confidence interval (CI),
with differences between medians analyzed using the Hodges–Lehmann method. There were no significant intergroup differences in PONV severity, onset time
or duration nor in antiemetic treatment.
Group D = dextrose; Group P = placebo; PONV = postoperative nausea and vomiting; PACU = postanesthesia care unit.
groups D and P. Thus, IV dextrose as administered was
not associated with a difference exceeding 20% in the incidence of PONV or in the severity of PONV within 2 hours
of anesthesia.
Our results are in contrast to those reported in 62 women
undergoing outpatient gynecologic surgery.16 In that study,
administration of IV dextrose in balanced salt solution
after surgery was associated with similar nausea scores but
fewer doses of antiemetic rescue administration compared
with administration of plain balanced salt solution. Despite
administration of antiemetic prophylaxis 30 minutes before
surgery end to all their subjects, nausea occurred in 54.8%
of their subjects (62.5% of control), similar to what we found
without antiemetic prophylaxis. The amount and rate of
IV dextrose administration was greater than our patients
received, and no comparison was made between baseline
and postinfusion blood glucose measurements. In a study
of 120 ASA physical status I female patients who did not
receive antiemetic prophylaxis,19 fewer patients developed PONV than we found: 29% in dextrose and 22% in
control group patients. Those patients had shorter surgery
(mean, 23 minutes) compared with ours (mean, 174 minutes) and received a larger amount of dextrose. While this
makes direct comparison difficult, the PONV incidence they
reported was similar to that found in our patients in whom
surgery duration was ≤60 minutes. Furthermore, because
intraoperative blood glucose levels were not reported, it is
XXX 2013 • Volume XX • Number XX
not possible to determine whether blood glucose changes
were related to PONV in their patients.
The finding of larger blood glucose increases after
study fluid administration in patients who developed
PONV within 2 hours after anesthesia (Fig. 4) was interesting. This difference was found in the time corresponding
to surgical closure, emergence and early PACU stay, not
during the majority of surgical manipulation. Although
more blood glucose samples would likely be necessary
to establish this, the timing of blood glucose increase we
found may indicate a stress response during emergence
and early recovery. Blood glucose increases in response
to surgical stress have been reported in both diabetic and
nondiabetic patients to whom IV dextrose infusion was
given during surgery in hopes of treating fasting hypoglycemia.24 While it is not clear whether blood glucose
increases directly contributed to PONV, blood glucose
increases may reduce gastric emptying and increase the
sensation of gastric fullness, which could perpetuate a
sensation of nausea.25 These relationships could be the
focus of future study.
There are several limitations to our study. More P group
patients were excluded from analysis for nitrous oxide
administration protocol violation, but analysis including
patients who received nitrous oxide did not alter results for
the primary outcome of PONV difference between groups
D and P or for the secondary outcome measures of PONV
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Relationship of IV Dextrose, Blood Glucose and PONV
Figure 2. Plot of individuals’ verbal postoperative nausea and vomiting descriptive scores obtained at 6 time points after anesthesia.
Interpretation of scores: 0 = no nausea or emesis episodes; 1 = nausea present but patient declines antiemetic medication; 2 = nausea present and patient accepts offered antiemetic medication; and 3 = nausea and either retching or emesis present. Blue triangles represent patients
given 250 mL lactated Ringer’s solution (Placebo, n = 75); red circles indicate patients given 250 mL 5% dextrose in lactated Ringer’s solution (Dextrose, n = 87) during emergence and early postanesthesia recovery. Box plots show median, 95% confidence interval of the median
and interquartile range. There were no significant intergroup differences at any time point (all P corrected for multiple comparisons >0.05).
PACU = postanesthesia care unit.
Figure 3. LOWESS plot shows the correlation (R2 = 0.82) of the sum of individuals’ postoperative nausea and vomiting (PONV) scores to
the number of antiemetic medication doses received within 2 hours of anesthesia. Blue triangles represent patients given 250 mL lactated
Ringer’s solution (Placebo, n = 75); red circles indicate patients given 250 mL 5% dextrose in lactated Ringer’s solution (Dextrose, n = 87)
during emergence and early postanesthesia recovery. The number of patients with each score in the groups is shown below the x-axis. In the
first 2 hours after postanesthesia care unit arrival, the sum of PONV severity scores was associated with the number of antiemetic medication
doses given (Kendall τ = 0.88; 95% confidence interval, 0.84–0.92).
