Post-operative Nausea and Vomiting Following Regional Anaesthesia at a Low-income Country Tertiary Hospital

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Nabukenya, Kojjo Charles, Tonny Stone Luggya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4611629/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract INTRODUCTION: Post-Operative Nausea and Vomiting (PONV) is one of the complications associated with surgery and anesthesia especially with current advancements in both specialties increasing operations done under regional anesthesia rather than general anesthesia. PONV incidence and associated factors in our setting after regional anesthesia remain unknown yet suboptimal management causes distress postoperatively. OBJECTIVE : We studied the incidence and the factors associated with Post-Operative Nausea and Vomiting among surgical patients undergoing regional anesthesia in Mulago National Referral and Teaching Hospital. METHODOLOGY : This was a prospective cohort study, registered at ClinicalTrials.gov as study number NCT03835234. Patients aged 18 years and above that were planned for surgery under regional anesthesia at Mulago National Referral and Teaching Hospital were consented and enrolled into the study over a six month period. Data was collected using pre-tested, semi structured questionnaires. Patients were post operatively observed for 24 hours. We determined the incidence of and factors associated with PONV which were submitted to multiple logistic regression analysis to determine a PONV causal relationship. RESULTS : Out of 364 participants, 140(38%) experienced PONV. Factors associated with PONV in our setting were history of nausea or vomiting(AOR=3.49, 95% CI 1.53 - 7.96 ), motion sickness(AOR= 2.36, 95% CI 1.20 - 4.65), history of PONV(AOR= 2.61, 95% CI 1.25 - 5.46 ), age(AOR= 1.03,95% CI 1.01 - 1.06),ASA 2 classification(AOR=0.36,p=0.016), less than two hours of preoperative fasting(AOR=4.09, 95% CI 0.16 - 0.83) and low blood pressure(AOR=4.99, 95% CI 1.72 - 14.48 ). Ninety two participants (25.3%) received anti-emetics perioperatively. CONCLUSION : The incidence of PONV following surgery under regional anesthesia at MNRTH is higher than elsewhere reported. Some factors associated with PONV were similar to those in other studies, while others were unique to this study. 25% of the patients received PONV prophylaxis. PONV regional anesthesia Surgery nausea vomiting Figures Figure 1 BACKGROUND Post-operative nausea and vomiting (PONV) is one of the most common side effects associated with anesthesia for many a surgical procedure [ 1 ]. PONV is defined as any retching, nausea or vomiting in the post-anesthesia care unit (PACU) or within 24 hours following surgery. It usually resolves or is treated without sequelae but may require unanticipated hospital admission and delay recovery room discharge [ 2 , 3 ]. Globally in 2004 approximately one in every 25 people underwent an operation requiring anesthesia with a global volume of major surgery between 187 and 281 million cases [ 4 ]. Some clinicians view PONV as a minor issue, some even regard it as a “normal” outcome, as it usually lasts a short time and responds to treatment [ 5 ], yet it is the most common cause of postoperative dissatisfaction with incidences of 30% in general and 80% in high risk patients [ 6 ]. Also PONV may have high incidences (70%) irrespective of antiemetic drug therapy [ 7 ]. Aside from the medical issues, PONV can result in psychological effects giving patients a distressing experience which impacts directly on patient outcomes after anaesthesia [ 8 ], hence its high rating among anesthesia outcomes patients would most like to avoid. It also results in patients experiencing anxiety about undergoing further surgery. There is paucity of data primarily investigating PONV associated with regional anesthesia [ 9 ] and PONV studies in Mulago National Referral and Teaching Hospital (MNRTH) showed an incidence of up to 40.7% [ 10 ], however this was done among general surgical patients. We thus studied the incidence of and factors associated with PONV following surgery under regional (spinal, blocks and local infiltration) anesthesia in MNRTH to identify gaps in the practice of its prevention and management. MATERIALS AND METHODS Study Setting: This was a single center study done at MNRTH which is located in Kampala, the capital city of Uganda. It is a 1790 bed tertiary hospital but can admit up to 2500 patients. It caters for approximately 140,000 patients annually. This study was carried out in various theatres of MNRTH that included the main operating theatre, obstetrics and gynecology theatres, the orthopedics and ophthalmology theatres with a total of eight operating tables averaging fifteen surgeries daily. Study Period: The study was conducted from August 2018 to January 2019. We recruited patients that met the inclusion criteria and consented to participate. Study procedure and Participant recruitment: Informed consent was sought from the study participants and confidentiality was observed throughout the study. The study population consisted of both male and female patients, aged 18 years and above, that were scheduled having emergency or elective surgery under regional anesthesia, American Society of Anesthesiologists (ASA) physiological class I, II, IIIand IV patients who consented to participation. Consecutive sampling for every patient was used for eligible and consenting patients whose age, sex, medical history, vitals (HR, BP and SPO2), anesthetic technique used, duration of surgery, intraoperative medication and any PONV assessed for in the PACU and at 24hours follow up period. Study variables : Independent: Socio demographic data such as age and sex, the diagnosis and type of procedure, ASA classification, history of PONV or motion sickness, non-smokers, peri-operative opioid use, period of pre-operative fasting, PONV prophylaxis use, duration of anesthesia and surgery were studied. Dependent: PONV measured by any retching, nausea or vomiting within 24 hours following surgery under regional anesthesia. Sample size calculation: Assuming an incidence of PONV in regional anaesthesia of 31.4% [1], with an absolute error of 0.05 and 95% CI Using Kish Leslie formula: N= Z 2 P (1-P) D 2 Where N=sample size required to determine incidence Z is the value corresponding to 95% confidence interval=1.96 P is the prevalence of PONV among patients undergoing surgery under regional anaesthesia=0.314 from previous studies D is the absolute error=0.05 N = 1.96 x 1.96 x 0.314 (1- 0.314) 0.05 x 0.05 N =331patients Adjusting for loss to follow up of 