TAP CHlY DLfOCLAM SANG 108 Tap 12-S64/2017
So sanh cac tac dung khong mong mudn cua levobupivacain va bupivaeain ciing ph6i h&p vol fentanyl Imcg/ml va adrenalin 5mcg/ml duong ngoai mang cung de giam dau sau mo cat tu* cung hoan toan duong bung
Comparison of the side effects of epidural analgesia after total abdominal hysterectomy by levobupivacain 0,075% vs bupivacaine 0,075% combined with fentanyl Imcg/ml and adrenalin 5mcg/ml
Nguyen Dire Lam*, *Tru&ng Bai hoc YHa Ndi Nguyen Anh Tho-**, **5^„^ ^.^„ j^gg. ^. ^^
VuVanDu*** * * ^ „ . , . , „, . „
^^^ Benh vien Phy. san Trung uong
Tom XiX
Muc tiiu: Nghiin cUu cle t i e dung khdng mong muon eOa gay t i ngoai mang cUng bang levobupivacain 0,075% + fentanyl 1 meg/ml + adrenalin 5meg/ml de g i l m dau sau md cat t d cung hoan toan dudng bung. 05/fi/pngvd pht/ongphdp: ThO'nghiim lam sang n g i u nhien co so sinh t r i n 70 b i n h nhan phau thuat cat t d cung hoan toan dudng bung, duoc g i l m dau sau md bang gay te ngoai mang ciJng, chia thanh hai nhdm: Nhdm LEVO sd dung dung dich levobupivacain 0,075% v l nhdm BUPl sii dung dung dich bupivaeain 0,075%, e l hai nhdm deu phdi hpp vdi fentanyl Imcg/ml v l adrenalin 5mcg/ml (adrenalin 1/200.000). Kit qud: Cd sU thay ddi ve tuan hoan, hd hap eua cle benh nhan trong thdi gian g i l m dau eua c l hai nhdm LEVO v l BUPl nhung eae ehi sd van nam trong gidi han binh thudng va khdng khae biet giCfa hai nhdm. Ty l i benh n h i n bj Uc che van dpng trong thdi gian g i l m dau d mUe Bromage I d nhdm LEVO la 17,14%, khdng khae b i i t vdi nhdm BUPl (20%). Ty le ngda, ndn va budn ndn, b i t i ^ u c u a nhdm LEVO cung khdng khac b i i t vdi nhdm BUPl (lan lupt I I : 11,43%, 17,14% v l 11,43% so vdi 8,57%; 20% va 14,29%)./fef/udn: Tie dung khdng mong mudn cCia phUOng phap g l y t i ngoai mang eiJng b i n g hdn hop levobupivacain 0,075% + fentanyl 1 meg/ml + adrenalin 5meg/ml de g i l m dau sau md e l t t d eung hoan t o l n dudng bung gap vdi X^ le thap, khdng khIc b i i t vdi nhdm dung bupivaeain eung ndng dp va cung cle thudc phdi hpp (p>0,05).
Td khda: Gilm dau ngoai mang cUng, c i t tU eung h o l n t o l n , tae dung khdng mong mudn levobupivacain, bupivaeain.
Summary
Objective: To study the side effects of the epidural analgesia after total abdominal hysterectomy by levobupivacaine 0.075% + fentanyl Imcg/ml and adrenaline 5meg/ml. Subject and method: A randomized clinical trial on 70 patients with total abdominal hysterectomy, underwent postoperative
Ngdy nhdn bdi: 21/02/2017. ngdy chdp nhgn ddng-19/03/2017
Ngicai phdn hdi: Vu Vdn Du, Email: [email protected] - Benh vien Phu sdn Trunguang
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12 - N''4/20 analgesia with epidural anesthesia. The patients were divided into two groups: LEVO group used levobupivacaine 0.075% and BUPl group used bupivacaine 0.075%, both groups were combined with fentanyl Imcg/ml and adrenaline 5mcg/ml (1/200 000 adrenaline), fiesu/f; There was a change in the circulation and respiration during the analgesia period of both groups but still in normal range and was not different between the two groups. The proportion of patients with motor block at Bromage I was 17.14% in LEVO group, not different from BUPl group (20%). The rates of itching, nausea and vomiting, and urinary retention in LEVO group did not differ from those in BUPl group (11.43%, 17.14% and 11.43% vs. 8.57%; 20% and 14.29% respectively). Conclusion: Side effects o f t h e epidural anesthesia with levobupivacain 0.075% -i- fentanyl Imcg/ml + adrenaline 5meg/ml for analgesia after total abdominal hysterectomy were seen at low rates and not different from the bupivacaine group (p>0.05).
