Severe allergic reactions following administration of Sugammadex with low tryptase levels but positive skin prick test: a case report

We describe here the case of a severe anaphylactic episode to Sugammadex administered to reverse neuromuscular block in a 54-year-old man who underwent lumbar discectomy under general anaesthesia. Induction to anaesthesia and the entire surgical procedure were without any peculiarities. At the end of the surgery, 200 mg of Sugammadex was administered. Three minutes later, he developed a severe anaphylactic reaction accompanied by severe bronchospasm, with high peak airway pressures, drop of pulse oxygen saturation down to 70% despite FiO2 of 1.0, moderate decrease of arterial blood pressure (lowest was 80/50 mmHg) and normal heart rate of 70/min. Also, five minutes later he developed generalized skin rash and piloerection. The patient recovered completely after initial medical treatment per guidelines for treatment of anaphylactic shock. He was extubated in the Intensivel Care Unit a few hours later. Repeated blood mastocyte tryptase levels showed only a mild increase during the acute reaction. The allergic reaction to Sugammadex was confirmed by a positive intradermal test to Sugammadex a couple months later

Obstructive sleep apnea and anesthesia - Time to wake up !

Opstrukcijska apneja tijekom spavanja, (OSA, engl. obstructive sleep apnea) najčešći je poremećaj disanja pri spavanju, okarakteriziran učestalim kolapsom gornjih dišnih putova uslijed smanjenog mišićnog tonusa ždrijela i izraženog negativnog intratorakalnog tlaka prilikom pojačanog respiratornog napora pri udahu, što biva popraćeno epizodama desaturacije arterijske krvi kisikom, hiperkarbijom i kratkotrajnim buđenjima uz pojavu glasnoga hrkanja. Klinički znakovi i anatomska obilježja koja upućuju na sindrom opstrukcijske apneje su glasno hrkanje, zamijećen prestanak disanja tijekom spavanja, abdominalni tip debljine i zadebljali vrat, te poremećena anatomija ždrijela. Klinički simptomi očituju se najčešće u neobjašnjivo pretjeranoj dnevnoj pospanosti, kardiopulmonalnim poremećajima i kognitivnoj disfunkciji. Prije dolaska na anesteziološki pregled većina bolesnika s opstrukcijskom apnejom nije prethodno klinički dijagnosticirana, što ima za posljedicu znatno povećanje rizika perioperativnih komplikacija i iznenadne smrti. Mogu se očekivati komplikacije zbog otežane uspostave i održavanja dišnoga puta, povećanog rizika aspiracije želučanoga soka, povećane osjetljivosti na primjenu anestezijskih lijekova, komplikacije povezane s čestim popratnim kardiovaskularnim i cerebrovaskularnim bolestima, uzročno povezanih s apnejom, te poslijeoperativni delirij. Prepoznavanje simptoma opstrukcijske apneje prije kirurškoga zahvata omogućava anesteziološkom timu planiranje odgovarajuće pripreme i načina vođenja anestezije, te perioperativnog nadzora bolesnika, što je osobito naglašeno u sve više zastupljenoj dnevnoj kirurgiji. Procjena kvalitete spavanja, kao i čimbenika rizika za poremećaje disanja pri spavanju i prekomjerne dnevne pospanosti, pomoću upitnika omogućuje jednostavno, jeftino i pouzdano otkrivanje opstrukcijske apneje tijekom spavanja kod kirurškog bolesnika. Perioperativne komplikacije moguće je smanjiti primjenom anestezioloških protokola i strategija za smanjenje povećanog operacijskoga rizika ovih bolesnika i njihovom daljnjom nadopunom na temelju znanstvenih dokaza.Obstructive sleep apnea (OSA) is the most common breathing sleep disorder characterized by collapse of the upper airway which is caused by reduced pharyngeal muscle tone and exaggerated negative intrathoracic pressure during respiratory effort on breathing. It is accompanied by episodes of arterial blood desaturation, hypercarbia and recurrent awakenings from sleep and loud snoring. Clinical signs and anatomical characteristics that indicate OSA are loud snoring, witnessed abnormal cessation of breathing during sleep, abdominal type of obesity, thickened neck and abnormal anatomy of the pharynx. Clinical symptoms of the obstructive sleep apnea is most commonly manifested as unexplained excessive daytime sleepiness, cardiopulmonary disorders and cortical dysfunction. The majority of patients with obstructive sleep apnea are not diagnosed before preoperative visit with potentially serious or even fatal perioperative complications. Complications are usually due to unanticipated difficult airway, aspiration, increased sensitivity to anesthetics, and complications due to multiple concomitant cardiovascular and cerebrovascular diseases, and postoperative delirium. Recognizing the symptoms of obstructive sleep apnea prior to surgery allows timely anesthesia planning, choice of appropriate anesthesia technique and perioperative monitoring, which is particularly important in daily surgery patients. Assessment of the quality of sleep, risk factors for disorders of breathing during sleep and excessive daytime sleepiness and the use of questionnaires allows easy, cheap, and reliable early detection of OSA in surgical patients. Perioperative complications can be reduced by the implementation of anesthetic protocols and strategies for reducing risks in patients with OSA. Further improvements of protocols should be evidence based