10% N =n (100+10)/100 =331(100+10)/100 =364 patients Data management and analysis: we used a structured and pretested questionnaire that was double entered into EPI data version 3.1 and subsequently exported to STATA version 14.0 for analysis. Continuous variables were expressed as means and standard deviations while categorical data was expressed as frequencies with their respective proportions. Cumulative incidence was assessed as the proportion of study participants who developed PONV within 24 hours of follow up divided by the total number of study participants enrolled into the study. Bivariate analysis with comparison of outcome variable using cross tabulation and then logistic analysis was done. Multivariate analysis was considered for variables with p-value less than 0.200 at bivariate analysis. P-value <0.05 variables were considered significant and data presentation was in tabular and graphic forms. RESULTS We screened 380 patients, excluded 16 patients (6 declined consent and 10 switched to general anaesthesia) and recruited 364 patients of which 74% were female, the youngest being 18 years and oldest was 82 years. ( Table 1 ) . 197 (54.1%) had obstetric surgery, 117 (32.1%) orthopedic surgery, 25 (6.9%) general surgery, 18 (4.9%) ophthalmic surgery and 7 (1.9%) had dental surgery, with the commonest duration of surgery of 30–60 minutes (in 53.3% cases). The incidence of PONV was 38%. See Fig. 1 . Table 1 Baseline characteristics of study participants Characteristics Freq [n, %] Urgency of surgery Elective 184 (50.6) Emergency 180 (49.4) Sex Male 94 (25.8) Female 270 (74.2) ASA classification 1 61 (16.8) 2 296 (81.3) 3 7 (1.9) Age ; median (IQR) 29 (23–38) Non-smoking status 356 (97.8) Alcohol use 57 (15.7) History of motion sickness 153 (42.0) History of PONV 58 (15.9) We had 300(82.4%) plain spinal anesthetics followed by 50 (13.8%) others (retro bulbar, peri-bulbar, wrist block, penile and infra-orbital) then local infiltration and brachial plexus blocks both at 7(1.9%) patients. Of the 140 that got PONV, 100(71.4%) were ASA2 followed by 35(25%) being ASA 1 patients (Adjusted Odds Ratio- AOR, 0.36, p = 0.016), patients with history of PONV were 2.6 times more likely to get PONV (p = 0.011), those with history of nausea and vomiting were 3.5 times more likely to have PONV and those who had a history of motion sickness were 2.4 times more likely to have PONV. Fasting duration of less than two hours had 4 times likelihood of PONV (AOR 4.09, p = 0.037) See Table 1 . Variables whose p value was less than 0.2 at bivariate analysis were entered into multivariate analysis and age, ASA 2 classification, history of PONV, history of nausea or vomiting, history of motion sickness etc. were found to be significantly associated with PONV as Seen in Table 2 & 3 . Female gender, alcohol use and use of postoperative opioids were not found to be of significant association with PONV. In this study, 92 (25.3%) patients received intraoperative anti-emetics. Table 2 Bivariate analysis for risk factors for PONV Characteristics PONV No (n = 140, %) Yes (n = 224, %) P-value Urgency of surgery 0.179 Elective 107 (58.2) 77 (41.8) Emergency 117 (65.0) 63 (35.0) Sex 0.650 Male 56 (59.6) 38 (40.4) Female 168 (62.2) 51 (37.8) ASA classification < 0.001 1 1 26 (42.6) 35 (57.4) 2 196 (66.2) 100 (33.8) 3 2 (28.6) 5 (71.4) Age ; median (IQR) 28 (23–37) 30 (24–42) 0.039 a History of PONV 23 (39.7) 35 (60.3) 2 197 (64.6) 108 (35.4) Type of feeds 0.018 Solids 82 (67.2) 40 (32.8) Semi-solids 57 (50.9) 55 (49.1) Liquids 85 (65.9) 44 (34.1) Duration of surgery (minutes) 0.867 30 24 (64.9) 13 (35.1) 30–60 119 (61.3) 75 (38.7) 60–120 59 (62.1) 36 (37.9) > 120 20 (55.6) 16 (44.4) Drugs used during anesthesia Opioids 114 (67.1) 56 (32.9) 0.056 Anti-emetics 49 (53.3) 43 (46.7) 0.062 Sedatives 19 (32.2) 0.285 SBP 0.001 1 < 110 121 (65.4) 64 (34.6) < 90 45 (44.6) 56 (55.4) < 50 1 (0.6) 0 (0.0) DBP 0.097 < 90 26 (76.5) 8 (23.5) < 70 113 (60.1) 75 (39.9) < 50 66 (55.9) 52 (44.1) Post-operative opioids received 0.800 Yes 136 (61.0) 87 (39.0) No 86 (62.3) 52 (37.7) P- chi-square p-values, P 1 - fishers exact p-values, P a - Rank sum p-values Table 3 Multivariable logistic regression model showing factors associated with Post-operative nausea and vomiting Characteristics Unadjusted Odds ratio (95% CI) P-value Adjusted Odds ratio (95% CI) P-value Age 1.03 (1.01–1.04) 0.003 1.03 (1.01–1.06) 0.011 Urgency Elective 1.00 1.00 Emergency 0.75 (0.49–1.14) 0.180 1.68 (0.82–3.44) 0.153 ASA classification 1 1.00 1.00 2 0.38 (0.22–0.66) 0.001 0.36 (0.16–0.83) 0.016 3 1.86 (0.33–10.34) 0.480 1.38 (0.17–11.32) 0.763 History of PONV No 1.00 1.00 Yes 2.91 (1.64–5.19) < 0.001 2.61 (1.25–5.46) 0.011 History of motion sickness No 1.00 1.00 Yes 1.96 (1.28–3.01) 0.002 2.36 (1.20–4.65) 0.013 Ever had nausea or vomiting No 1.00 1.00 Yes 1.89 (1.14–3.13) 0.014 3.49 (1.53 − 7.96) 0.003 Time since last feed (hours) > 2 1.00 1.00 ≤ 2 2.16 (1.23–3.80) 0.007 4.09 (1.70–9.87) 0.002 DBP < 90 1.00 1.00 < 70 2.16 (0.93–5.02) 0.074 4.72 (1.69–13.12) 0.003 < 50 2.56 (1.07–6.12) 0.035 4.99 (1.72–14.48) 0.003 Anti-emetics Yes 1.00 1.00 No 0.64 (0.39–1.03) 0.063 1.15 (0.60–2.20) 0.673 Opioids Yes 1.00 1.00 No 1.52 (0.99–2.33) 0.057 1.38 (0.81–2.38) 0.239 Type of feeds Solids 1.00 1.00 Semi-solids 1.98 (1.17–3.36) 0.012 2.08 (1.05–4.15) 0.037 Liquids 1.06 (0.63–1.79) 0.824 1.68 (0.75–3.73) 0.206 DISCUSSION We studied adult patients who had elective or emergency surgery at MNRTH- a low-income country tertiary facility, to determine the incidence and factors associated with PONV following regional anesthesia. The incidence of retching, nausea or vomiting occurring within 24 hours of surgery was found to be 38%, with age, ASA 2 classification, history of PONV, history of nausea and vomiting, history of motion sickness, hypotension, short fasting time and semi-solid last feed being significantly associated with its occurrence. Out of every 5 patients undergoing surgery under regional anesthesia at MNRTH, 2 were likely to develop PONV. This is a high incidence compared to studies done elsewhere: 10.8% in the study by Morino et al. [ 11 ] but similar to 31.4% by Quinn et al [ 12 ] The higher incidence in our study could be explained by the fact that most of the regional anesthesia was spinal anesthesia (84%) which has been shown to have higher incidences of PONV than other regional blocks [ 13 ] Furthermore 54% of the surgery done was in obstetric patients who are already at risk of pregnancy induced nausea and vomiting[ 14 ]. In addition to that, only a few patients received prophylaxis for PONV which may have contributed