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A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home

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A comparative analysis of isopropyl alcohol
and ondansetron in the treatment of
postoperative nausea and vomiting from the
hospital setting to the home
LCDR Jonathan W. Cotton, CRNA, MS, NC, USN
Little Creek, Virginia
LCDR Lana R. Rowell, CRNA, MS, NC, USN
Yokosuka, Japan
CDR Raymond R. Hood, CRNA, MS, NC, USN(ret)
Portsmouth, Virginia
CAPT Joseph E. Pellegrini, CRNA, DNSc, DNP, NC, USN
Bethesda, Maryland
We compared the efficacy of inhaled isopropyl alcohol (IPA)
with ondansetron for the control of postoperative nausea
and vomiting (PONV) during a 24-hour period in 100 ASA
class I-III women undergoing laparoscopic surgery. Nausea
was measured postoperatively using a 0 to 10 verbal
numeric rating scale (VNRS). The control group received
ondansetron, 4 mg intravenously, and the experimental
group inhaled IPA vapors. Breakthrough PONV was treated
with 25-mg promethazine suppositories.
Demographic and anesthesia characteristics were similar between groups. There was a significant difference
between groups in mean ± SD time to alleviation of PONV
symptoms: for a 50% reduction in VNRS scores, 15.00 ±


ostoperative nausea and vomiting (PONV)
are among the most common and distressing symptoms that occur following surgery.
Often, a patient will report that the psychological and physical distress experienced
secondary to PONV were the worst part of the entire
surgical experience.1,2 Several individual patient and
surgical factors have been identified that predispose a
patient to PONV. The individual patient factors
include age, gender, weight, amount of stomach contents, motion sickness, a history of nonsmoking, prior
PONV, and presence of inner ear pathology.1,2 Surgical
factors include the length of surgery (>60 minutes),
type of surgery performed (gynecologic and laparoscopic), type of anesthesia administered (general vs
regional), degree of hypotension experienced, opioid
requirements during and following the procedure,
and the amount of postoperative pain.1,2 Based on
these findings, anesthesia practition; ers have customized anesthetic management plans that include
controlling for some of the factors and administering


10.6 vs 33.88 ± 23.2 minutes was required in the experimental vs the control group ( P = .001). A total of 21 subjects (10 control; 11 experimental) reported PONV symptoms following discharge to home. The IPA treatment was
successful in alleviating PONV symptoms in the home in
91% of the experimental group.
We determined that using IPA after discharge from the
postanesthesia care unit is a valuable method to control
PONV in the hospital and at home. The results of this study
suggest that IPA is much faster than ondansetron for 50%
relief of nausea.
Key words: Aromatherapy, isopropyl alcohol, ondansetron,
postoperative nausea and vomiting.

prophylactic antiemetic agents to patients who are at
high risk for PONV. Despite these anesthetic treatment plans, the overall incidence can remain as high
as 50% in certain patient populations.1,2
In addition to the problem of the patient’s psychological and physical discomfort that can result from
PONV, other complications may occur secondary to
PONV. These include aspiration of stomach contents,
dehydration, electrolyte disturbances, and interruption of the surgical incision. In addition, PONV can
have a major impact on healthcare delivery—it has
been noted that patients who experience PONV tend
to require longer hospitalization and have a delayed
return to the workforce, so PONV acts as a conduit for
driving up the cost of healthcare.2,3
The exact mechanism of PONV is poorly understood. It is hypothesized that the nausea response is
coordinated via a central vomiting center (VC) in the
medulla called the chemoreceptor trigger zone (CTZ).
When stimulated by noxious substances, receptors
relay the information to the vomiting center, which

