British Journal of Anaesthesia 87 (3): 5024 (2001)

Prophylactic ondansetron does not improve patient satisfaction in

women using PCA after Caesarean section
V. T. Cherian1 and I. Smith2*
1

Department of Anaesthesia, Christian Medical College and Hospital, Vellore 632 004, India and
Department of Anaesthesia, North Staffordshire Hospital, Stoke-on-Trent, Staffordshire ST4 6QG, UK
*Corresponding author
Eighty-one consenting women undergoing elective Caesarean section under spinal anaesthesia
were randomly divided into two groups. In Group O patients, ondansetron 4 mg was given
intravenously at the end of the surgery and 8 mg added to the morphine solution in the PCA
syringe. Patients in Group P received only morphine via PCA syringe. Analgesia and nausea
were measured until PCA was discontinued 24 h after the operation. Women in the two
groups were similar with respect to age, duration of use of the PCA, amount of morphine
used, previous history of PONV, and incidence of motion sickness and morning sickness during
the current pregnancy. The number of women who complained of nausea and those needing
rescue antiemetic medication was signicantly less in Group O. However, there was no statistically signicant difference between the two groups in the patient's perception of the control
of nausea and their overall satisfaction. It was noted that PONV was more frequent among
women who had signicant morning sickness during early pregnancy and ondansetron was
benecial in reducing PONV in these women. Although the ondansetron reduced the incidence
of PONV and the need for further antiemetic medication, this did not affect patient's satisfaction regarding their postoperative care.
Br J Anaesth 2001; 87: 5024
Keywords: vomiting, nausea, postoperative; analgesia, patient-controlled; vomiting,
antiemetics, ondansetron; anaesthesia, obstetric
Accepted for publication: March 15, 2001

Patient-controlled analgesia (PCA) with i.v. opioids provides effective postoperative analgesia, but may be limited
by nausea and vomiting (PONV). Adding droperidol
(0.050.2 mg ml1) to morphine in the PCA syringe reduces
the incidence of PONV,16 but is associated with increased
sedation and extrapyramidal side effects. Ondansetron, a
5HT3 receptor antagonist, may be preferable in the
postpartum period because it lacks sedative effects that
may delay bonding with the baby. Although most studies on
ondansetron have shown that it reduces the incidence of
PONV, some workers regard this as only a `surrogate'
endpoint.7 8 Few investigators have examined the patient's
satisfaction with their treatment of PONV, which may be
regarded as the more important outcome.7 8
The aim of our study was to evaluate whether administering prophylactic ondansetron along with morphine via
PCA decreased PONV in obstetric patients and patient
satisfaction.

Methods and results

This double-blind, placebo-controlled study was approved by the local research ethics committee. Eightyone women undergoing elective Caesarean section at
term under spinal subarachnoid block were selected and
gave written informed consent. The sample had 80%
power to detect a halving of PONV from our baseline
value of 60%, found in an earlier audit. Patients with
hepatic, renal, psychiatric or neurological diseases and
those with pre-eclampsia were excluded. History of
PONV, motion sickness, smoking, and morning sickness
were noted. Subarachnoid anaesthesia was administered
using 2.52.8 ml of hyperbaric 0.5% bupivacaine,
through a 25-G pencil-point needle. All patients received
co-amoxyclav 1.2 g and oxytocin 10 units i.v. after the
baby was delivered and diclofenac 100 mg p.r. at the
end of the operation.

The Board of Management and Trustees of the British Journal of Anaesthesia 2001

Prophylactic ondansetron in women using PCA after Caesarean section

Table 1 Severity of postoperative nausea and vomiting and patient satisfaction with their control of nausea and vomiting and their overall level of care in the
two treatment groups. Values represent the most severe score recorded in the postoperative period (during PCA use) and are number (%) of occurrences or
responses

Nausea and vomiting (none/mild/severe/vomited)

Patients with morning sickness (n=52):
No PONV
Any PONV
Patients without morning sickness (n=29):
No PONV
Any PONV
Control of nausea and vomiting:
Good
Moderate
Poor
Overall satisfaction with care:
Good
Moderate
Poor

Group P (n=40)

Group O (n=41)

P value

15/2/5/18

26 / 5 / 3 / 7

7 (26%)
20 (74%)

16 (64%)
9 (36%)

0.023
0.005

8 (62%)
5 (38%)

10 (63%)
6 (37%)

24 (60%)
10 (25%)
6 (15%)

30 (73%)
9 (22%)
2 (5%)

35 (87.5%)
4 (10%)
1 (2.5%)

35 (85%)
5 (12%)
1 (3%)