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Table 3. Comparison of Changes in Blood Glucose Between Placebo and Dextrose Groups
Baseline
At surgeon closing
After study fluid infusion
Changes in blood glucose
Baseline to surgeon closing
Baseline to after study fluid infusion
Comparison of blood glucose measures by treatment group
Results shown as mg/dL median, 95% CI
Dextrose (n = 87)
Placebo (n = 75)
94, 92 to 97
91, 90 to 95
116, 112 to 123
115, 110 to 120
137, 128 to 151
107, 102 to 117
23, 17 to 32
42, 31 to 53
22, 19 to 29
13, 10 to 28
Difference, 95% CI
−2, −5 to 1
−2, −8 to 5
−25, −35 to −16
P value
0.15
0.59
<0.0001
0, −7 to 6
23, −33 to −14
0.95
<0.0001
Data were not normally distributed (Shapiro–Wilk, all P ≤ 0.01) thus were analyzed by Wilcoxon test, reported as median, 95 confidence interval (CI), and
differences between medians were analyzed using the Hodges–Lehmann method. As expected, blood glucose increased more after infusion of study fluid in
Dextrose patients.
Table 4. Demographic and Intraoperative Characteristics of Those Without and With PONV in the First 2
Hours After Anesthesia Regardless of Study Group
No PONV (n = 81)
Categorical data, n (%)
ASA physical status II
H/O PONV
H/O smoking
Unplanned admission
Continuous data (median, 95% CI except age)
Age (y; mean, 95% CI)
Body mass index (kg/m2)
Estimated blood loss (mL)
Length of surgery (min)
Recovery room length of stay (min)
Operating room fentanyl dose (µg/kg/h)
Recovery room fentanyl dose (µg/kg/h)
Blood glucose at baseline (mg/dL)
Blood glucose at surgeon closing (mg/dL)
Blood glucose after study fluid infusion (mg/dL)
Change in blood glucose: baseline to surgeon closing
(mg/dL)
Change in blood glucose: baseline to after study fluid
infusion (mg/dL)
Difference, 95% CI
P value
(75.3%)
(35.8%)
(12.4%)
(9.9%)
7.4%, −5.3% to 19.7%
−7.4%, −21.4% to 7.0%
−3.7%, −7.3% to 14.5%
−7.4%, −15.0% to 5.7%
0.33
0.40
0.65
0.10
47.3, 44.8 to 49.8
27.0, 24.4 to 29.0
45, 30 to 50
136, 111 to 167
128, 121 to 139
1.2, 1.0 to 1.4
0.5, 0.3 to 0.7
95, 93 to 98
115, 110 to 121
113, 108 to 126
18, 16 to 25
44.5, 2.0 to 47.0
27.0, 25.0 to 29.9
50, 40 to 100
167, 144 to 178
133, 129 to 140
1.2, 1.0 to 1.3
0.7, 0.5 to 1.0
91, 89 to 94
116, 112 to 121
132, 123 to 145
28, 22 to 32
–2.8, −6.4 to 0.7
0.1, −1.9 to 1.9
5, −8 to 25
30, 6–58
2, −7 to 10
0.0, −0.2 to 0.2
0.2, 0–0.4
−3, −6 to 0
1, −6 to 7
13, 2–24
5, −2 to 11
0.11
0.92
0.38
0.02
0.66
0.85
0.04
0.03
0.87
0.03
0.16
24, 13 to 29
41, 30 to 55
16, 7 to 27
0.001
67
23
13
2
(82.7%)
(28.4%)
(16.1%)
(2.5%)
PONV (n = 81)
61
29
10
8
Bivariate data was tested by χ2 using Fisher exact test. Age was normally distributed and compared by t test, and remaining continuous data were not normally
distributed (Shapiro–Wilk, all P ≤ 0.01) and were analyzed by Wilcoxon test, with differences between medians analyzed using the Hodges–Lehmann method.
Blood glucose increased more after infusion of study fluid in patients who developed PONV within 2 hours of anesthesia. There was a trend toward larger blood
glucose increase after infusion of study fluid in patients whose PONV treatment required >2 vs ≤2 doses of antiemetic (69; 16–87 mg/dL vs 36; 14–59 mg/dL;
P = 0.05) and in those who needed >1 vs ≤1 class of antiemetic drug (47; 16–75 mg/dL vs 31; 12–59 mg/dL; P = 0.05).