significantly to the high incidence. This was probably due to limited available resources and the variations in practice of the anesthesia providers. It has been highlighted by Gan et al. that the low compliance to recommendations is the biggest hindrance to PONV management [ 15 ]. In our study we found that 100 (71.4%) ASA2 patients had PONV showing that a higher ASA score increased chance of PONV.. We posit this was due to majority of our study patients 197 (54.1%) undergoing obstetric surgery hence were already ASA2; also apfel in 2012 found female gender as the strongest patient specific predicator for PONV [ 16 ] We found out that history of PONV, motion sickness or nausea and vomiting had significant association with PONV which is similar to prior studies [ 13 , 17 ]. Hypotension was associated with increased nausea and vomiting as seen in other studies done in regional anesthesia [ 18 ]. Hypotension is thought to cause reduction of blood flow to the brain stem and influence on the chemoreceptor trigger zone (CTZ) that lead to dizziness and disturbance of the vestibular system hence predisposing to PONV [ 19 ] This study did not demonstrate the almost consistent strong risk factor for PONV of female gender as in several other studies [ 16 ]. 97.8% of our study population were non-smokers and it was not found to be protective against PONV. Postoperative opioid use did not predispose to PONV in this study, which may be due to the fact that few of the participants received opioids. Opioids in our setting are not readily available or easily accessible as they are stored under lock and key by ward in charges and are costly for families when asked to purchase The main limiting factor of this study was the event reports which were subject to recall bias by the study participants, Consecutive sampling at the cross-section interval studied may not be reflective of the whole spectrum of cases done at MNRTH, CONCLUSION The incidence of PONV following surgery under regional anaesthesia at Mulago hospital was found to be high. History of PONV, history of motion sickness, history of nausea or vomiting, age, ASA II classification, hypotension, less than two hours of preoperative fasting, and semi-solid last meal before surgery were associated factors. Declarations ACKNOWLEDGEMENTS: We acknowledge colleagues at the Department of Anaesthesia and Critical Care, Makerere University and Uganda Cancer Institute, Mulago NRTH for their contribution plus support towards this work. The tireless and dedicated operating theater staff of Mulago National Referral and Teaching Hospital ETHICS APPROVAL AND CONSENT: We obtained ethical approval from the School of Medicine Research and Ethics Committee of Makerere University and MNRTH IRB to conduct this study. It was registered at clinicalTrials.gov as study number NCT03835234 [20] CONSENT FOR PUBLICATION: The authors give consent for publication COMPETING INTERESTS: The authors declare that they have no conflict of or competing interests either financial or non-financial. FUNDING: This was self-funded academic research for Masters in Medicine degree. DUPLICATE PUBLICATION: This is an original manuscript whose work is not under consideration elsewhere, copyright has not been breached in seeking publication and the publication has been approved by all co-authors and responsible authorities at MNRTH References Quinn AC, Brown JH, Wallace PG, Asbury AJ. Studies in postoperative sequelae. Nausea and vomiting—still a problem. Anaesthesia. 1994;49(1):62–5. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective study. Can J Anaesth. 1998;45(7):612. Hill RP, Lubarsky DA, Phillips-Bute B, Fortney JT, Creed MR, Glass PS, Gan TJ. Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo. J Am Soc Anesthesiologists. 2000;92(4):958–67. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139–44. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramèr MR. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analgesia. 2003;97(1):62–71. Pierre S, Whelan R. Nausea and vomiting after surgery. Continuing Education in Anaesthesia. Crit Care Pain. 2013;13(1):28–32. ENQVIST B, BJÖRKLUND C, ENGMAN M. J. JAKOBSSON: Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts, Acta Anaesthesiologica Scandinavica. : 30 December 2008. https://doi.org/10.1111/j.1399-6576.1997.tb04831.x . Nowak H, Wolf A, Rahmel T, et al. Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients - A Post hoc Analysis of a Randomized Controlled Trial. Front Psychol. 2022;13:898326. 10.3389/fpsyg.2022.898326 . Published 2022 Jul 15. Borgeat A, Ekatodramis G, Schenker CA. Postoperative nausea and vomiting in regional anesthesia: a review. J Am Soc Anesthesiologists. 2003;98(2):530–47. Ssebuufu R, Kakande I, Okello M. Post-operative nausea and vomiting at Mulago Hospital. East Cent Afr J Surg. 2009;14(2):50–7. Morino R, Ozaki M, Nagata O, Yokota M. Incidence of and risk factors for postoperative nausea and vomiting at a Japanese Cancer Center: first large-scale study in Japan. J Anesth. 2013;27(1):18–24. Quinn AC, Brown JH, Wallace PG, Asbury AJ. Studies in postoperative sequelae. Nausea and vomiting—still a problem. Anaesthesia. 1994;49(1):62–5. Koivuranta M, Läärä E, Snåre L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia. 1997;52(5):443–9. Shaikh SI, Nagarekha D, Hegade G, Marutheesh M. Postoperative nausea and vomiting: A simple yet complex problem. Anesth essays researches. 2016;10(3):388. Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, Watcha M, Chung F, Angus S, Apfel CC, Bergese SD. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analgesia. 2014;118(1):85–113. Apfel CC, Heidrich FM, Jukar-Rao S, Jalota L, Hornuss C, Whelan RP, Zhang K, Cakmakkaya OS. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth. 2012;109(5):742–53. 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. J Am Soc Anesthesiologists. 