AANA Journal/February 2007/Vol. 75, No. 1


then acts on the efferent pathways, initiating vomiting. The CTZ is located in the highly vascularized area
on the brain surface that is lacking a real blood-brain
barrier; therefore, it can react to neurotransmitters
involved in eliciting an emetic response. These neurotransmitters include serotonin (5-HT3), dopamine,
histamine (H1), and acetylcholine. It has been shown
that blockade of one or more of these neurotransmitters at the level of CTZ decrease the incidence of
PONV. Specific pharmacological agents have been
developed that successfully block the transmission of
these neurotransmitters at the level of the CTZ; however, there is no single agent identified that will block
all pathways.4 To offset this, many practitioners use a
combination of neurotransmitter antagonists to block
more than one pathway, an approach shown to be
more successful than use of separate agents. However,
using a monomodal or multimodal pharmacological
approach to treat PONV can result in profound sedation and hypotension, resulting in increased morbidity. Therefore, alternative methods to treat PONV that
have little to no impact on patient sensorium or vital
signs need to be found.
Most health professionals would agree that the best
PONV treatment should be cost-effective, self-administered, and cause few to no side effects. One such
treatment modality that seems to have all of these
characteristics is inhaled isopropyl alcohol (IPA). Several studies have reported the clinical efficacy of
inhaled IPA in the treatment of PONV. Most notable
are the studies by Wang et al,5 who found that the
inhalation of IPA in children was effective in achieving
transient relief of motion related nausea, and Winston
et al,6 who found that inhaled IPA was as effective in
the treatment of PONV as ondansetron but also
worked considerably faster in alleviating PONV symptoms. However, limitations noted in both studies were
that IPA was only clinically effective for a short time
and that subsequent treatments were often required to
adequately treat PONV. In addition, these studies were
designed to analyze IPA efficacy in a very limited setting (during transport and in the postanesthesia care
unit [PACU]), and it was unclear whether IPA would
be effective beyond these limited uses. Therefore, the
purposes of this study were to validate the results
reported by Winston et al6 and to determine whether
IPA was just as effective through a patient’s entire hospitalization and in the home setting.

Once institutional review board approval was
obtained, a prospective, randomized study was conducted with 100 women, ASA physical status I, II, or


AANA Journal/February 2007/Vol. 75, No. 1

III, ages 18 to 65 years who were scheduled for laparoscopic same-day surgery. Patients were excluded from
the study if they had recent upper respiratory tract
infections, inability or impaired ability to breathe
through the nose, or history of hypersensitivity to
IPA, 5-HT3 antagonists, promethazine, or any other
anesthesia protocol medication. Patients also were
excluded if they reported using an antiemetic within
24 hours of surgery; were pregnant or currently
breast-feeding; had a history of inner ear pathology,
motion sickness, or migraine headaches; or were taking disulfiram, cefoperazone, or metronidazole. Once
it was determined that a patient was eligible for inclusion and agreed to participate in the study, the patient
was randomly assigned to the control group or the
experimental group by using a computer-generated
random numbers program.
Following informed written consent, a baseline 0
to 10 verbal numeric rating scale (VNRS) score, in
which “0” indicated “no nausea” and “10” indicated
the “worst imaginable nausea,” was obtained and
recorded. Demographic information also was obtained, including age, height, weight, race, and type of
surgery. All subjects were prepared for surgery using
standard operating procedures that included intravenous (IV) cannulation, prehydration with crystalloid solution, and anxiolysis with midazolam up to 5
mg IV at the discretion of the provider.
Subjects were then transported to the operative
suite where standard monitors were placed, including
a noninvasive blood pressure device, an electrocardiogram monitor, and pulse-oximetry and capnography
devices. All subjects were then administered 100%
oxygen via face mask for 5 minutes before induction
of anesthesia. Administration of IV lidocaine up to 1
mg/kg; propofol, 1.5 to 2.0 mg/kg; fentanyl up to 5
µg/kg; and a nondepolarizing or depolarizing muscle
relaxant of choice were used to induce anesthesia.
Following induction, the trachea was intubated and
an orogastric tube placed to decompress the stomach.
The orogastric tube was removed immediately before
extubation of the trachea.
Maintenance of anesthesia was accomplished using
desflurane, isoflurane, or sevoflurane in combination
with a 50% nitrous oxide–oxygen mixture or a 50%
oxygen–air mixture. In addition, all subjects were
given up to 5 µg/kg of fentanyl IV to maintain analgesia. Approximately 15 to 30 minutes before the end of
the surgical procedure, all subjects were given 30 mg
of IV ketorolac. If required, neuromuscular blockade
was reversed using neostigmine, 0.05 mg/kg IV, and
glycopyrrolate, 0.01 mg/kg IV. All subjects were transferred to the PACU after extubation. All preoperative


