We're here to help during this unprecedented time. Click here to access the Fear Free COVID-19 resource page. Visit the Fear Free COVID-19 resource page

Preventing Perioperative Vomiting: An Evidenced-Based Discussion

Dog awakening from anesthesia after tumor surgery. Ill labrador retriever in veterinary clinic.

Sharon Campbell, DVM, MS, DACVIM

Fear, anxiety and stress (FAS) associated with veterinary visits affects many of our patients and is likely compounded when the patient is hospitalized for procedures that require anesthesia. Factors that can lead to an elevation of FAS with hospitalization include separation from owners; being placed in an unfamiliar environment with loud sounds, unusual lighting, fearful smells and strange people; and being surrounded by other animals that are either competitors or predators. Additionally, many of our anesthetic agents are emetogens. Perioperative vomiting (POV) is an unpleasant experience that can further exacerbate the FAS of our hospitalized patients.

We prescribe previsit pharmaceuticals to manage our patients’ anxiety and we provide preemptive analgesics to control pain. Why not consider pre-operative antiemetics to prevent POV? We are all familiar with the risks of vomiting perioperatively, including aspiration pneumonia, and esophageal damage. We can readily think of patients where controlling vomiting is critical – our brachycephalic patients, those with gastrointestinal disease, etc. But POV is a negative experience for all our patients, and so should be prevented since negative experiences can beget negative experiences resulting in increase in the patient’s FAS level during future visits.

Several studies have demonstrated that Cerenia (maropitant citrate) is effective at controlling POV associated with morphine or hydromorphone.1-8 Two additional benefits of using Cerenia preoperatively, better recoveries and early return to feeding, were identified in a blinded, randomized, placebo controlled study by Ramsey et. al.8

In this study, dogs received a subcutaneous injection of Cerenia at 1.0 mg/kg (n=15) or saline as a placebo (n=16) 45 minutes before an injection of morphine (the pre-emptive analgesic used in this protocol). Dogs were observed for episodes of vomiting for 30 minutes after receiving morphine, then induced and maintained under general anesthesia for either a castration or ovariohysterectomy. Recovery quality was evaluated for three hours postoperatively (using a scale of “0” for a smooth recovery, “1” for moderate recovery, and “2” for a rough recovery) and return to normal feeding (normal feeding = 100 g of food) for 20 hours postoperatively.

Within the first 30 minutes postoperatively, no dogs in the Cerenia-treated dogs experienced a rough recovery vs. two (12.5%) of the placebo-treated dogs. During the remaining three hours of recovery observation, all the Cerenia-treated dogs experienced a smooth recovery compared to 25% of the placebo-treated dogs who experienced a moderate recovery.

A smooth recovery is important to ensure patient safety and minimize FAS. It is also important for the veterinary team to reduce their level of stress caused by observing a dog undergoing a rough recovery and for hospital efficiency. Typically, one team member is required to observe a dog in recovery. However, multiple individuals are required to manage and administer appropriate medications to a dog undergoing a rough recovery, which can also prolong the recovery time and the time need to observe the dog.

The Ramsey study also reported on the dogs’ return to feeding. At 20 hours post-op, 93.3% of the Cerenia-treated dogs returned to normal feeding vs. 46% of the placebo-treated dogs. Additionally, the average amount of food consumed by the Cerenia-treated dogs (190.0 g) was nearly 5x that consumed by the placebo-treated (39.1 g); this difference was statistically significant at p=0.0272.

Return to normal feeding is important for several reasons. For the patient, it indicates that the dog is not painful, anxious, fearful, or stressed and allows the dog to return to a positive plane of nutrition to facilitate healing. Additionally, there are certain conditions where an early return to normal feeding is critical, including diabetic dogs (for glucose regulation) and toy breeds and young dogs (prevent hypoglycemia). For the veterinary healthcare team (VHT), reducing the need to handle calls from owners worried about their dog not eating can decrease their stress and improve hospital efficiencies. Finally, owners perceive return to feeding as a sign of a successful surgery and an indication that their dog has returned to normal, thus building confidence in the VHT.

Preventing POV, providing better recoveries and returning patients to normal feeding are benchmarks of success for any anesthesia protocol. Achieving these goals are also important to reduce the FAS and improve the welfare of the patient, to reduce the VHT stress and inefficiencies and to build the bond between the owner and the clinic. You may already include Cerenia as part of your preoperative protocols to prevent vomiting for specific patients such as brachycephalic, diabetes, those with GI disease, etc. However, consider including for your patients, as approproate, not just to prevent vomiting, but also to provide the added benefits of improved recoveries and rapid return to feeding.

For an expert panel review of the benefits of controlling postoperative vomiting, click here.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

IMPORTANT SAFETY INFORMATION: Use CERENIA (maropitant citrate) Injectable for vomiting in cats 4 months and older; use subcutaneously for acute vomiting in dogs 2 to 4 months of age or either subcutaneously or intravenously in dogs 4 months of age and older. Safe use has not been evaluated in cats and dogs with gastrointestinal obstruction, or those that have ingested toxins. Use with caution in cats and dogs with hepatic dysfunction. Pain/vocalization upon injection is a common side effect. In people, topical exposure may elicit localized allergic skin reactions, and repeated or prolonged exposure may lead to skin sensitization. See included Product Insert for full Prescribing Information.

References

  • Hay Kraus BL. Efficacy of maropitant in preventing vomiting in dogs premedicated with hydromorphone. Vet Anaesth Analg. 2013;40(1):28–34.
  • Hay Kraus BL. Efficacy of orally administered maropitant citrate in preventing vomiting associated with hydromorphone administration in dogs. J Am Vet Med Assoc. 2014;244(10):1164–1169.
  • Hay Kraus BL. Effect of dosing interval on efficacy of maropitant for prevention of hydromorphone-induced vomiting and signs of nausea in dogs. J Am Vet Med Assoc. 2014:245(9):1015–1020.
  • Koh RB, Isaza N, Xie H, Cooke K, Robertson SA. Effects of maropitant, acepromazine, and electroacupuncture on vomiting associated with administration of morphine in dogs. J Am Vet Med Assoc. 2014;244(7):820–829,
  • Claude AK, Dedeaux A, Chiavaccini L, et al. Effects of maropitant citrate or acepromazine on the incidence of adverse events associated with hydromorphone premedication in dogs. J Vet Intern Med. 2014; 28: 1414–1417.
  • Lorenzutti AM, Martin-Flores M, Litterio NJ, Himelfarb MA, Zarazaga MP. Evaluation of the antiemetic efficacy of maropitant in dogs medicated with morphine and acepromazine. Vet Anaesth Analg. 2016;43(2):195–198.
  • Lorenzutti AM, Martin-Flores M, Litterio NJ, Himelfarb MA, Invaldi SH, Zarazaga MP. A comparison between maropitant and metoclopramide for the prevention of morphine morphine-induced nausea and vomiting in dogs. Can Vet J. 2017;58(1):35–38.
  • Ramsey D, Fleck T, Berg T, et al. Cerenia prevents perioperative nausea and vomiting and improves recovery in dogs undergoing routine surgery. Intern J Appl Res Vet Med. 2014;12(3):228–237.

Sponsored by our friends at Zoetis Petcare. CER-00463

Happy Paws Magazine

Spring/Summer 2020 Issue Available Now!