1999;91(3):693. Crocker JS, Vandam LD. concerning nausea and vomiting during spinal anesthesia. InThe Journal of the American Society of Anesthesiologists 1959 Sep 1 (Vol. 20, No. 5, pp. 587–92). The American Society of Anesthesiologists. Hitomi Nakatani Y, Naito M, Ida M, Sato N, Okamoto T, Nishiwada. Masahiko Kawaguchi; Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective analysis of 247 thyroidectomy cases. Brazilian Journal of Anesthesiology (English Edition),2021. https:// clinicaltrials.gov/ct2/show/ NCT03835234?term=NCT03835234&draw=2&rank=1 Additional Declarations No competing interests reported. Supplementary Files Questionnaire1PONV1.xls Questionnaire2PONV3.xls Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4611629","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":319213459,"identity":"30f5bc8d-5e5d-4e11-acd6-212407a37da3","order_by":0,"name":"Dorothy Turitwenka","email":"","orcid":"","institution":"Mulago Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dorothy","middleName":"","lastName":"Turitwenka","suffix":""},{"id":319213460,"identity":"6985db20-2fde-4632-84f6-707b144867d1","order_by":1,"name":"Mary T. Nabukenya","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"T.","lastName":"Nabukenya","suffix":""},{"id":319213461,"identity":"092e503d-973e-4885-b3d4-244a6e36865c","order_by":2,"name":"Kojjo Charles","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Kojjo","middleName":"","lastName":"Charles","suffix":""},{"id":319213462,"identity":"4f1b3c29-7d2e-436b-89d0-fd836a6a29f7","order_by":3,"name":"Tonny Stone Luggya","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBAC+QYwZQHhfWBgMCCoxeAYmJIAk4wziNLChqSFmYcoLfLNxx58YJBInO+/xvCzbY6dMQP74QfMPL9wa5FvY0s3nAHUsvHGG2Pp3G3JZgw8aQbMvH14rDnGYybNA9Iy44wBUAuzDQNDDgMzbw8BLX8gWox/W26rt2Hgf0OEFgaQX/h7zKQZtx02Y5AA2sLzA4/3j6WlSfYYSBhvkGArs+zddtyYTeKZwcG5DXi833z4mMSPChvZ+f2HN9/4ua3asJ8/+eGDN3/wOAxiFxDdyIBECSiiDjC2EdICsq7/+AMkLkFbRsEoGAWjYAQBAKIdS3SEJHaaAAAAAElFTkSuQmCC","orcid":"","institution":"Makerere University","correspondingAuthor":true,"prefix":"","firstName":"Tonny","middleName":"Stone","lastName":"Luggya","suffix":""}],"badges":[],"createdAt":"2024-06-20 12:06:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4611629/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4611629/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60705310,"identity":"371f3a9b-48a2-4d1a-aeb7-e872332a57ba","added_by":"auto","created_at":"2024-07-19 19:16:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93858,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePONV Incidence in patients having surgery under Regional Anaesthesia\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4611629/v1/fd787b9dfdd93e984fbe36f6.jpg"},{"id":61629516,"identity":"b2d3d6b6-c9ed-4262-83e3-8b8b690d4c6b","added_by":"auto","created_at":"2024-08-02 07:35:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":931342,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4611629/v1/78a903e8-ed9a-406c-b3aa-8eb5f9a498e2.pdf"},{"id":60705313,"identity":"9b7c3842-c580-494b-b03a-3f7abc682095","added_by":"auto","created_at":"2024-07-19 19:16:53","extension":"xls","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":142416,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnaire1PONV1.xls","url":"https://assets-eu.researchsquare.com/files/rs-4611629/v1/4dd3b572bdf4f3e94f1f176e.xls"},{"id":60705998,"identity":"62363814-311c-4dd9-aa47-a1fe68ce6f87","added_by":"auto","created_at":"2024-07-19 19:24:53","extension":"xls","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":204828,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnaire2PONV3.xls","url":"https://assets-eu.researchsquare.com/files/rs-4611629/v1/70390a57a2e55ba796032221.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePost-operative Nausea and Vomiting Following Regional Anaesthesia at a Low-income Country Tertiary Hospital\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePost-operative nausea and vomiting (PONV) is one of the most common side effects associated with anesthesia for many a surgical procedure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. PONV is defined as any retching, nausea or vomiting in the post-anesthesia care unit (PACU) or within 24 hours following surgery. It usually resolves or is treated without sequelae but may require unanticipated hospital admission and delay recovery room discharge [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally in 2004 approximately one in every 25 people underwent an operation requiring anesthesia with a global volume of major surgery between 187 and 281\u0026nbsp;million cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Some clinicians view PONV as a minor issue, some even regard it as a \u0026ldquo;normal\u0026rdquo; outcome, as it usually lasts a short time and responds to treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], yet it is the most common cause of postoperative dissatisfaction with incidences of 30% in general and 80% in high risk patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Also PONV may have high incidences (70%) irrespective of antiemetic drug therapy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Aside from the medical issues, PONV can result in psychological effects giving patients a distressing experience which impacts directly on patient outcomes after anaesthesia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], hence its high rating among anesthesia outcomes patients would most like to avoid. It also results in patients experiencing anxiety about undergoing further surgery. There is paucity of data primarily investigating PONV associated with regional anesthesia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and PONV studies in Mulago National Referral and Teaching Hospital (MNRTH) showed an incidence of up to 40.7% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], however this was done among general surgical patients. We thus studied the incidence of and factors associated with PONV following surgery under regional (spinal, blocks and local infiltration) anesthesia in MNRTH to identify gaps in the practice of its prevention and management.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Setting:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThis was a single center\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003estudy done at MNRTH which is located in Kampala, the capital city of Uganda. It is a 1790 bed tertiary hospital but can admit up to 2500 patients. It caters for approximately 140,000 patients annually. This study was carried out in various theatres of MNRTH that included the main operating theatre, obstetrics and gynecology theatres, the orthopedics and ophthalmology theatres with a total of eight operating tables\u0026nbsp;averaging\u0026nbsp;fifteen surgeries daily.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Period:\u003c/em\u003e\u003c/strong\u003e\u0026nbsp; The study was conducted from August 2018 to January 2019. We recruited patients that met the inclusion criteria and consented to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy procedure and Participant recruitment:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eInformed consent was sought from the study participants and confidentiality was observed throughout the study. The study population consisted of both male and female patients, aged 18 years and above, that were scheduled having emergency or elective surgery under regional anesthesia, American Society of Anesthesiologists (ASA) physiological class I, II, IIIand IV patients who consented to participation.