Keywords: Epidural analgesia, laparotomy total hysterectomy, sides effects, levobupivacaine, bupivacaine.
1 . Dat van dc
Phau t h u l t eat tli'eung hoan toan dUdng bung la mdt phau t h u l t phu khoa Idn gay dau nhieu sau md d mUc nhieu den dau dU dpi, n i n can p h l i dupe g i l m dau tdt sau md, flay cCing I I ioai phau t h u l t d vung dudi rdn nen gay te ngoai m I n g cUng vung t h i t lUng la phuang phap g i l m dau rat tdt va thich hop. Hiin nay, vdi sU xuat hien bam tiem t u ddng loai sii dung mdt lan da giiip cai thien dang ke sU thoai mai cho b i n h nhan, hp ed the deo tiii bam tiem tU dpng n l y di lai, t u phue vu. Tuy n h i i n , ca benh nhan va cle b l e sy phu khoa d i u ludn quan tam lo l i n g den eac tac dung khdng mong mudn cua phuong phap giam dau nay, d i e b i i t khi sU dung thude te eu la bupivaeain vi thudc n l y cd ddc tinh eao t r i n than kinh va tim mach.
Thudc te levobupivacain I I thude te mdi ft gay Uc che van ddng va it g l y dpc tinh t r i n tim maeh v l than kinh han buplvacain n i n d l dan dugc lua chpn thay the bupivaeain trong g i l m dau sau md d ele nUde phat trien. Tuy n h i i n , d nUdc ta, do thude mdi dUpc nhap khau tUvai nam nay nen ehUa cd nhieu n g h i i n cUu v i sU dung thude te nay di g i l m dau ngoai mang eUng sau md eat XiS eung hoan toan dUdng bung, vi vay, ehiing tdi tien hanh de t l i nay n h l m mue t i i u Nghien cdu cdc tdc dung khdng mong mudn cda gdy ti ngodi mdng cdng bdng levobupivacain 0,075% + fentanyl Imcg/ml + adrenalin 5mcg/ml de gidm dau sau mo cdt tdcung hoan todn dUdng bung.
2. Doi tUcfng va phUtfng phap 2.1.Dditd0ig
70 benh n h i n phau thuat cat Xii cung hoan toan dudng bung, vd cam bang gay t i tiliy sdng v l g l i m
dau sau md b^ng gay t i ngoai m I n g eUng, di/oc chpn vao n g h i i n eUu va dUpc bde tham chia ngau nhien thanh hai nhdm:
Nhdm LEVO: Giam dau sau md b i n g truyin lien tuc qua catheter ngoai mang edng dung djch levobupivacain 0,075% phdi hpp vdi fentanyl 1 meg/ml va adrenalin 5mcg/ml.
Nhdm BUPl: G i l m dau sau md bSng truyen li^n tue qua catheter ngoai mang eUng dung dich bupivaeain 0,075% phdi h p ^ vdi fentanyl Imcg/ml va adrenalin 5mcg/ml.
Tiiu chudn logi trd: Cac trudng hpp ed chdng chi dmh eua gay t i tiiy sdng va gay te ngoai mang cijfng (rdi loan ddng m l u , nhiem trung t o l n t h i n hole tai chd choc kim, benh tim nang...); khdng gay t i ngoai mang cUng dupe, khdng dat dupe catheter vao khoang ngoai mang eUng, d[ Ung vdi thudc te va fentanyl, ele benh nhan ung thU Xii cung hole ung t h u budng trUng.
2.2. Phdifng phap: T i i n eUu, thU nghiim lam sang, ngau nhien, cd so sanh.
2.3. Phddng phap tien hanh
Chuan bi binh nhdn trudc mo: KhIm benh nhan trude mo 1 ngay, g i l i thich eho b i n h nhan ve cuoc md va phuang phap g i l m dau sau md.