PONV = postoperative nausea and vomiting; CI = confidence interval.
severity. Similarly, more group P patients were excluded
for other protocol violations, but analysis including those
patients did not alter results for the primary outcome or
for secondary measures. Our sample size would need to be
much larger (>2000 patients) to show statistical significance
for the difference in PONV we found. Surgery type was not
identical between groups. However, results of analysis in
each subgroup of patients by surgery type for the primary
outcome of PONV difference between groups D and P were
the same as for all patients. Recovery room stay was not
longer in patients with PONV, which may reflect nursing
protocols rather than readiness for discharge, which we did
not assess. We did not find more PONV in patients with
a history of PONV, in contrast to the previously reported
importance of patient history of PONV as a predictive
factor.21 This may reflect the increased PONV risk from
3 PONV risk factors on average, potentially limiting the
predictive power of additional risk factors.26 We found
an apparent effect of increasing surgery length because
XXX 2013 • Volume XX • Number XX
patients who experienced PONV had longer surgery.
Furthermore, PONV was less common in patients whose
surgery was <1 hour duration compared with longer surgery. However, this study was not designed to investigate
the combined interactions of surgery type and duration
on analgesic requirements and PONV, which could be of
interest for future investigations. It is unlikely that the lack
of difference between groups was related to the type of
fluid given, because the use of IV crystalloid or colloid was
reported to have no impact on PONV.27
We sought to investigate the relationship of dextrose
infusion during anesthesia emergence to PONV and did not
find a positive or negative impact of dextrose as administered. Dextrose administration during emergence from and
early recovery after anesthesia was not associated with differences in the frequency of PONV exceeding 20% or in the
severity of PONV. The relationship of PONV to the optimal
dose and timing of dextrose administration remains unclear
and may warrant further study. E
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Relationship of IV Dextrose, Blood Glucose and PONV
Name: Richard L. Applegate II, MD.
Contribution: This author was involved in study design, conduct of the study, data collection, data analysis, and manuscript
preparation.
Attestation: Richard L. Applegate II, MD, approved the final
manuscript, attests to the integrity of the original data and the
analysis reported in this manuscript, and is the archival author.
This manuscript was handled by: Peter S. A. Glass, MB, ChB.
Figure 4. Change in blood glucose from baseline after infusion of
study fluid in patients who had postoperative nausea and vomiting
episodes (PONV) within 2 hours of anesthesia and those who did
not. Patients who received 250 mL 5% dextrose in lactated Ringer’s
solution (Dextrose; n = 87) are shown as red circles; patients
who received 250 mL lactated Ringer’s solution (Placebo; n =
75) are shown as blue triangles. Horizontal lines indicate median
and 95% confidence interval (CI). Patients who had PONV within
2 hours of the end of anesthesia had a larger increase in blood
glucose after infusion of study fluid (median, 41; 95% CI, 30–55
mg/dL) compared with patients who did not (median, 24; 95% CI,
13–29 mg/dL; difference between medians, 16; 95% CI, 7–27 mg/dL;
P = 0.001).
‍‍‍‍DISCLOSURES
Name: Parul Patel, MD.
Contribution: This author was involved in study design, conduct of the study, data collection, data analysis, and manuscript
preparation.
Attestation: Parul Patel, MD, approved the final manuscript
and attests to the integrity of the original data and the analysis
reported in this manuscript.
Name: Minhthy N. Meineke, MD.
Contribution: This author was involved in conduct of the study,
data collection, data analysis, and manuscript preparation.
Attestation: Minhthy N. Meineke, MD, approved the final
manuscript and attests to the integrity of the original data and
the analysis reported in this manuscript.
Name: Thomas Rasmussen, MD.
Contribution: This author was involved in conduct of the
study, data collection, and manuscript preparation.
Attestation: Thomas Rasmussen, MD, approved the final
manuscript.
Name: Donald L. Anderson, MD.
Contribution: This author was involved in conduct of the
study, data collection, and manuscript preparation.
Attestation: Donald L. Anderson, MD, approved the final
manuscript.
Name: Jennifer Brown, MSN, CRNA.
Contribution: This author was involved in data collection and
manuscript preparation.
Attestation: Jennifer Brown, CRNA, approved the final
manuscript.
Name: Sam Siddighi, MD, MS.
Contribution: This author was involved in conduct of the
study and manuscript preparation.
Attestation: Sam Siddighi, MD, MS, approved the final
manuscript.
8 www.anesthesia-analgesia.org
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