and intraoperative medications that were administered
were noted and recorded on a data collection sheet.
While in the PACU, the nursing staff was instructed
to treat any incidence of shivering with 12.5 mg of
meperidine and complaints of pain with 1 to 3 mg of
IV morphine sulfate (up to a maximum of 0.15
mg/kg). The PACU personnel were instructed to note
time, dose, and effectiveness of all analgesics on the
data collection sheet.
In addition to the baseline measurement of the
VNRS score for nausea, an additional VNRS score was
obtained for all subjects on emergence from anesthesia
and at any time they complained of nausea. If a subject
complained of nausea, VNRS scores were obtained on
initial complaint, every 5 minutes following treatment
for 30 minutes, and every 15 minutes thereafter until
discharge from the PACU. All treatments and VNRS
scores were recorded on the data collection sheet. Successful treatment with ondansetron or IPA was defined
as a 50% reduction in the VNRS score.
For subjects assigned to the ondansetron (control)
group, nausea was treated with ondansetron, 4 mg IV,
every 15 minutes, up to an 8-mg maximum total dose.
The PACU personnel were instructed to record the
time, dose, and the VNRS scores on the data collection
sheet. For subjects assigned to the IPA (experimental)
group, nausea was treated by having the PACU nursing
personnel hold a folded alcohol pad approximately ½
inch from the opening of the patients’ nares and
instructing the patient to take 3 deep breaths of the
vapors in and out through the nose. The IPA treatments
were ordered to be administered on an as needed basis,
every 5 minutes, up to a total of 3 administrations. All
PACU personnel and subjects were instructed as to the
specific use of the IPA and the parameters of the study
before the initiation of the study.
Following discharge from the PACU, all subjects
were transported to the same-day surgery unit
(SDSU). The SDSU nursing personnel were instructed
about the specific parameters of the study and protocols before initiation of the study. For complaints of
nausea, SDSU personnel were instructed to use the
same treatment regimen as that used in the PACU,
including the administration of ondansetron, IPA, and
recording of VNRS scores for nausea. In case nausea
persisted in the ondansetron group following a total
IV dose of 8 mg of ondansetron (cumulative amount
between PACU and SDSU), nursing personnel were
instructed to administer a 25-mg promethazine suppository. If nausea was refractory to treatment in the
IPA group, all nursing personnel were instructed to
treat nausea with ondansetron, 4 mg IV, every 15 minutes, up to a total dose of 8 mg. All complaints of nau-


sea and treatment regimens used were recorded on a
data collection sheet.
Following discharge from the SDSU, all subjects
were discharged to home with a data collection tool
on which they were asked to record nausea and vomiting events, what treatment was used, and clinical
effectiveness of the treatment. Subjects were asked to
record this data for a period of 24 hours.
Before discharge from the hospital, all subjects
were given two 25-mg promethazine suppositories
and instructed on self-administration. All subjects
were given written and verbal instructions concerning
treatment of PONV at home. Subjects randomized to
the ondansetron group were asked to treat episodes of
nausea and/or vomiting at home by self-administration of one 25-mg promethazine suppository every 6
hours as needed. Subjects randomized to the IPA
group were asked to take 3 deep inhalations from an
IPA pad every 15 minutes as needed to a maximum of
3 inhalational treatments. If the IPA was not working
to the subject’s satisfaction, or if 3 treatment regimens
had been performed, IPA subjects were asked to selfadminister a 25-mg promethazine suppository every 6
hours as needed, not to exceed 2 administrations. In
addition, all subjects were asked to note the time of
administration and the time they “felt relief” following administration. Before discharge from the hospital, all subjects in both groups were given instruction
concerning the use and administration of promethazine suppositories.
All home data collection information was obtained
and recorded by 2 investigators (J.W.C and L.R.R.)
approximately 24 hours following discharge via a
postoperative telephone interview. In addition, all
subjects were asked to rate their anesthesia experience
using a 4-point ordinal scale in which a score of 1
indicated a “poor” experience, 2 indicated a “fair”
experience, 3 indicated a “good” experience, and 4
indicated an “excellent” experience.
Before initiation of the study, a power analysis was
performed based on previous studies that indicated
that at 5 minutes following treatment, VNRS scores
would decrease from a mean of 5.0 at baseline to a
mean ± SD of 4.5 ± 2.7 in the ondansetron group and
2.1 ± 2.5 in the IPA group. This indicated a sample
size of only 15 subjects per group would be required
to show significance when an α of .05 and a β of .20
were used. However, it was assumed that only approximately 30% of the population as a whole would have
complaints of PONV; therefore, the sample size was
adjusted; 50 subjects per group would be required to
show significance. All data were analyzed for entry
errors, missing data, and consistency before statistical