Ky thudt vd cdm trong mo: Binh nhan difflc truyen tmh maeh dung djch Ringer laetat lOml/kg, theo ddi cac thdng sd ve hd hap v l tuan hoan, diidc g l y te ngoai mang ciing d L2-L3 b^ng ky t h u l t mat sUe e l n , sau khi luon xong catheter ngoai mIng cUng s i dupe g l y te tCiy sdng dUdng b i n eung 6 L2- L3 bSng 9mg bupivaeain -i- 40meg fentanyl de mo eat tCf eung.
TAP CHl Y DUOC LAM SANG 108 T$p12-S6 4/2017
Gidm dau sau mo: Khi b i n h n h i n dau, VAS > 4, b^t dau t i i n hanh dieu t n dau bang tiem tCTng lieu 5ml dung dich thude te qua catheter ngoai mang cUng each nhau 10 phut eho den khi het dau. Sau dd, c l e b i n h nhan dupe t r u y i n lien tuc mdt trong hai loai dung djch thudc t i d tren qua catheter ngoli mang cUng trong vdng 48 gid sau mo bang bam tiem t u ddng loai sCi dung mdt l l n eua Nhat Ban vdi tde dp tU 3 - 8ml/gid tuy theo mUe d d dau cua b i n h n h i n .
Gidi cdu dau: Khi benh nhan van cdn dau (VAS >
4) du da di tdc dp bom t i i m tU ddng la SmI/gid s i dupc tiem them thudc te qua catheter ngoai mang
cUng (5ml dung djch thude te moi lan t i i m va cleh nhau 10 phiit eho d i n khi VAS < 3). Khi benh nhan van cdn dau thi cd the phdi hpp dat hau mdn 1 vien dan diclofenac lOOmg, sau 30 phiit, n i u benh nhan v I n ehUa het dau, se dupe giam dau b§ng t i i m morphin ehuan dp tinh mach (2mg moi lan tiem, cleh nhau 7 phiit).
Cdc chi tiiu nghiin cdu: Cle benh n h i n n l y dupe theo ddi l i i n tyc eae ehi sd sinh tdn, diem dau VAS, mUe dp Uc che van ddng theo Bromage, c l e t i e dung khdng mong mudn: Ndn, budn ndn, bi tieu, dau d a u . . . trong sudt thdi gian n g h i i n eUu (48 gid).
3. Ket qud
Bing 1 . Dac diem chung, tien sflfcOa doi tUtfng nghien cuTu va dac diem phau thuat
Tuoi (nam) Chieu cao (cm) Can nang (kg) Chi so BMI ASA
D o i Doll Tien si] benh nhan
HCitthu6cla Saytau xe Diijfng C h i ^ n h phau thuat
UxotLTcung
Lac npi mac tCf cung trong CO tLf cung U xo tiJf cung va u nang buong trilng Thdi gian phau thuat (phut) Thdi gian trung tien (gid) Thdi gian nam v i i n (ngay)
Nhom LEVO (n = 35) 46,3 ± 5,8 156,7 ±5,6 56,7 ± 7,6 23,1 ± 2,9
91,4%
8,6%
0 6(17,14%)
1 (2,86%)
27(77,14%) 3 (8,57%) 5(14,29%) 54,4 ±13,7 20,2 ± 3,6 4,2 ± 0,5
Nhom BUPl (n = 35) 47,6 ± 3,9 156,9 ±4,7 54,1 ±5,7 22 ± 2,6
91,4%
8,6%
0 7 (20%) 1 (2,86%)
28 (80%) 4(11,43%) 3 (8,57%) 55,3 ±14,6 20,7 ± 3,7 4,1 ± 0,6
P
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY
Bang 2. Lieu thuoc te va thu6c giam dau tieu thu
Tong lieu thuoc te tieu thu trong 24 gid dau (mg) Tong lieu fentanyl tieu thu trong 24 gid dau (meg) Tong lieu thuoc t§ tieu thu trong 24 gid tiep theo (mg) Tong lieu fentanyl tieu thu trong 24 gid tiep theo (meg) T^ le b^nh nhan phSi dung them thuoc diclofenac dat hau mdn (n %)
Nhom LEVO (n = 35) 141,1 ±17,3 188,4 ±22,3
80,1 ± 7,7 106,6 ±11,1 6(17,1%)
