Althea Vol 4 No 1 full text.indd


Althea Medical Journal. 2017;4(1)

58     AMJ March 2017

Incidence of Postoperative Nausea and Vomiting in Dr. Hasan Sadikin 
General Hospital Bandung Period May to October 2013 

Aisyah Ummu Fahma,1 Iwan Fuadi,2 Jimmy Setiadinata3
1Faculty of Medicine, Universitas Padjadjaran, 2Department of Anesthesiology and Intensive 

Care Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 
3Department of Anantomy, Cell Biology and Physiology Faculty of Medicine Universitas 

Padjadjaran

Abstract

Background: Postoperative nausea and vomiting (PONV) is common complication in patients undergoing 
surgery with anesthesia. The incidence of PONV is ranging between 20% and 30%. Despite many other 
studies about PONV in other regions, the descriptive data about PONV in Dr. Hasan Sadikin General Hospital 
Bandung is still unknown. The aim of this study was to determine the incidence of PONV in Dr. Hasan Sadikin 
General Hospital Bandung.
Methods: This descriptive study used a cross-sectional method. As many as 521 medical records in 
Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin General Hospital Bandung from May 
5th to October 31st 2013 were reviewed. The subjects were taken by using total sampling technique.  Data 
collected were gender, age, type of surgery, type of anesthesia, duration of surgery, administration of nitrous 
oxide, and administration of neostigmine.
Results: Of 521 patients,the incidence of PONV was 20.5%. Female had higher incidence of PONV than male. 
Postoperative nausea and vomiting was the most frequent in the age category 6−20 years old. The Ear Nose 
and Throat (ENT) surgery was revealed as surgery with the highest incidence. Regional anesthesia had a 
higher incidence than general anesthesia. Operation lasting 181−210 minutes was considered as category 
which PONV mostly occured. Patients receiving nitrous oxide were more likely to experience PONV, and 
patients who were given neostigmine as muscle relaxant had lower incidence of PONV compared to those 
who were not.
Conclusions: The incidence of PONV was similar to the study presumed earlier and this may influenced by 
many factors including patients, surgical, and aenesthtical factor. [AMJ.2017;4(1):58–63]

Keywords: Anesthesiology, incidence, postoperative nausea, vomiting.

Correspondence: Aisyah Ummu Fahma, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang 
Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 85263862979 Email: aisyah.fahma@ymail.com

Introduction

Postoperative nausea and vomiting (PONV), is 
defined as nausea and/or vomiting occuring 
within 24 hours after surgery. The PONV is 
a common problem following surgery and 
anesthesia and it is anesthesiology’s “big 
little problem”. Some efforts are focused on 
strategies to reduce the frequency of this 
problem. Nausea is an unpleasant sensation 
in the epigastrium that is associated with an 
urge to vomit while vomiting is the forceful 
expulsion of gastric contents. Avoiding PONV 
becomes the main priority for doctors and 
patients. PONV is still a big problem, besides 

dissatisfaction and discomfort of the patient 
and healthcare staff, medical risks such as 
increased abdominal pressure, increased 
central venous pressure, aspiration of gastric 
contents, sympathetic nervous system 
response with increasing blood pressure and 
heart rate as well as parasympathetic responses 
producing bradycardia and hypotension. It 
also results in increased morbidity, prolonged 
Post Anesthesia Care Unit stays and increased 
cost related to length of hospital stay. Most 
patients consider that nausea and vomiting is 
more disturbing than the operation itself.1−5

Nausea and vomiting in the postoperative 
period occurs in 20% to 30% of patients. In10% 



Althea Medical Journal. 2017;4(1)

59

of patients, PONV occurs in recovery room and 
in 30% patients 24 hours after surgery. The 
incidence of PONV varies with many potential 
causes.This depends on involving anesthetic 
agents, the type of procedure, and patient 
factors.2,3,6,10

Despite many other studies about PONV in 
the other regions, the descriptive data about 
the incidence of PONV in Dr. Hasan Sadikin 
General Hospital Bandung is still unknown. 
Considering the huge effects of PONV, this 
study was aimed to determine the incidence 
of PONV in Dr. Hasan Sadikin General Hospital 
Bandung.

Methods

This cross-sectional descriptive study 
was conducted in the Department of 
Anesthesiology and Intensive Care, Dr. Hasan 

Sadikin General Hospital Bandung. This study 
collected and analyzed data from medical 
records of postoperative patients in Dr. Hasan 
Sadikin General Hospital Bandung from May 
5th to October 31st 2013 that were selected 
by using total sampling method. Inclusion 
criteria of this study was all the patients 
who had undergone elective surgery with 
anesthesia and was in recovery room 2 hours 
postoperative. Incomplete medical record was 
excluded from this study.

Data were collected and analyzed based 
on gender, age, types of surgery, types of 
anesthesia, duration of surgery, administration 
of nitrous oxide, and administration of 
neostigmine.

Secondary data were collected from each 
subject, then organized and analyzed using 
descriptive statistical analysis. Frequency and 
percentage of the mentioned variables were 
calculated.

