Many surgery patients wake up nauseated

Roughly one-third of all surgical patients spend the hours and days after their operation throwing up.

Doctors have known about this problem for decades, but have stepped up their attention to it in recent years, as more life-or-death issues in anesthesia are resolved, and more patients are expected to walk out the door within hours of surgery -- potentially aggravating the symptoms of nausea. Research is beginning to identify who is most susceptible and how best to save patients from nausea.

According to a study published last month in the New England Journal of Medicine, women who don't smoke, have a history of motion sickness, and receive opiates to dull the pain of surgery are the most likely to suffer from postoperative nausea and vomiting.

Patients with more of these risk factors are more likely to have problems, according to Dr. Christian C. Apfel, lead author of the study -- so male smokers who don't get heavy-duty pain medications and don't have a history of nausea have only a 10 percent chance of throwing up after surgery. Women who fit the profile have an 80 percent likelihood. Everyone else falls in between.

The type and duration of the surgery are also important: gynecological, hernia, eye, and inner ear surgery patients run the highest risk of getting sick. There are many suspicions that various ethnic types are at higher risk, but that has not been scientifically corroborated, said Dr. Beverly K. Philip, director of ambulatory anesthesia at Brigham and Women's Hospital.

Harvard student Zachary Rothstein is well acquainted with postoperative nausea. After an emergency appendectomy last fall, Rothstein, a nonsmoker with a history of nausea, was given morphine and spent that night throwing up.

"It was kind of like a nightmare," said Rothstein, then a freshman. "I couldn't eat anything. I would vomit water, and when I took Tylenol with codeine, I would vomit it back up."

In an unusual complication, Rothstein's nausea led to aspiration pneumonia -- and sent him back to Mount Auburn Hospital.

"They told me I'd developed pneumonia because when I vomited, some of the stuff went down into my lungs," he said.

For most patients, postoperative nausea does not pose a health risk -- but it can affect their ability to take care of themselves after surgery, and their overall impression of their care.

"The problem of nausea and vomiting is really one of comfort and perception," said Dr. Carl Rosow, an anesthesiologist at Massachusetts General Hospital.

"They say, by gosh, the surgery was easy, everything was fine, except I was so sick afterwards."

Philip said she regularly sees patients who have had previous "not-so-good" experiences with anesthesia, and she designs her treatment around their risk factors. She carefully chooses her anesthetic, minimizes narcotics, and administers nausea-preventing medications after surgery.

Apfel's study also showed that a commonly prescribed combination of anti-nausea drugs works well to prevent postoperative nausea, but the cheaper medications, at $1 to $2 per dose, are just as effective.

Anesthesiologists say the recent worry about nausea and vomiting after surgery is a testament to how well they do their work; the focus is on what happens when the patient wakes up, rather then whether the patient will wake up at all.

"It's an ongoing education process and it's relatively new because in the past, we were all focused on serious permanent complications," Philip said. "We're starting to work on these issues that are important, but not life-threatening."

Jessica T. Lee can be reached at jtlee@globe.com.