Nhom BUPl (n = 35) 133,8 ±24,1 180,2 ±28,1 91,7 ±22,6 118,6 ±25,6 7 (20%)
P
>0,OS
>0,05
>0,05 *
>o,os
>0,05
*
- * - Buplvacain-fenlanyl - • - LevobuplvBcairvlenlanyl
0,25 0,6 1 2 4 6 8 16 Thd^ iHim sau phiu thu^t (glir)
24 36 4S Sau rdi catheter 6h
Bieu ad 1 . Dien bien tan sd tim ciia hai nhdm nghien cUu
• bupivacain-fentanyl
• - H l f i H H i H ,
0 0.2S 0.5 1 2 4 6 8 16 24 36 48 Sau nit catheter 6h Th6i gian sau phiu thuit (gl6')
Bleu do 2. Dien bien huyit ap ddng mach eua hai nhdm nghiin cufu
TAP CHl Y DUOC L A M S A N G 108 Tap 12-So 4/2017
Bdng 3. Cac tac dung ithong mong muon Ithac
Tac dung ithong mong muon ijc che van dong sau mo
Khdng lie che van dong Cfc che van dong mijfc Bromage 1 N g i ^
Ndn, buon ndn B i t i l u Ha huyet ap > 30%
Roi loan nhjp tim
Nhom LEVO (n = 35)
29 (82,86%) 6(17,14%) 4(11,43%) 6(17,14%) 4(11,43%)
0 0
Nhom BUPl (n = 35)
28 (80%) 7 (20%) 3 (8,57%) 7 (20%) 5(14,29%)
1 (2,86%) 1 (2,86%)
P
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 Trong nghien cufu nay, ehiing tdi khdng gap eac bien chiJng nguy hiem eua gay te ngoai mang cdng nhu: Bau dau do rach mang ciJng khi gSy te ngoai mang eifng, t u mau khoang ngoai mang eu'ng, ap xe khoang ngoai mang cufng...
4. Ban luan
Ve cae dae diem ehung, benh nhan d hai nhdm trong nghidn cu'u cCia chiing tdi kha tUOng ddng v^:
Tudi, chieu cao, can nang, chi sd BMI,.., do dd se it anh hu'dng den ket qua nghien cufu. Tien sii benh nhan ehiing tdi can quan tam d day la: Ti^n sCf say tau xe, nghien thude la va tien sii dj ij'ng vi cac yeu t d nay lien quan den ty' le ndn va budn ndn sau md theo thang diem Apfel. Theo tae giS nay, cae yiu t d lam tang nguy cd ndn va budn ndn sau m d la: Gidi nCf, khdng nghien thudc la, ti^n sCf ndn, budn ndn sau md hoae say tau xe, ed sii dung cae thude hg morphin trong va sau md [6]. Ndn, budn ndn la tae dung khdng mong mudn gay khd chju thiJ hai sau dau, vl vay, dieu trj va dir phdng ndn can ph^i dUdc dae biet quan tam de giSm khd chju va Ccii thien sif hai Idng eua ngudi benh. Chi djnh phau thuat eua cae benh nhan trong ea hai nhdm nghien cufu cua chiing tdi eung khdng ed su" khae biet cd y nghTa thdng ke, da sd cae tradng hop la phau thuat eat Xii eung hoan toan do u xo tCr eung, day la mdt benh ly thudng gap nhat trong phu khoa.
Tdng lieu thudc te levobupivacain va bupivaeain sif dung t r o n g 24 gid sau m d d hai nhdm nghien cufu khdng ed sii khae biet ed y nghTa t h d n g ke. Trong nghien cufu eua chiing tdi, lieu thudc levobupivacain tidu thy trong 24 gid dau trung blnh
la 141,11 ± 17,31mg, thap hon so vdi ket qua cCia Sitsen (314,4 + 14,4mg), ed the do Sisten dung ndng dp thude eao hon ehiing tdi (levobupivacain 0,125%) va trong nghien culi cOa tac gia nay sir dung phiiong phap vd cam la gay me toan than nen thdi gian bat dau sCf dung thudc gISm dau md eung sdm hon [5].