Women were randomly allocated into two groups by

computer-generated random numbers in sequentially-numbered envelopes. Group P received a PCA with morphine (1
mg ml1), while Group O received ondansetron 4 mg
intravenously at the end of surgery plus 8 mg added to the
PCA morphine syringe (60 ml) (nal ondansetron concentration 0.13 mg ml1). The PCA pump was programmed to
deliver 1 ml per demand with a 3 min lockout and no
background infusion. Prochlorperazine 12.5 mg i.m. was
available as a rescue antiemetic to any patient who
requested it.
The incidence and severity of pain, sedation, nausea and
vomiting were assessed using four-point scales at 15 min
intervals in the immediate recovery period and then 4 hourly
until the PCA pump was discontinued. A midwife, unaware
of the contents of the PCA syringe, made all postoperative
assessments. Twenty-four hours later, one of the investigators assessed the patient for her perception regarding overall
satisfaction with her care, control of nausea and vomiting
and analgesia, using a scale of good, moderate or poor.
Data were analysed using the StatView statistical
package. Discrete variables were analysed using an
unpaired t-test or non-parametric tests. Categorical variables were analysed using the chi squared or Fisher's exact
test, as appropriate. In all cases a P value of <0.05 was
considered signicant.
Patient characteristics between the two groups were
similar except that the women in Group O were slightly
heavier. There were no signicant differences in the amount
of morphine used, history of motion sickness, morning
sickness, smoking, and PONV. The incidence of intraoperative hypotension and the requirement for an infusion
of oxytocin to assist postoperative uterine contraction did
not differ between the groups. There were no differences in
the degree of pain between the two treatment groups at any
time. Most patients were either pain-free or had only mild
pain. All patients were awake or arousable to voice at all
times.

0.960
0.258

0.9525

The incidence of nausea and vomiting was signicantly

lower in the ondansetron group (Table 1). Twenty-three
(57%) patients in Group P experienced severe nausea or
vomiting compared with 10 (24%) in Group O (P<0.01).
Eighteen women from Group P needed rescue antiemetic,
compared with only ve from Group O (P<0.01).
Ondansetron was effective in reducing the incidence of
PONV in those patients who had previously experienced
morning sickness but not in those who had not (Table 1).
There was no differential efcacy of ondansetron in patients
with and without previous PONV, smoking or motion
sickness, although the number of patients with these risk
factors was relatively small. Six patients in Group P and two
in Group O felt that the control of nausea and vomiting was
`poor', the difference was not signicant. One patient in
each group felt their overall care was unsatisfactory
(Table 1).

Comment
In post-Caesarean section patients, we found that adding
ondansetron to morphine in the PCA syringe reduces the
incidence of PONV and the requirement for antiemetic
rescue without increasing sedation. However, it seemed to
make little difference to the patient's perception of the
control of their nausea or her feeling of satisfaction with the
overall quality of care. This is consistent with other workers
who reported that reducing the incidence of PONV did not
improve patient satisfaction.9
There are various factors that may contribute to PONV.10
The most important predictors are female gender, previous
PONV, prolonged surgery, non-smoking, and motion sickness.10 We found that the incidence of PONV was higher
among women who had signicant morning sickness during
early pregnancy. Ondansetron was benecial in reducing
PONV in these women, but appeared to make little
difference in patients who did not experience signicant
morning sickness.

503

Cherian and Smith

Prophylaxis of PONV is usually administered once or

intermittently. There are a few studies where the antiemetic
was added into the PCA syringe.16 Droperidol was used in
most of these and was found to be effective, but caused
increased sedation, a side effect that we felt was undesirable
in the postpartum period. Postoperative sedation was rare in
our patients and was not increased by the use of
ondansetron. Alexander and colleagues showed that a
bolus of ondansetron 4 mg plus 0.13 mg ml1 in the PCA
syringe was effective in reducing PONV after orthopaedic
surgery.2 This technique has not previously been investigated in postpartum patients.
When questioned about their perception of nausea and
overall care, the responses of the two groups were similar,
despite considerable differences in the incidence of PONV
and request for rescue antiemetics. The high level of
satisfaction could partly be a result of the euphoria of having
a newborn baby and to the extra attention given by a
sympathetic investigator who spent extra time with them.
However, this should have applied equally to both groups.
Ondansetron is safe and effective, with a low incidence of
adverse effects such as headache, dizziness, and increased
liver enzymes. It has also been shown to be compatible with
morphine sulphate.2 There are no reports of adverse effects
of ondansetron in women who are breast feeding, although
the manufacturer cautions against its use in this situation.
However, similar advice applies to droperidol and prochlorperazine.

References

Acknowledgement
This study was conducted at the North Staffordshire Hospital, Stoke-onTrent, and was not funded by the pharmaceutical industry.

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