Table 1 Distribution of Postoperative Nausea and Vomiting based on Age
Age (Year) Population (n) Frequency of PONV Percentage 

<1 9 0 0
1−5 16 0 0
6−20 70 19 27.1
21−30 54 5 9.2
31−60 290 64 22.1
>60 82 19 23.2
Total 521 107 20.5

Aisyah Ummu Fahma, Iwan Fuadi, Jimmy Setiadinata: Incidence of Postoperative Nausea and Vomiting in Dr. 
Hasan Sadikin General Hospital Bandung Period May to October 2013 

Table 2 Distribution of Postoperative Nausea and Vomiting based on Types of Surgery
Type of Surgery Population (n) Frequency of PONV Percentage

Pediatric surgery 10 0 0
Digestive Surgery 125 30 24.0
Oral Surgery 35 4 11.4
Plastic surgery 39 2 5.1
Neurological Surgery 17 1 5.9
Genitourinary Surgery 34 9 26.5
Gynecological Surgery 92 16 17.4
Oncology Surgery 80 23 28.8
Ortophaedic Surgery 54 11 20.4
ENT Surgery 25 9 36.0
Thorax and cardiovascular surgery 10 2 20.0
Total 521 107 20.5

Note: ENT=Ear Nose and Throat



Althea Medical Journal. 2017;4(1)

60     AMJ March 2017

Results

In total, 521 postoperative patients were 
analyzed. Incidence of PONV in Dr. Hasan 
Sadikin General Hospital Bandung was 
20.5% which occurred on 107 post-operative 
patients.

The PONV on female (22.6%) was 1.3 times 
more prevalent than male (17.7%). PONV was 
more frequent among patients age 6 to 20 
years old (27.1%) (Table 1).

The Ear Nose and Throat (ENT) surgery 
was the most frequent cause of postoperative 
nausea and vomiting (36.0%), followed by 
oncology surgery (28.6%) and genitourinary 
surgery (26.5%) (Table 2).

Patients who had undergone surgery with 
regional anesthesia, would have a higher risk 
of PONV (27.5%)(Table 3).

The highest percentage of postoperative 
nausea and vomiting based on duration of 
surgery was on category 181−210 (50.0%) 
(Table 4).

Incidence of PONV is higher on patient 
who have received nitrous oxide (22.7%) than 
those who have not (Table 5).

Incidence of PONV increased among 
patients who had not received neostigmineand 
allowed to recover spontaneously from 
muscular blockade (26.5%)(Table 6).

Discussions
 

The PONV is one of the commonest 
postoperative complication which sometimes 
is more disturbing than the operation itself. 
The complex act of vomiting is controlled by 
the emetic center in which can be stimulated 

Table 3 Distribution of Postoperative Nausea and Vomiting based on Types of Anesthesia
Type of Anesthesia Population (n) Frequency of PONV Percentage

General Anesthesia 481 96 19.9
Regional Anesthesia 40 11 27.5
Total 521 107 20.5

Table 4 Distribution of Postoperative Nausea and Vomiting based on Duration of Surgery
Duration of Surgery 

(minutes) Population (n) Frequency of PONV Percentage 

<30 10 0 0
30–60 45 9 20.0
61–90 17 1 5.9
91–120 139 21 15.1
121–150 43 11 25.6
151–180 145 30 20.7
181–210 8 4 50.0
211–240 59 21 35.6
241–270 2 0 0
271–300 18 5 27.8
301–330 − − −
331–360 20 2 10.0
361–390 3 0 0
391–420 2 0 0
421–450 − − −
451–480 10 3 30.0
Total 521 107 20.5



Althea Medical Journal. 2017;4(1)

61Aisyah Ummu Fahma, Iwan Fuadi, Jimmy Setiadinata: Incidence of Postoperative Nausea and Vomiting in Dr. 
Hasan Sadikin General Hospital Bandung Period May to October 2013 

by several areas, including afferents from 
pharynx, gastrointestinal tract, mediastinum, 
as well as afferent from the higher cortical 
centers and the chemoreceptor trigger zone 
(CTZ) in the area postrema.5,12 There are 
many surgery procedures and aenesthetic 
drugs which are able to stimulate the emetic 
center.7 PONV is influenced by many factors, 
they are patient, surgical, aenesthetic and 
postoperative factor.11

According to the study’s result, the incidence 
of PONV in Dr. Hasan Sadikin General Hospital 
Bandung from May 5th to October 31st 2013 
was 20.5%. Based on literature, incidence of 
PONV was ranged between 20% and 30%.8,9

Nausea and vomiting in females was about 
1.3 times as common as in males. Koivuranta 
et al.14 reported that the proportion of 
females was about twice as male and men 
are generellay less succeptible to nausea.10,12 
Based on other studies, female sex was an 
important risk factor for PONV that maybe 
caused by variations in serum gonadotropin or 
other hormon levels. Some studies were even 
concerned with the relationship of PONV and 
phase of menstrual cycle. Particularly, female 
who is on 3rd−4th week of their menstruation 
cycles was more tend to experience PONV 
caused by changing and high level of 
progesteron, estrogen and gonadotropin 
hormone level.8,11,12 Furthermore, female who 
undergone gynecology surgery increase the 
risk of PONV caused by stimulation of afferents 
in uterus, broad ligament and cervix.15