AANA Journal/February 2007/Vol. 75, No. 1


analysis. Statistical analysis was performed using SPSS
statistical software (version 11.0, SPSS, Chicago, Ill).
The VNRS scores were analyzed with the Student t
test; demographic data and frequency data were analyzed using a χ2 test. Satisfaction scores were analyzed
using a Mann-Whitney U test. A P value of less than
.05 was considered significant.

Of the 100 subjects enrolled, 28 were disenrolled due
to failure to adhere to protocol. Protocol violations
included 12 subjects in the ondansetron group who
were given IPA treatments in SDSU, 6 subjects given
other antiemetic agents in the PACU before IPA treatments, and the remaining subjects losing their IPA or
promethazine following discharge to home. This left a
total of 72 subjects for study (34 control and 38 experimental). Of the 72 subjects, 68 underwent laparoscopic gynecologic procedures, and 4 had other general surgery laparoscopic procedures. Demographic
characteristics with regard to age, weight, height, anesthesia times, and PACU and SDSU times were similar
between groups (Table). When the intraoperative and
postoperative analgesics given, the concentrations of
volatile agents administered, and IV medications used
were analyzed separately, no significant differences
were noted between groups. (P > .05).
Nausea events reported in the PACU included 5
subjects (15%) in the control group and 8 subjects
(21%) in the experimental group who required treatment. No subject in either group had an emetic event
in the PACU or SDSU. Nausea events reported in the
SDSU included 15 subjects (44%) in the control group
and 21 subjects (55%) in the experimental group who
required treatment. We noted significant differences
between groups when times to a 50% reduction in
VNRS scores were analyzed for the first and second
treatments. For the first treatment of PONV symptoms, subjects in the control group required a mean ±
SD of 33.88 ± 23.2 minutes to achieve a 50% VNRS
score reduction compared with 15.00 ± 10.6 minutes
for the experimental group (P = .011). Similar results
also were noted for second treatments: the control
group required a mean ± SD of 26.25 ± 7.5 minutes to
achieve relief as opposed to 15.00 ± 5.25 minutes for
the experimental group (P = .013) (Figure 1). Only 1
subject (IPA group) reported 3 separate PONV events;
therefore, no analysis was performed on time to alleviation for the third nausea event.
When the incidence of subjects requiring rescue
treatment in the SDSU was analyzed, it was noted that
13 (38%) of the control group required rescue treatment, whereas only 10 (26%) of the experimental group


AANA Journal/February 2007/Vol. 75, No. 1

Table. Demographic data and times for anesthesia,
postanesthesia care unit (PACU), and same-day
surgery unit (SDSU).*
Isopropyl alcohol
(n = 38)
Age (y)
30.47 ± 5.7
Height (in)
68.74 ± 2.4
Weight (kg)
78.87 ± 17.3
95 ± 39.0
time (min)
PACU time
63.23 ± 30.2
SDSU time 191.81 ± 103.4

(n = 34)
31.15 ± 5.0
64.82 ± 2.5
73.29 ± 12.6
95.24 ± 36.9


62.62 + 29.7


197.71 ± 124.5 .073

* Data are given as mean ± SD.

required rescue treatment (P = .319). A total of 21 subjects reported nausea events at home (10 control; 11
experimental); however, 5 subjects in the control group
reported using promethazine for rescue treatment compared with only 1 subject in the experimental group (P
= .064) (Figure 2). All remaining subjects in the IPA
group reported that their PONV at home was adequately
treated by self-administration of IPA.
No significant difference was noted when satisfaction scores for anesthesia experience were analyzed:
both groups reported scores of 3 (good) or 4 (excellent) when quantifying their overall anesthesia experience (P > .05).

