Correspondence | 637

These uncomfortable symptoms lower postoperative patient References

quality of life after anaesthesia. However, sufficient predictive or
1. Kuwamura A, Komasawa N, Kori K, Tanaka M, Minami T.
preventive methods of these non-specific symptoms have not
Preventive effect of preoperative administration of Hange-
been developed. Anaesthetists should focus not only on major
Shashin-To on postoperative sore throat: a prospective, double-
complications but also minor ones to improve postoperative
blind, randomized trial. J Altern Complement Med 2015; 21: 485–8
patient outcome and quality of life.
2. Gan TJ. Risk factors for postoperative nausea and vomiting.
Anesth Analg 2006; 102: 1884–98
Declaration of interest 3. Staender S, Schaer H, Clergue F, et al. A Swiss anaesthesiology
closed claims analysis: report of events in the years
None declared.
1987-2008. Eur J Anaesthesiol 2011; 28: 85–91

doi: 10.1093/bja/aex062

Ice pops in the recovery room: effects on postoperative nausea and

vomiting
D. E. Johns, V. Gerling, P. C. M. Pasker-de Jong*
Amersfoort, The Netherlands
*E-mail: [email protected]

Editor—Postoperative nausea and vomiting (PONV) is common joint replacement surgery in 3 months before and after introduc-
in all age groups1 and can have a significant negative impact on tion of the ice pop in the recovery room at Meander Medical
patient comfort and recovery after surgery.2 Recent guidelines Centre (Amersfoort, The Netherlands). Patients with tracheosto-
describe pharmacological options for prophylaxis and treatment mies, intubated patients, and patients who were unconscious
of PONV, but non-pharmacological options are rarely explored.2 3 in the 24 h postoperative were excluded. In total, 96 patients
We investigated the effects of ice pops on PONV after elective (44 males, mean age 58 yr) in the pre-ice pop period and 97
major orthopaedic joint replacement surgery. Our hypothesis patients (38 males, mean age 58 yr) in the ice pop period were
was that an ice pop during the immediate postoperative time evaluated. Data on administration of opioids and anti-emetic
period in the recovery room reduces the incidence of PONV. drugs during surgery and on the wards in the first 24 h after
We retrospectively studied the medical records of a random the operation were collected. All patients operated in 2015 were
sample of all 1668 patients >18 yr of age who underwent elective considered treated with an ice pop and those operated in 2014

Table 1 Characteristics of patients with and without ice pop offered after surgery

Patient characteristics Without ice pop With ice pop P-value

n 96 97
Age (yr); mean (SD) 58.3 (17.5) 57.5 (19.6) 0.78
Median [minimum–maximum] 60 [18–99] 60 [18–88]
Male sex [n (%)] 44 (45.8) 38 (39.2) 0.38
Smoking [n (%)] 13 (13.5) 16 (16.5) 0.69
Type of orthopaedic operation [n (%)] 0.05
Knee 42 (43.8) 46 (47.4)
Hip 23 (24.0) 19 (19.6)
Shoulder 9 (9.4) 20 (20.6)
Other elective 22 (22.9) 12 (12.4)
Duration of operation [min; mean (SD)] 39.9 (29.0) 54.1 (45.4) 0.01
Duration >60 min [n (%)] 27 (28.1) 46 (47.4) 0.007
Opioid use [n (%)] 62 (64.6) 69 (71.1) 0.36
Postoperative nausea and vomiting [n (%)] 14 (14.4) 7 (7.1) 0.11
None [n (%)] 82 (85.4) 90 (92.8) j
Nausea only [n (%)] 5 (5.2) 5 (5.2) j 0.03
Vomiting only [n (%)] 3 (3.1) 2 (2.1) j
Both [n (%)] 6 (6.3) 0 (0) j
Anti-emetic drugs [n (%)] 16 (16.7) 9 (9.3) 0.14
638 | Correspondence

