The Effect of Ringer versus Haemaccel Preload on Incidence of Postoperative Nausea and Vomiting

1 Department of Nursing, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Tabriz, Iran 2 Department of Nursing, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Tabriz, Iran 3 Department of Anesthesiology, Medicine Faculty, Zanjan University of Medical Sciences, Zanjan, Iran 4 Department of Nursing, Nursing and Midwifery Faculty, Zanjan University of Medical Sciences, Zanjan, Iran


Introduction
2][3][4] It occurs in 70% to 80% in high risks patients without prophylaxis, 5 indicating the importance of prevention of this stressful complication. 6][15] PONV may also lead to expanded nursing care, all factors that increase health care costs. 16,17The annual cost for the treatment of PONV in the United States is approximately one billion dollars. 184][15] PONV may also lead to expanded nursing care, all factors that increase health care costs. 16,17The annual cost for the treatment of PONV in the United States is approximately one billion dollars. 18oreover, surgical patients prefer to experience pain rather than suffer from PONV and even they would like to pay more money for an effective antiemetic treatments. 19For these reasons, PONV control is the main priority for patients receiving spinal anesthesia. 10And it is essential to prevent and control PONV as efficiently as possible. 1In these situations, using of pharmacologic prophylaxis may increase the danger of adverse drug side effects for the patient along with increasing overall health care costs. 20reload rehydration is a recommended approach to reduce PONV but there is no consensus as to which type of fluid or volume is ideal for preventing of this complication. 21,22][26][27][28] Furthermore, information regarding the effect of the various intravascular fluid replacement solutions remains unclear. 29The choice of crystalloid or colloid as an optimal ideal strategy for fluid replacement therapy remains unresolved, and there is disagreement over the selection of colloid or crystalloid as the optimal approach for prevention of postoperative nausea and vomiting. 30,31ome author has recommended the crystalloid solution, 10 but there are fewer data on colloid preload.Because colloids enhance circulation volume more than crystalloid solution, they may be more useful than crystalloids. 32he aim of this study, therefore, was to examine the effect of crystalloid fluid (Ringer solution) versus colloid (Haemaccel solution) on the incidence of postoperative nausea and vomiting in patients receiving spinal anesthesia.

Materials and methods
Following approval by the Research Ethics Committee (Zanjan University of Medical Sciences, Zanjan, Iran), we selected patients who met the inclusion criteria.Patients were included in this study only if they met the following criteria: 1-The patient was willing and able to sign the patient informed consent form.2-Patients who scheduled to undergo spinal anesthesia.3-Patients aged 18-45 years.
Exclusion criteria included patients who had a history of coagulation disorder, cardiorespiratory disease, renal failure, hypertension, and excessive preoperative blood loss.The study was done at the Ayat Ollah Moosavi Hospital, a central teaching hospital in Zanjan city.
We invited the patients who met the inclusion criteria to participate in the study.Then, we obtained informed written consent from all patients who wanted to participate in the study.
Prospective power analysis according to the previous study showed that 25 patients in each group would give 80% power with α=0.05 to distinguish 20% difference among two groups.We recruited 27 patients for each group by allowing for potential dropouts. 10 total 54 patients was selected according to the inclusion and exclusion criteria during the period of March 2014 to August 2014 (Figure 1).Our study was supervised by an anesthetist as a co-researcher.Patients were randomly allocated to one of two groups using a sealed envelope.
The crystalloid group received Ringer solution (Shahid Gazi Company, Tabriz, Iran) at a volume of 7 ml/kg and colloid group received 7ml/kg of 3% Modified Gelatin also known as Haemaccel (Samen drug company, Mashhad, Iran) as an preoperative intravenous bolus.All selected patients received these solutions before induction of anesthesia at the operating room.
All participants were not aware of group assignment.We used a standard Verbal Rating Scale (VRS) for assessing the nausea and vomiting occurrence.This scale consists of two parts.The first part assessed the vomiting occurrence (yes= patient had vomiting, no= patient had not vomiting) and the second part assessed the nausea intensity (0=no nausea, and 10=worst possible nausea).Patients' characteristics such as age, gender, type of surgery, and other relevant data were collected by a checklist.We used content validity for these instruments which ten faculty members of Zanjan University of Medical Sciences reviewed the instruments and we revised it by using their comments.
We used test-retest method for assuring the reliability of the instruments.The correlation between test retest results was 0.86.
A single data collector assessed the patients at 1 hours, 4 hours, and every 4 hours until 24 hours postoperatively.This person was not aware of group assignment too.In other word, this was a double-blinded study.
Data were analyzed by using SPSS software version 13.The χ 2 test and independent t-test were used for comparison of data between two groups.Means and standard deviation used for presenting the normally distributed data and medians and interquartile range was reported for data that was not normally distributed.