Women undergoing laparoscopic surgeries seem to be
at a higher risk for PONV than other populations and,
thus, were selected as our target population.2,6,7
Ondansetron was chosen as our control agent for
comparison with IPA because of its proven efficacy in
treating PONV and low incidence of side effects.6-10
Several investigations have reported that the inhalation of IPA is efficacious for the treatment of PONV
and has minimal to no associative side effects.6,11,12 Of
these studies, the study that used a method similar to
ours was performed by Winston et al.6 As with our
present study, Winston et al6 chose to have the patient
inhale the vapors produced from a folded alcohol pad
at the first complaint of nausea and then they
recorded the time to achieve a 50% reduction in the
VRNS score for nausea. The study by Winston et al6
reported that a 50% reduction in PONV was achieved
in approximately 10 minutes in the IPA group,
whereas it took a mean average of 30 minutes in the
ondansetron group. This finding by itself was impor-


Figure 1. Time to 50% reduction in 0-10 verbal
numeric rating scale (VNRS) nausea scores

Figure 2. Number of patients requiring rescue




Ondansetron group

Ondansetron group
IPA group

IPA group




Time to 50% reduction of nausea VRNS scores (min)







Second episode

First episode

Episodes of nausea

Subjects randomized to the control (ondansetron) group
required a mean ± SD of 33.88 ± 23.2 minutes to achieve
a 50% reduction in nausea VNRS scores compared with
15.00 ± 10.6 minutes for the experimental (isopropyl
alcohol [IPA]) group (P = .011). Following the second
treatment for complaints of PONV, a significant difference
also was noted between groups: control group subjects
required a mean ± SD of 26.25 ± 7.5 minutes to achieve
50% resolution, compared with 15.00 ± 5.25 minutes for
the experimental group subjects (P = .013).
* Significance P < .05

tant but needed further validation with follow-up
studies. We found similar results to the 50% reduction, although it took a mean of about 15 minutes in
the IPA group and about 34 minutes in the
ondansetron group. Although these times are different, they validate the findings from the first study,
which concluded that IPA worked significantly faster
and was as effective as ondansetron in reducing PONV
symptoms in women undergoing a laparoscopic surgical procedure.
Many practitioners prophylactically treat patients
for PONV with the medication ondansetron.
Ondansetron costs approximately $20 per 4-mg dose
and, therefore, can be a significant factor in the cost of
care. Because the incidence of PONV is reported to be
40% to 50%, some practitioners advocate a “wait and
see” philosophy regarding the routine prophylactic




Location of treatment

There were no significant differences in the need to
facilitate rescue treatment between groups in the
postanesthesia care unit (PACU), same-day surgery unit
(SDSU), and home settings; however, following
discharge from the PACU, subjects assigned to the
isopropyl alcohol (IPA; experimental) group required
less intervention than subjects assigned to the
ondansetron (control) group.

treatment of PONV.13 We argue that administration of
a prophylactic dose of an antiemetic agent should not
be routine and that it would be more cost-effective
and expose the patient to less medication if PONV
was only treated when symptoms were present. Some
investigators report that none of the current regimens
used to prevent PONV with antiemetic agents are sufficient in preventing PONV and are only effective if
given for treatment.14 Therefore, because our study
showed that IPA is highly effective in the treatment of
PONV and costs only pennies per application, it
would be more cost-effective and perhaps safer to
treat patients who experience PONV with IPA rather
than the antiemetic agents commonly used in clinical
practice. However, we realize that given the limited
scope of the patient population used in our study, further studies need to be performed to validate such a
bold supposition. One of the most attractive aspects of
treating PONV with IPA is that all patients could be
sent home with alcohol pads that they could selfadminister for an episode in transit or while at home.