untreated. We calculated odds ratios with 95% confidence inter- vomiting, and anti-emetic administration was negligible and did
vals (CIs) for PONV and anti-emetic use with ice pops as the not change with the introduction of ice pops.
determinant. Other potential determinants of nausea were For patients at high risk for PONV, use of ice pops provides a
studied where available and the association corrected for those cheap, non-invasive, and easy-to-use intervention that appears
that confounded the association. Odds ratios and asymptotic effective in reducing PONV, notably in patients treated with
95% CIs were calculated from contingency tables. Correction for opioids.
confounders was done using logistic regression analysis.
Characteristics of the patients are shown in Table 1. After
introduction of ice pops, both PONV and use of anti-emetic drugs
Declaration of interest
occurred less frequently and were less severe. Most potential de- None declared.
terminants of both PONV and the use of anti-emetics were more
frequent after the introduction of ice pops than before.
Adjustment for age, sex, smoking, use of opioids, and a long dur-
References
ation of the operation resulted in an odds ratio of 0.26 (95% CI 1. Brookes CD, Turvey TA, Phillips C, Kopp V, Anderson JA.
0.1–1.0, borderline significance) for PONV. The odds ratio for use Postdischarge nausea and vomiting remains frequent after Le
of anti-emetics was 0.26 (95% CI 0.1–0.9). We evaluated the effect Fort I osteotomy despite implementation of a multimodal
of ice pops separately among those with opioids because PONV antiemetic protocol effective in reducing postoperative nau-
occurred mainly among these patients. Ice pops had an odds sea and vomiting. J Oral Maxillofac Surg 2015; 73: 1259–66
ratio for PONV of 0.27 (95% CI 0.09–0.78) and for use of anti- 2. Gan TJ, Diemunsch P, Habib AS, et al. Consensus Guidelines
emetics of 0.33 (95% CI 0.1–0.9). In the multivariate analyses, ad- for the management of postoperative nausea and vomiting.
justing for age, sex, smoking, duration of the operation, and use Anesth Analg 2014; 118: 85–113
of opioids reduced the odds ratio to 0.24 for PONV (95% CI 0.08– €
3. Obrink E, Jildenstål P, Oddby E, Jakobsson JG. Post-operative
0.76) and 0.24 for anti-emetics (95% CI 0.08–0.69). nausea and vomiting: update on predicting the probability
This simple single-centre retrospective study showed that and ways to minimize its occurrence, with focus on ambula-
the occurrence of PONV and use of anti-emetics were more than tory surgery. Int J Surg 2015; 15: 100–6
halved after introduction of ice pops in a homogeneous popula-
tion of elective orthopaedic patients undergoing major joint
replacement surgery. The effect was evident only in patients
doi: 10.1093/bja/aex063
who had received morphine for postoperative analgesia. In those
who did not receive morphine, the occurrence of nausea,

Reply: allostatic load as an approach to support the theoretical

assumptions of the Brief Measure of Emotional Preoperative Stress
(B-MEPS)
W. Caumo1,2,3,4,*, J. D. Segabinazi1,2 and L.P.C. Stefani1,4
1
Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul
(UFRGS), Porto Alegre, Brazil, 2Laboratory of Pain and Neuromodulation at UFRGS, Porto Alegre, Brazil, 3Pain
and Palliative Care Service at Hospital de ClÚnicas de Porto Alegre (HCPA) and 4Pain and Anesthesia in
Surgery Department, School of Medicine, UFRGS, Porto Alegre, Brazil.
*E-mail: [email protected]

Editor—We are grateful to Scott and McCracken1 for their analysis intended users and uses, the content domain to be measured,
and comments on our paper. The authors underscored the ab- and the expected examinee population. The greater challenge in
sence of a clear conceptual definition of the construct measured by the process to develop the B-MEPS was to identify a set of items
the Brief Measure of Emotional Preoperative Stress (B-MEPS). We that more precisely assessed preoperative stress. In fact, the
aimed to explain the theoretical assumptions considered to define B-MEPS scale was developed from several different tools cur-
the domain of interest in the development of B-MEPS as well as rently used to measure depression symptoms, anxiety, minor
the psychometric foundations investigated thus far. We would like psychiatric problems, and future self-perceptions.3 Thus the
to highlight that the development of the measure agrees with the B-MEPS content items are related to stress since they were
latest assumptions on test design published in the Standards for extracted from tools previously used to identify emotional
Educational and Psychological Testing.2 Regarding test specifica- aspects, including the surgical setting, to determine individual
tions, the standards state that the nature of the test development propensity for severe postoperative pain.45
(the way in which the test is created) may vary widely as a function We understand that in evaluations using the B-MEPS, it could
of the nature of the test and its intended uses. be emphasized that the examinee population answers should be
As recommended by the Standards (2014), in the process of related to their thoughts and feelings associated specifically
developing the B-MEPS we stated the purpose(s) of the test, the with the surgery. In the B-MEPS development to discriminate