The Effect of Propofol and Fentanyl as Compared with Sevoflurane on Postoperative Vomiting in Children after Adenotonsillectomy

Postoperative vomiting (PV) after adenotonsillectomy in children is a common problem with an incidence as high as 40–80%. Only few studies in the recent literature compared the effect of different anesthetic techniques concerning PV in children. The aim of this study was to compare the incidence of PV in two groups of children who underwent two different general anesthesia techniques in order to determine what type of anesthetic technique is more related to less PV. The clinical trial included 50 children (physical status ASA I, 3–12 years old) divided into 2 groups and monitored for PV 24 hours following the surgery. Group one (G1) consisted of 25 children who underwent general anesthesia with gas mixture 60% nitrous oxide and 40% oxygen and anesthetic propofol, opioid fentanyl and muscle relaxant vecuronium intravenously and group two (G2) included 25 children to whom volatile anesthesia with sevoflurane in the same gas mixture was given. Demographic characteristics (gender, age, weight, history of motion sickness and earlier PV) as well as surgical data (length of surgery and anesthesia, intraoperative blood loss) were recorded. There were no significant differences considering demographic characteristics and surgical data between the investigated groups. The incidence of PV was relatively low 3 children (12%) in G1 group and 5 children (20%) in G2 group. Statistically there was no significant difference between the groups regarding the incidence of PV and both anesthetic techniques can be used equally safe regarded to PV

Obstructive sleep apnea and anesthesia - Time to wake up !