AANA Journal/February 2007/Vol. 75, No. 1


Implementing the use of IPA for the treatment of
PONV for self-administration at home is also reassuring to practitioners and patients because no adverse
effects have been associated with the brief inhalation
of IPA vapors.
The primary limitations of our study were related to
the methods and design. It would be nearly impossible
to blind this type of study. Second, data collection
among 3 units, providers, and the patients themselves
proved challenging. Many practitioners in the PACU
and SDSU treated patients with IPA despite patient
assignment to the ondansetron group. When these
PACU and SDSU nursing personnel were asked about
reasons for this breach of protocol, they reported that
at the bedside, they administered the IPA because of its
convenience and its already proven efficacy that had
been noted when other patients were treated with IPA
for episodic PONV. Despite breaches in protocol, a
total of 72 subjects were included in analysis, and we
thought that this number would prove sufficient to
determine whether there was difference in the clinical
efficacy of each treatment regimen.
A possible future study would be to determine the
efficacy of IPA as the principal treatment of PONV in
the PACU, SDSU, and home settings in a group of
patients given a prophylactic dose of antiemetic agent
intraoperatively because the prophylactic administration of antiemetics is common in many anesthesia
practices. Another avenue of future study could be the
efficacy of IPA administration in a wider variety of
patients who have undergone surgical procedures. We
chose to limit our patient population to women having any type of same-day laparoscopic procedure in an
effort to validate the results of the study by Winston
et al6 and because this target population is particularly
susceptible to PONV. Finally, another area of future
study may be to investigate whether administration of
IPA prophylactically would have any effect on the
occurrence of PONV in the postanesthesia settings
outlined in this study.
Isopropyl alcohol could become an invaluable tool
for anesthesia providers, postanesthesia nursing personnel, and patients for treatment of this often distressing, uncomfortable, and all-too-common aspect
of undergoing a surgical procedure.

2. Kenny G. Risk factors for postoperative nausea and vomiting.
Anaesthesia. 1994;49:6-10.
3. Hirsch J. Impact of postoperative nausea and vomiting in the surgical setting. Anaesthesia. 1994;49(suppl):30-33.
4. Morgan GE, Mikhail MS. Clinical Anesthesiology. 2nd ed. New
York, NY: McGraw-Hill; 1996.
5. Wang SM, Hofstadter MB, Kain ZN. An alternative method to alleviate postoperative nausea and vomiting in children. J Clin Anesthesiol. 1999;11:231-234.
6. Winston AW, Rinehart RS, Riley GP, Vacchiano C, Pellegrini JE.
Comparison of inhaled isopropyl alcohol and intravenous
ondansetron for treatment of postoperative nausea and vomiting.
AANA J. 2003;71:127-132.
7. Fujii Y, Toyooka H, Tanaka H. Prevention of PONV with
granisetron, droperidol and metoclopramide in female patients
with history of motion sickness. Can J Anaesth. 1997;44:820-824.
8. Claybon L. Single dose intravenous ondansetron for the 24-hour
treatment of postoperative nausea and vomiting. Anaesthesia.
9. Helmy SA. Prophylactic anti-emetic efficacy of ondansetron in
laparoscopic cholecystectomy under total intravenous anaesthesia:
a randomized, double-blind comparison with droperidol, metoclopramide and placebo. Anaesthesia. 1999;54:266-271.
10. Liberman M, Howe S, Lane M. Ondansetron versus placebo for
prophylaxis of nausea and vomiting in patients undergoing ambulatory laparoscopic cholecystectomy. Am J Surg. 2000;179:60-62.
11. Langevin PB, Brown MM. A simple, innocuous, and inexpensive
treatment for postoperative nausea and vomiting [abstract]. Anesth
Analg. 1997;84(suppl):S15.
12. Smiler BG, Srock M. Isopropyl alcohol for transport-related nausea. Anesth Analg. 1998;87:1211-1216.
13. Tramer MR. A rational approach to the control of postoperative
nausea and vomiting: evidence from systematic review, part II: recommendations for prevention and treatment and research agenda.
Acta Anaesthesiol Scand. 2001;45:14-19.
14. McQuay HJ, Moore RA. Postoperative analgesia and vomiting,
with special reference to day-surgery: a systematic review. Health
Technol Assess. 1998;21-236.

LCDR Jonathan W. Cotton, CRNA, MS, NC, USN, is a staff nurse anesthetist, Fleet Surgical Team 4, Little Creek, Va.
LCDR Lana R. Rowell, CRNA, MS, NC, USN, is a staff nurse anesthetist, Yokosuka, Japan.
CDR Raymond R. Hood, CRNA, MS, NC, USN(ret), is a staff nurse
anesthetist, Naval Medical Center Portsmouth, Va.
CAPT Joseph E. Pellegrini, CRNA, DNSc, DNP, NC, USN, is director of research, Navy Nurse Corps Anesthesia Program, Bethesda, Md.

Support was received from the US Navy Clinical, Investigation Department, study #P01-0037.

1. Thompson HJ. The management of post-operative nausea and
vomiting. J Adv Nurs. 1999;29:1130-1136.


AANA Journal/February 2007/Vol. 75, No. 1

The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defense, or the United States Government.