\u003c/p\u003e\n\u003cp\u003eConsecutive sampling for every patient was used for eligible and consenting patients whose age, sex, medical history, vitals (HR, BP and SPO2), anesthetic technique used, duration of surgery, intraoperative medication and any PONV assessed for in the PACU and at \u0026nbsp;24hours follow up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy variables\u003c/em\u003e: Independent:\u003c/strong\u003e Socio demographic data such as age and sex, the diagnosis and type of procedure, ASA classification, history of PONV or motion sickness, non-smokers, peri-operative opioid use, period of pre-operative fasting, PONV prophylaxis use, duration of anesthesia and surgery were studied. \u003cstrong\u003eDependent:\u0026nbsp;\u003c/strong\u003ePONV measured by any retching, nausea or vomiting within 24 hours following surgery under regional anesthesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSample size calculation:\u003c/em\u003e\u003c/strong\u003e Assuming an incidence of PONV in regional anaesthesia of 31.4% [1], with an absolute error of 0.05 and 95% CI\u003c/p\u003e\n\u003cp\u003eUsing Kish Leslie formula:\u003c/p\u003e\n\u003cp\u003eN=\u003cu\u003eZ\u003csup\u003e2\u003c/sup\u003e P (1-P)\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; D \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhere N=sample size required to determine incidence\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Z is the value corresponding to 95% confidence interval=1.96\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; P is the prevalence of PONV among patients undergoing surgery under regional anaesthesia=0.314 from previous studies\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; D is the absolute error=0.05\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;N =\u003cu\u003e1.96 x 1.96 x 0.314 (1- 0.314)\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0.05 x 0.05\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;N =331patients\u003c/p\u003e\n\u003cp\u003eAdjusting for loss to follow up of 10%\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;N =n (100+10)/100\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; =331(100+10)/100\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;=364 patients\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData management and analysis:\u003c/em\u003e\u003c/strong\u003e\u0026nbsp; we used a structured and pretested questionnaire that was double entered into EPI data version 3.1 and subsequently exported to STATA version 14.0 for analysis. Continuous variables were expressed as means and standard deviations while categorical data was expressed as frequencies with their respective proportions. Cumulative incidence was assessed as the proportion of study participants who developed PONV within 24 hours of follow up divided by the total number of study participants enrolled into the study. \u0026nbsp;Bivariate analysis with comparison of outcome variable using cross tabulation and then logistic analysis was done. Multivariate analysis was considered for variables with p-value less than 0.200 at bivariate analysis. P-value \u0026lt;0.05 variables were considered significant and data presentation was in tabular and graphic forms.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe screened 380 patients, excluded 16 patients (6 declined consent and 10 switched to general anaesthesia) and recruited 364 patients of which 74% were female, the youngest being 18 years and oldest was 82 years. \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. 197 (54.1%) had obstetric surgery, 117 (32.1%) orthopedic surgery, 25 (6.9%) general surgery, 18 (4.9%) ophthalmic surgery and 7 (1.9%) had dental surgery, with the commonest duration of surgery of 30\u0026ndash;60 minutes (in 53.3% cases). The incidence of PONV was 38%. \u003cem\u003eSee\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFreq [n, %]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUrgency of surgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e184 (50.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (49.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (25.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e270 (74.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (16.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e296 (81.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge ; median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (23\u0026ndash;38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-smoking status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e356 (97.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (15.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of motion sickness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (42.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of PONV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe had 300(82.4%) plain spinal anesthetics followed by 50 (13.8%) others (retro bulbar, peri-bulbar, wrist block, penile and infra-orbital) then local infiltration and brachial plexus blocks both at 7(1.9%) patients.\u003c/p\u003e \u003cp\u003eOf the 140 that got PONV, 100(71.4%) were ASA2 followed by 35(25%) being ASA 1 patients (Adjusted Odds Ratio- AOR, 0.36, p\u0026thinsp;=\u0026thinsp;0.016), patients with history of PONV were 2.6 times more likely to get PONV (p\u0026thinsp;=\u0026thinsp;0.011), those with history of nausea and vomiting were 3.5 times more likely to have PONV and those who had a history of motion sickness were 2.4 times more likely to have PONV. Fasting duration of less than two hours had 4 times likelihood of PONV (AOR 4.09, p\u0026thinsp;=\u0026thinsp;0.037) \u003cem\u003eSee\u003c/em\u003e Table\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Variables whose p value was less than 0.2 at bivariate analysis were entered into multivariate analysis and age, ASA 2 classification, history of PONV, history of nausea or vomiting, history of motion sickness etc. were found to be significantly associated with PONV as \u003cem\u003eSeen in\u003c/em\u003e Table\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026amp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Female gender, alcohol use and use of postoperative opioids were not found to be of significant association with PONV. In this study, 92 (25.3%) patients received intraoperative anti-emetics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate analysis for risk factors for PONV\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePONV\u003c/p\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;140, %) Yes (n\u0026thinsp;=\u0026thinsp;224, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgency of surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.650\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (59.