Nhdm bupivaeain eua ehiing tdi eung tieu thu nhieu hon so vdi nghidn cdu cOa Nguyen The Ldc (129,3 ± 48,6mg), do tac gia sLf dung ndng do thudc Idn hdn chiing tdi (bupivaeain 0 , 1 % phdi hop fentanyl 2meg/ml). Trong nghien eua ehiing tdi, mu'c do dau sau md thudng dQ ddi nhat d thdi diem t i i 6 - 1 0 gid dau sau md, dau nhat 6 ngay dau tien, giam dan d cae ngay sau. Ngay thU hai sau md, sd lUong thudc te tieu thu giam d ea hai nhdm: 80,14 + 7,67mg levobupivacain va 91,73 ± 22,55mg buplvacain, phan vl giam lieu truyen lien tue, phan vl b^nh nhan thay da d d dau rat nhieu nen ehu ddng ngCftig thude. So vdi eac tae gia khae lieu thude cCia chiing tdi thap hon nhieu, cd le do ddi tugng nghien e i i ^ ciia ehiing tdi la phu nO chau A vdi chieu eao, can nang thap hon eac phu nuf chau Au [2], [4], [5].
Chiing tdi chi sii dung dung djch thude te ehii"a 1 meg/ml fentanyl, ndng do nay thap ban so vdi Nguyen The Lde, tuy nhien, theo eae nghien cufu gan day, ndng dp eao hon I m c g / m l fentanyl khdng lam tang tac dung giam dau ma ed the gay tang eac tac
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoLl2-N°4/2017
dung khdng mong muon, dac biet la gay ndn, budn ndn sau md [1].
Trong nghidn cufu nay, chiing tdi cd sd dung phdi hpp vdi adrenalin 5mcg/ml (1/200.000).
Adrenalin da dupc sii dung Xii lau de pha vdi thude t^ trong g3y te ngoai mang euYig de tang thdi gian gay te, giam ndng dp dinh ciia thude te trong huyet tuong, cai thten dp tin eay ciia gay te va tang cudng c h i t lupng vd cam, chat lUpng g i l m dau ngoai mang eiJfng. Adrenalin keo dai thdi gian gay te ngoai mang eUng bang each giam hap thu eua thude te vao he thdng tuan hoan do lam co maeh ddi vdi eae d i m rdi tTnh mach ngoai mang edng.
Trong nghien edu nay, ehiing tdi khdng t h I y ed sU khae biet ve tan sd t i m , huydt ap ddng maeh giUa hai nhdm nghidn cufu tai cCing mdt thdi diem. Cd the do ed mau nghl&n ciiu ciia ehiing tdi chua dii Idn.
Tuy nhien, theo dUpc ddng hpe eua levobupivacain thi thudc la ddng phan ddi quang eiia bupivaeain (s-isomer), do dd thude it gay dde tfnh tren tim mach va than kinh hon so vdi bupivaeain [4].
Cac tac dung khdng mong mudn phai ke den la g l y ij'c che van ddng, trong nghien cUu eua ehiing tdi 100% benh nhan dugc dat catheter vung that lung khe lien dot L2-L3. 0 nhdm LEVO ed 6 benh nhan chiem 17,14%, nhdm BUPl ed 7 benh nhan chi^m 20% g i l m van ddng mdt chan d mUe Bromage dp 1 trong 24 gid dau, tuy nhien, su khac bi^t nay khdng cd y nghTa thdng ke vdi p>0,05.
Nhufng benh n h i n trong nghien cUu eCia chiing tdi sau khi dupc g i l m tde dp bom tiem t u ddng thl Ue che van ddng deu giam, hau nhu ve mUc Bromage dp 0 khi chay vdi tde dp 3ml/gid. Vi tac dung khdng mong mudn n l y nen trong y van khuyen eao dat catheter d vung ngUe de g i l m dau cho phau thuat vCing bung [2], [3]. Trong nghien eUu eua ehiing tdi, rj' \i b f n h nhan ngufa sau md d hai nhdm tUPng duong nhau 11,4% d nhdm LF va 8,57% d nhdm BF.
Ngda thudng gap d viing ed, mat va ngiie trong ngay thii' nhat sau md va tU het khdng can dieu trj.