Opstrukcijska apneja tijekom spavanja, (OSA, engl. obstructive sleep apnea) najčešći je poremećaj disanja pri spavanju, okarakteriziran učestalim kolapsom gornjih dišnih putova uslijed smanjenog mišićnog tonusa ždrijela i izraženog negativnog intratorakalnog tlaka prilikom pojačanog respiratornog napora pri udahu, što biva popraćeno epizodama desaturacije arterijske krvi kisikom, hiperkarbijom i kratkotrajnim buđenjima uz pojavu glasnoga hrkanja. Klinički znakovi i anatomska obilježja koja upućuju na sindrom opstrukcijske apneje su glasno hrkanje, zamijećen prestanak disanja tijekom spavanja, abdominalni tip debljine i zadebljali vrat, te poremećena anatomija ždrijela. Klinički simptomi očituju se najčešće u neobjašnjivo pretjeranoj dnevnoj pospanosti, kardiopulmonalnim poremećajima i kognitivnoj disfunkciji. Prije dolaska na anesteziološki pregled većina bolesnika s opstrukcijskom apnejom nije prethodno klinički dijagnosticirana, što ima za posljedicu znatno povećanje rizika perioperativnih komplikacija i iznenadne smrti. Mogu se očekivati komplikacije zbog otežane uspostave i održavanja dišnoga puta, povećanog rizika aspiracije želučanoga soka, povećane osjetljivosti na primjenu anestezijskih lijekova, komplikacije povezane s čestim popratnim kardiovaskularnim i cerebrovaskularnim bolestima, uzročno povezanih s apnejom, te poslijeoperativni delirij. Prepoznavanje simptoma opstrukcijske apneje prije kirurškoga zahvata omogućava anesteziološkom timu planiranje odgovarajuće pripreme i načina vođenja anestezije, te perioperativnog nadzora bolesnika, što je osobito naglašeno u sve više zastupljenoj dnevnoj kirurgiji. Procjena kvalitete spavanja, kao i čimbenika rizika za poremećaje disanja pri spavanju i prekomjerne dnevne pospanosti, pomoću upitnika omogućuje jednostavno, jeftino i pouzdano otkrivanje opstrukcijske apneje tijekom spavanja kod kirurškog bolesnika. Perioperativne komplikacije moguće je smanjiti primjenom anestezioloških protokola i strategija za smanjenje povećanog operacijskoga rizika ovih bolesnika i njihovom daljnjom nadopunom na temelju znanstvenih dokaza.Obstructive sleep apnea (OSA) is the most common breathing sleep disorder characterized by collapse of the upper airway which is caused by reduced pharyngeal muscle tone and exaggerated negative intrathoracic pressure during respiratory effort on breathing. It is accompanied by episodes of arterial blood desaturation, hypercarbia and recurrent awakenings from sleep and loud snoring. Clinical signs and anatomical characteristics that indicate OSA are loud snoring, witnessed abnormal cessation of breathing during sleep, abdominal type of obesity, thickened neck and abnormal anatomy of the pharynx. Clinical symptoms of the obstructive sleep apnea is most commonly manifested as unexplained excessive daytime sleepiness, cardiopulmonary disorders and cortical dysfunction. The majority of patients with obstructive sleep apnea are not diagnosed before preoperative visit with potentially serious or even fatal perioperative complications. Complications are usually due to unanticipated difficult airway, aspiration, increased sensitivity to anesthetics, and complications due to multiple concomitant cardiovascular and cerebrovascular diseases, and postoperative delirium. Recognizing the symptoms of obstructive sleep apnea prior to surgery allows timely anesthesia planning, choice of appropriate anesthesia technique and perioperative monitoring, which is particularly important in daily surgery patients. Assessment of the quality of sleep, risk factors for disorders of breathing during sleep and excessive daytime sleepiness and the use of questionnaires allows easy, cheap, and reliable early detection of OSA in surgical patients. Perioperative complications can be reduced by the implementation of anesthetic protocols and strategies for reducing risks in patients with OSA. Further improvements of protocols should be evidence based

Jednodnevna očna kirurgija i antikoagulantna terapija - noviji pristupi

One of the most common surgeries in elderly patients is eye surgery. An increasing number of patients undergoing ambulatory eye surgery are on antithrombotic therapy. These drugs may increase the risk of perioperative bleeding associated with ophthalmic needle blocks and/or eye surgery. Intraoperative bleeding and postoperative hemorrhagic complications may lead to the loss of vision or even eyes. On the other hand, stopping anticoagulants and antiplatelets before the surgery may increase the risk of thrombotic events with potentially life-threatening complications. The aim of this narrative review is to provide a systematic review of the published evidence for the perioperative antithrombotic management of patients undergoing different types of eye surgery in ambulatory settings. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from January 2015 to December 2018 was performed. The database searches included studies providing evidence relevant to ambulatory eye surgery and perioperative antiplatelet medications and anticoagulants. Updated recommendations will be given for continuation, discontinuation, and modification of antithrombotic agents in order to optimize the management of antithrombotic therapies in outpatients scheduled for eye surgery.U populaciji bolesnika starije dobi očni kirurški zahvati su jedni od najčešćih kirurških zahvata. Sve više bolesnika kojima je potreban kirurški zahvat na očima su starije dobi i većinom su na kroničnoj terapiji lijekovima uključujući antitrombocitne lijekove. Ti lijekovi mogu povećati rizik od perioperacijskog krvarenja prilikom izvođenja regionalnih očnih blokova ili kirurškog zahvata. Krvarenje tijekom operacije oka i hemoragijske komplikacije poslije zahvata mogu dovesti do gubitka vidne funkcije ili čak samog oka. S druge strane, prekidanje uzimanja antitrombocitnih i antikoagulacijskih lijekova prije kirurškog zahvata dovodi do povećanog rizika za nastanak ozbiljnih i za život opasnih tromboembolijskih komplikacija. Cilj ovoga narativnog preglednog članka je sustavni pregled objavljenih dokaza o perioperacijskom antitrombotskom liječenju očnih bolesnika planiranih za različite zahvate u dnevnoj očnoj kirurgiji. Pretražene su baze medicinskih podataka pomoću PubMed, Ovid Medline® i Google Scholar za razdoblje od siječnja 2015. godine do prosinca 2018. godine. Obuhvaćene su studije relevantne za planirane očne operacije u jednodnevnoj kirurgiji i perioperacijsko liječenje antitrombocitnim i antikoagulacijskim lijekovima s naglaskom na sadašnje stavove u pogledu nastavka, prekida ili modifikacije antitrombotske terapije kako bi se pospješila priprema bolesnika za očne zahvate