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168 (62.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196 (66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge ; median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (23\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (24\u0026ndash;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of PONV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of motion sickness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (54.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.227\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon Smoker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.712\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime since last feed (hours)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e197 (64.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (35.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of feeds\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSolids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (67.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemi-solids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiquids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of surgery (minutes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.867\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDrugs used during anesthesia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOpioids\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.056\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnti-emetics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.062\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSedatives\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.285\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDBP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.097\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113 (60.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (39.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-operative opioids received\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.800\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (62.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eP- chi-square p-values, P\u003csup\u003e1\u003c/sup\u003e- fishers exact p-values, P\u003csup\u003ea\u003c/sup\u003e- Rank sum p-values\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMultivariable logistic regression model showing factors associated with Post-operative nausea and vomiting\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnadjusted\u003c/p\u003e \u003cp\u003eOdds ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted\u003c/p\u003e \u003cp\u003eOdds ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03 (1.01\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.03 (1.01\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrgency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.75 (0.49\u0026ndash;1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.180\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.68 (0.82\u0026ndash;3.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.153\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.38 (0.22\u0026ndash;0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.36 (0.16\u0026ndash;0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.86 (0.33\u0026ndash;10.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.480\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.38 (0.17\u0026ndash;11.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.763\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of PONV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.91 (1.64\u0026ndash;5.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.61 (1.25\u0026ndash;5.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of motion sickness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.96 (1.28\u0026ndash;3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.36 (1.20\u0026ndash;4.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver had nausea or vomiting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.89 (1.14\u0026ndash;3.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.49 (1.53 \u0026minus;\u0026thinsp;7.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime since last feed (hours)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.16 (1.23\u0026ndash;3.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.09 (1.70\u0026ndash;9.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDBP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.16 (0.93\u0026ndash;5.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.074\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.72 (1.69\u0026ndash;13.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.56 (1.07\u0026ndash;6.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.99 (1.72\u0026ndash;14.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnti-emetics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.64 (0.39\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.063\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.15 (0.60\u0026ndash;2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.673\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOpioids\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.52 (0.99\u0026ndash;2.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.057\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.38 (0.81\u0026ndash;2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.239\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of feeds\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSolids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemi-solids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.98 (1.17\u0026ndash;3.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.08 (1.05\u0026ndash;4.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiquids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.06 (0.63\u0026ndash;1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.824\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.68 (0.75\u0026ndash;3.