Results
In our study, two groups (Ringer group and Haemaccel group) were comparable for participant characteristics such as age, marriage status, educational level, and the number of blocked segments.Therefore, there were not significant differences in these parameters (P>0.05)(Table 1).
The result showed that the incidence of postoperative nausea and vomiting was less frequent in both groups.The incidence of PONV was not significantly different at 1hours, 4 hours, and every 4 hours until 24 hours postoperatively between two groups (P<0.05).
Also there was no significant difference in the intensity of nausea between two groups at any time point (P<0.05)(Table 2).

Discussion
Over the past years, as the risk of major mortality related to surgery has decreased, attention has moved to addressing causes that harmfully influence patient satisfaction and patient morbidity, for example postoperative nausea and vomiting. 5st operative nausea and vomiting is not just a distressing and unpleasant experience, but may be a main factor in disturbing postoperative convalescence . 33is study aimed to determine whether Haemaccel solution may have any advantage over Ringer solution on PONV.We did not find any such advantage and the incidence of nausea and vomiting did not decreased by using Haemaccel.Therefore, the effect of Haemaccel as a colloid solution is similar to ringer solution as a crystalloid solution.Using crystalloids and colloids solution as a preoperative intravenous fluid supplementation decreased the incidence of PONV.The incidence of PONV was 18.52% and 14.82% at 1 hour of postoperative time in Ringer and Haemeccel group respectively.Our findings are similar to Ngan Kee et al., who investigated preloading with 4% gelatin colloid solution (Gelofusine) with no preload (control group).They found that nausea was less frequent in the gelatin group (6 vs. 24%), but the other outcome was similar in gelatin and control groups. 32hile obeying to preoperative fasting strategies, patients routinely are hypovolemic in the operating room.So, many patients experience the hypovolemic episodes and it increases the incidence of nausea and vomiting after spinal anesthesia.Therefore preloading before spinal anesthesia is proposed as a one of the preventive strategy. 34arious strategies have been proposed for prevention of PONV in patients receiving spinal anesthesia. 8,35,36everal studies supported the use of preoperative intravenous fluids for prophylaxis of PONV. 17,37,38lte et al., 39 and Magner et al., 40 reported an overall reduction in the occurrence of PONV by preloading intravenous solutions.
Volume preloading by different solutions can effectively prevent PONV induced by spinal anesthesia. 29,41,42ince Ringer solution is most physiological fluid and its osmolality is very similar to plasma, most of the authors have used it as preloading fluid in their studies.Our results was consistent with Sujata et al., 13 work, in which they concluded that both crystalloids and colloids were equally effective in preventing PONV.Other researcher had selected modified Gelatin (haemaccel) as preloading fluid because its osmolality and PH are similar to plasma. 43ut the result of our study is not consistent with the findings of Christine et al., 44 study in which the incidence of nausea and vomiting did not reduced by using intravenous crystalloid infusion.This Copyright © 2015 by Tabriz University of Medical Sciences difference may be related to the solution type which used in these studies.We used Ringer solution but they administrated compound sodium lactate (CSL) as a crystalloid infusion.In another study Capel Cardoso et al., compared the incidence of hypotension in patients submitted to cesarean section under spinal anesthesia with crystalloid or colloid preload (modified gelatin).They showed that colloid (modified gelatin) was similar to crystalloid (lactate Ringer) in decreasing or preventing the incidence of hypotension. 45It seems the difference between Capel Cardoso work and our study is that we used ringer solution instead of lactate Ringer.
In a study of patients undergoing laparoscopic cholecystectomy, Chaudhary et al., 13 did not show any significant differences on PONV between groups receiving Ringers lactate (as a crystalloid fluid) or Hydroxyethyl starch (as a colloid fluid) before the induction of anaesthesia.
Our finding is also similar to Kotake et al., 32 results who found that preload with gelatin 15ml/kg decreased the incidence of nausea and vomiting.In the other study Holte et al., 39 showed that intravenous fluid administration improves postoperative symptoms such as nausea and vomiting and shorten time to reaching discharge criteria.

Conclusion
Preoperative fluid administration decreases the incidence of PONV.Both Crystalloids (Ringer) and colloids (Haemaccel) were found to be equally effective in prevention of PONV.Therefore, both Ringer and Haemaccel can be used for prevention of these symptoms.

Table 1 .
Demographic data of patients in Ringer and Haemaccel group (n=54).