Incidence of PONV was higher in category 
age 6−20 years old. Based on theories, the 

percentage of PONV on patient’s age that 
is less than 12 months is low. Infant and 
adolescent patients have an increased risk 
PONV. PONV decreases as patient age. It is 
unclear whether this resulted purely from age 
itself or difference of aenesthetic drugs used 
and surgical procedure performed.7

In the present study, there was variation 
in the incidence of PONV based on the type 
of surgery. The study results showed that the 
highest percentage of PONV was on category 
of ENT surgery, followed by the patients with 
oncological surgery, and genitourinary surgery. 
According to the literature, the procedure on 
middle ear will stimulate vestibular afferent 
nerve that will stimulate the vomiting 
center.7,8,10,11

Despite the high incidence of PONV in 
surgeries mentioned earlier, PONV was also 
common in patients with digestive surgery, 
and ortophaedic surgery. It has to be noted 
that the emetic center is stimulated by 
several visceral afferents including digestive 
tract, and manipulation in this area could 
activate gastrointestinal responses.1,7,10 
Also, laparoscopy was one of the procedure 
performed in digestive surgery. Based on the 
references, laparoscopic surgeries was known 
to be a risk of PONV. It might be due to increase 
in carbondioxide absorbtion into the intestine 
and increase intraabdominal pressure.11 
Another literature showed that incidence of 
PONV was also high in orthopaedic procedure, 
but the mechanism was still unclear.8

This study results revealed that patients 
who received regional anesthesia were more 

Table 5 Distribution of Postoperative Nausea and Vomiting based on Anesthesia Inducing 
  Agent

Agent used for anesthesia 
maintenance Population (n) Frequency of PONV Percentage

Nitrous Oxide 317 72 22.7
Without Nitrous Oxide 204 35 17.2
Total 521 107 20.5

Table 6 Distribution of Post operative Nausea and Vomiting based on Administration of 
  Reverse Muscle Relaxant

Agent used for recover 
from muscular blockade Population (n) Frequency of PONV Percentage

Neostigmine 404 76 18.8
Without Neostigmine 117 31 26.5
Total 521 107 20.5



Althea Medical Journal. 2017;4(1)

62     AMJ March 2017

likely to experience PONV than patients 
with general anesthesia. Meanwhile, a study 
conducted by Aftab et al.13 in Karachi reported 
that patients who received general anesthesia 
experienced three times more incidence of 
PONV, compared to regional anesthesia. This 
differences might be due to the limitation of 
the study.

According to the study results, the highest 
percentage of PONV based on duration of 
surgery was on category 181−210 minutes 
(50.0%). The study conducted by Ku et al.8 
in Singapore reported that the  incidence of 
PONV was 2.7% in surgery with duration less 
than 30 minutes, and 27.7% in patients with 
operation lasting 150−180 minutes. This 
possibilities might happen because in long 
duration of surgery, patient received larger 
number of potentially emetic drug.7

In this study, incidence of PONV in 
patients receiving nitrous oxideas anesthetic 
maintenance is 5.5% higher than who did 
not. This was similar to the study conducted 
by Doubravska et al.11 which noted that the 
incidence of PONV innitrous oxide were 
higher than those not (15.8% vs 2.4%). Earlier 
study suggested that nitrous oxide causes 
stimulation of the medullary periventricular 
dopaminergic system, which includes the CTZ, 
and this could be responsible for the nausea 
and vomiting observed after nitrous oxide 
anaesthesia.8

According to the study results, the 
incidence of PONV in patients receiving 
neostigmine as muscle relaxant and 
patients who spontaneously recovered from 
muscular blockade were 18.8% and 26.5% 
respectively, while the study conducted by 
Kim et al.15 reported that patients treated with 
neostigmine had higher rates of PONV (68% vs 
32%).This discrepancy may attributable due 
to the limititation of the study.

From 521 respondents who had undergone 
elective surgery with anesthesia at the Dr. 
Hasan Sadikin General Hospital, 20.5% 
experienced postoperative nausea and 
vomiting. Female has the highest incidence 
based on gender. Patients aged 6-20 years 
old, patients with ENT, oncological and 
genitourinary surgery had an increased risk of 
PONV. Based on category of anesthesia, PONV 
in patients receiving regional anesthesia was 
more common. Based  on  duration of surgery, 
category 181-210 minutes was the highest 
duration on the incidence of PONV. The PONV 
was more prevalent to patients receiving 
nitrous oxide than those who did not. Patients 
who were given neostigmine as reverse muscle 

relaxant had a lower incidence of PONV than 
the patients who recovered spontaneously. 

Reccomendation of this study is about 
data completeness in medical record should 
be corrected. Many incomplete data made 
difficult to  find the exact result.

To know more about PONV, for further 
research, it needs to be conducted with larger 
population and more variable included. 

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Aisyah Ummu Fahma, Iwan Fuadi, Jimmy Setiadinata: Incidence of Postoperative Nausea and Vomiting in Dr. 
Hasan Sadikin General Hospital Bandung Period May to October 2013