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.206\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe studied adult patients who had elective or emergency surgery at MNRTH- a low-income country tertiary facility, to determine the incidence and factors associated with PONV following regional anesthesia. The incidence of retching, nausea or vomiting occurring within 24 hours of surgery was found to be 38%, with age, ASA 2 classification, history of PONV, history of nausea and vomiting, history of motion sickness, hypotension, short fasting time and semi-solid last feed being significantly associated with its occurrence.\u003c/p\u003e \u003cp\u003eOut of every 5 patients undergoing surgery under regional anesthesia at MNRTH, 2 were likely to develop PONV. This is a high incidence compared to studies done elsewhere: 10.8% in the study by Morino et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] but similar to 31.4% by Quinn et al [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] The higher incidence in our study could be explained by the fact that most of the regional anesthesia was spinal anesthesia (84%) which has been shown to have higher incidences of PONV than other regional blocks [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Furthermore 54% of the surgery done was in obstetric patients who are already at risk of pregnancy induced nausea and vomiting[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition to that, only a few patients received prophylaxis for PONV which may have contributed significantly to the high incidence. This was probably due to limited available resources and the variations in practice of the anesthesia providers. It has been highlighted by Gan et al. that the low compliance to recommendations is the biggest hindrance to PONV management [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study we found that 100 (71.4%) ASA2 patients had PONV showing that a higher ASA score increased chance of PONV.. We posit this was due to majority of our study patients 197 (54.1%) undergoing obstetric surgery hence were already ASA2; also apfel in 2012 found female gender as the strongest patient specific predicator for PONV [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe found out that history of PONV, motion sickness or nausea and vomiting had significant association with PONV which is similar to prior studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hypotension was associated with increased nausea and vomiting as seen in other studies done in regional anesthesia [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hypotension is thought to cause reduction of blood flow to the brain stem and influence on the chemoreceptor trigger zone (CTZ) that lead to dizziness and disturbance of the vestibular system hence predisposing to PONV [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study did not demonstrate the almost consistent strong risk factor for PONV of female gender as in several other studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. 97.8% of our study population were non-smokers and it was not found to be protective against PONV. Postoperative opioid use did not predispose to PONV in this study, which may be due to the fact that few of the participants received opioids. Opioids in our setting are not readily available or easily accessible as they are stored under lock and key by ward in charges and are costly for families when asked to purchase\u003c/p\u003e \u003cp\u003eThe main limiting factor of this study was the event reports which were subject to recall bias by the study participants, Consecutive sampling at the cross-section interval studied may not be reflective of the whole spectrum of cases done at MNRTH,\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe incidence of PONV following surgery under regional anaesthesia at Mulago hospital was found to be high. History of PONV, history of motion sickness, history of nausea or vomiting, age, ASA II classification, hypotension, less than two hours of preoperative fasting, and semi-solid last meal before surgery were associated factors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eACKNOWLEDGEMENTS:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWe\u0026nbsp;acknowledge colleagues at the Department of Anaesthesia and Critical Care, Makerere\u0026nbsp;University and Uganda Cancer Institute, Mulago NRTH\u0026nbsp;for their contribution plus support towards this work.\u003c/li\u003e\n \u003cli\u003eThe tireless and dedicated operating theater staff of Mulago National Referral and Teaching Hospital\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eETHICS APPROVAL AND CONSENT: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe obtained ethical approval from\u0026nbsp;the School of Medicine Research and Ethics Committee of Makerere University and MNRTH IRB to conduct this study. It was registered at\u0026nbsp;clinicalTrials.gov as study number NCT03835234 [20]\u003c/p\u003e\n\u003cp\u003eCONSENT FOR PUBLICATION:\u0026nbsp;The authors give consent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOMPETING INTERESTS: \u0026nbsp;The authors declare that they have no conflict of or competing interests either financial or non-financial.\u003c/p\u003e\n\u003cp\u003eFUNDING: \u0026nbsp;This was self-funded academic research for Masters in Medicine degree.\u003c/p\u003e\n\u003cp\u003eDUPLICATE PUBLICATION: \u0026nbsp;This is an original manuscript whose work is not under consideration elsewhere, copyright has not been breached in seeking publication and the publication has been approved by all co-authors and responsible authorities at MNRTH\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQuinn AC, Brown JH, Wallace PG, Asbury AJ. Studies in postoperative sequelae. Nausea and vomiting\u0026mdash;still a problem. Anaesthesia. 1994;49(1):62\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery\u0026mdash;a prospective study. Can J Anaesth. 1998;45(7):612.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill RP, Lubarsky DA, Phillips-Bute B, Fortney JT, Creed MR, Glass PS, Gan TJ. Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo. J Am Soc Anesthesiologists. 2000;92(4):958\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tram\u0026egrave;r MR. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analgesia. 2003;97(1):62\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePierre S, Whelan R. Nausea and vomiting after surgery. Continuing Education in Anaesthesia. Crit Care Pain. 2013;13(1):28\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eENQVIST B, BJ\u0026Ouml;RKLUND C, ENGMAN M. J. JAKOBSSON: Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts, \u003cem\u003eActa Anaesthesiologica Scandinavica.