T]^ \i benh nhan bi ngufa ciia chiing tdi nhieu ban nghien ciili eCia Nguyen The Ldc. T;^ le ndn va budn ndn trong nghien eiJu eua chiing tdi cao hon so vdi
N g u y i n The Ldc (17,14% d nhdm LEVO va 20% t nhdm BUPl so vdi 12%), cd the do ddi tUpng nghidn eUu ciia chiing tdi ed nhieu yeu t d nguy eo nfln budn ndn sau md ban. Tuy nhien, ndn, budn non chi gap d ngay thU nhat sau md, mu'c dp nhe va khfing ed benh nhan nao p h l i dieu trj bang thu6c Primperan. Chung tdi gap t i le b i tieu d nhdm LEVO la 14,29% va 17,14% d nhdm BUPL Tuy nhien khong ed trudng hop n I o phai dat lai dng thdng bang quang. Su khac biet ve ti le b i tieu giOfa hai nhom khdng ed y nghTa thdng ke. Trong nghien euli cua ehiing tdi ed gap mdt b f n h n h i n d nhdm diing bupivaeain 0,075% cd huyet ap tam thu giam hon 20% so vdi huyet ap nen va phai dung ephedrin 3mg tTnh maeh chiem 2,9%, ket qua nay ciia chiing tdi t h I p hon nghidn eifu cOa N g u y i n The Ldc (8%), dieu nay eho thay gay te ngoai mang cUng rat it gay thay ddi huyet ddng d lieu giam dau ma chiing toi sU dung [2]. TJ l# rdi loan nhip tim eOa cac benh n h i n trong qua trinh giam dau ciia hai nhdm nghien cijfu khdng ed sU khac biet cd y nghTa thdng ke, co the do ed mau cua ehung tdi chua dii Idn.
5. K^t luan
Tae dung khdng mong mudn eCia phuong phSp gay te n g o l i mang cUng bang hon hop levobupivacain 0,075% + fentanyl Imcg/ml + adrenalin 5meg/ml de giam dau sau md c i t tif cung hoan toan dUdng bung gap vdi ty le thap, khong nguy hiem, khdng khae biet vdi nhdm diing bupivaeain eiing ndng dp va ciing ele thudc phoi hop: Tan sd tim va huyet ap ddng mach khdng c6 si/
khIe biet giCfa hai nhdm, X'if le bj u'c che van dong mijfc Bromage I la 17,14% so vdi 20%; t;^ le ngila, nfln va budn ndn, b i t i e u , lan lUdt la: 11,43%, 17,14% va 11,43% so vdi 8,57%; 20% va 14,29% d nhdm BUPl.
Tai lieu t h a m k h d o
1. Nguyen The Ldc (2016) Nghiin cdu hiiu qud cua phuong phdp gdy ti tdy sdng vd ngodi mdng cUng phdi hgp di mo vd gidm dau sau m6 cdt td cung hoan todn tgi binh viin phu sdn trung uang. Tap chi Y hpc thUe h l n h , tr. 218-220.
TAP CHlYDLTOC LAM SANG 108 Tap 12-S6 4/2017
Senard M, Kaba A, Jaequemin MJ et al (2004) Epidural levobupivacaine 0.1% or ropivacaine 0.1%
combined with morphine provides comparable analgesia after abdominal surgery. Anesth Analg 98(2): 94-389.
Konigsrainer I, Bredanger S, Drewel-Frohnmeyer R et al (2009) Audit of motor weakness and premature catheter dislodgement after epidural analgesia in majorabdominalsurgery. Anaesthesia 640): 27-3^.
Lee BB, Ngan Kee WD, Plummet JL et al (2002) The effect of the addition of epinephrine on early systemic absortion of epidural ropivacaine in humans. Anesth Analg 95:1402-1407.
Sitsen E, Van Poorten F, Jansen G et al (2012J A comparison of the efficacy of levobupivacaine 0.125%, ropivacaine 0.125% and ropivacaine 0.2%, all combined with sufentanil 0.5 microg/mL, in patient-controlled epidural analgesia after hysterectomy under combined epidural and general anesthesia. Acta Anaesthesiol Beig 63(4): 75-169.
Weilbaeh C, Rahe-meyer N, Raymondos K et al (2006) Postoperative nausea and vomiting (PONV):
Usefulness of the Apfel-score for identification of high riskpatients for PONV. Acta Anaesthesiol BeIg 57(4).