\u003c/em\u003e : 30 December 2008. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1399-6576.1997.tb04831.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1399-6576.1997.tb04831.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNowak H, Wolf A, Rahmel T, et al. Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients - A \u003cem\u003ePost hoc\u003c/em\u003e Analysis of a Randomized Controlled Trial. Front Psychol. 2022;13:898326. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2022.898326\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2022.898326\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2022 Jul 15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorgeat A, Ekatodramis G, Schenker CA. Postoperative nausea and vomiting in regional anesthesia: a review. J Am Soc Anesthesiologists. 2003;98(2):530\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSsebuufu R, Kakande I, Okello M. Post-operative nausea and vomiting at Mulago Hospital. East Cent Afr J Surg. 2009;14(2):50\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorino R, Ozaki M, Nagata O, Yokota M. Incidence of and risk factors for postoperative nausea and vomiting at a Japanese Cancer Center: first large-scale study in Japan. J Anesth. 2013;27(1):18\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinn AC, Brown JH, Wallace PG, Asbury AJ. Studies in postoperative sequelae. Nausea and vomiting\u0026mdash;still a problem. Anaesthesia. 1994;49(1):62\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoivuranta M, L\u0026auml;\u0026auml;r\u0026auml; E, Sn\u0026aring;re L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia. 1997;52(5):443\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaikh SI, Nagarekha D, Hegade G, Marutheesh M. Postoperative nausea and vomiting: A simple yet complex problem. Anesth essays researches. 2016;10(3):388.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, Watcha M, Chung F, Angus S, Apfel CC, Bergese SD. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analgesia. 2014;118(1):85\u0026ndash;113.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApfel CC, Heidrich FM, Jukar-Rao S, Jalota L, Hornuss C, Whelan RP, Zhang K, Cakmakkaya OS. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth. 2012;109(5):742\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApfel CC, L\u0026auml;\u0026auml;r\u0026auml; E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. J Am Soc Anesthesiologists. 1999;91(3):693.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrocker JS, Vandam LD. concerning nausea and vomiting during spinal anesthesia. InThe Journal of the American Society of Anesthesiologists 1959 Sep 1 (Vol. 20, No. 5, pp. 587\u0026ndash;92). The American Society of Anesthesiologists.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHitomi Nakatani Y, Naito M, Ida M, Sato N, Okamoto T, Nishiwada. Masahiko Kawaguchi; Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective analysis of 247 thyroidectomy cases. Brazilian Journal of Anesthesiology (English Edition),2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ehttps://\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eclinicaltrials.gov/ct2/show/\u003c/span\u003e\u003cspan address=\"http://clinicaltrials.gov/ct2/show/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eNCT03835234?term=NCT03835234\u0026amp;draw=2\u0026amp;rank=1\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PONV, regional anesthesia, Surgery, nausea, vomiting","lastPublishedDoi":"10.21203/rs.3.rs-4611629/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4611629/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eINTRODUCTION: \u003c/strong\u003ePost-Operative Nausea and Vomiting (PONV) is one of the complications associated with surgery and anesthesia especially with current advancements in both specialties increasing operations done under regional anesthesia rather than general anesthesia. PONV incidence and associated factors in our setting after regional anesthesia remain unknown yet suboptimal management causes distress postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOBJECTIVE\u003c/strong\u003e: We studied the incidence and the factors associated with Post-Operative Nausea and Vomiting among surgical patients undergoing regional anesthesia in Mulago National Referral and Teaching Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODOLOGY\u003c/strong\u003e: This was a prospective cohort study, registered at ClinicalTrials.gov as study number NCT03835234. Patients aged 18 years and above that were planned for surgery under regional anesthesia at Mulago National Referral and Teaching Hospital were consented and enrolled into the study over a six month period. Data was collected using pre-tested, semi structured questionnaires. Patients were post operatively observed for 24 hours. We determined the incidence of and factors associated with PONV which were submitted to multiple logistic regression analysis to determine a PONV causal relationship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e: Out of 364 participants, 140(38%) experienced PONV. Factors associated with PONV in our setting were history of nausea or vomiting(AOR=3.49, 95% CI 1.53 - 7.96 ), motion sickness(AOR= 2.36, 95% CI 1.20 - 4.65), history of PONV(AOR= 2.61, 95% CI 1.25 - 5.46 ), age(AOR= 1.03,95% CI 1.01 - 1.06),ASA 2 classification(AOR=0.36,p=0.016), less than two hours of preoperative fasting(AOR=4.09, 95% CI 0.16 - 0.83) and low blood pressure(AOR=4.99, 95% CI 1.72 - 14.48 ). Ninety two participants (25.3%) received anti-emetics perioperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e: The incidence of PONV following surgery under regional anesthesia at MNRTH is higher than elsewhere reported. Some factors associated with PONV were similar to those in other studies, while others were unique to this study. 25% of the patients received PONV prophylaxis.\u003c/p\u003e","manuscriptTitle":"Post-operative Nausea and Vomiting Following Regional Anaesthesia at a Low-income Country Tertiary Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-19 19:16:48","doi":"10.21203/rs.3.rs-4611629/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd7bb9e4-ca5d-4a36-9876-751bb1a7ddf9","owner":[],"postedDate":"July 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-02T07:27:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-19 19:16:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4611629","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4611629","identity":"rs-4611629","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}