Nausea and vomiting - the "big little problem" during recovery after anesthesia

Poslijeoperativna mučnina i povraćanje česte su i vrlo neugodne nuspojave u bolesnika nakon primjene anestezije. Unatoč primjeni modernih anestetika i minimalno invazivnih kirurških tehnika, učestalost ove nuspojave još uvijek je velika, te iznosi i do 30% kada se koristi antiemetska profilaksa. Ukoliko nema antiemetske zaštite može biti čak i do 80%. Etiološki, poslijeoperativna mučnina i povraćanje uzrokovane su brojnim čimbenicima koji mogu proizlaziti iz određenih karakteristika i sklonosti pacijenta, anestezioloških lijekova, te vrste operacije i kirurške tehnike. Procjena čimbenika povećanog rizika za nastanak poslijeoperativne mučnine i povraćanja pomaže anesteziolozima u odabiru najprikladnije antiemetske zaštite. Terapijski postupci kod poslijeoperativne mučnine i povraćanja obuhvaćaju procjenu bolesnikovog rizika za njihov nastanak, strategiju smanjenja osnovnog rizika, primjenu antiemetske zaštite kod bolesnika s umjerenim i visokim rizikom, te tretiranje mučnine i povraćanja nakon neuspješne antiemetske zaštite. Osnovni rizik svakog pojedinog bolesnika potrebno je objektivno procijeniti pomoću validiranog bodovnog zbroja koji sadrži nekoliko prediktora. Predviđanje nastanka poslijeoperativne mučnine i povraćanja pomoću prediktivnih modela ima umjerenu pouzdanost. Danas poznati modeli predviđanja za nastanak poslijeoperativne mučnine i povraćanja imaju praktičnu vrijednost za stupnjevanje rizika, no osuvremenjen individualni pristup pojedinom bolesniku potreban je za utvrđivanje klinički važne poslijeoperativne mučnine i povraćanja. Kliničko iskustvo anesteziologa i poznavanje pouzdanosti i sigurnosti farmakoloških i nefarmakoloških antiemetskih metoda može poboljšati zadovoljstvo bolesnika, ujedno smanjujući poslijeoperativni pobol i troškove liječenja. Nova istraživanja o ulozi gena u individualnom odgovoru bolesnika na antiemetske lijekove može pomoći kliničarima u oblikovanju terapije poslijeoperativne mučnine i povraćanja prilagođene svakom pojedinom kirurškom bolesniku.Postoperative nausea and vomiting (PONV) are the most common and very unpleasant side effects after general anesthesia. Despite modern anesthetics and non-invasive surgical techniques, the overall incidence still remains high. It is about 30% even with PONV prophylaxis, but can go as high as 80% without prophylaxis. The etiology of PONV is complex and has a multifactorial cause, including patients, anesthetic and surgical risk factors. An assessment of the PONV risk factors helps anesthesiologists to use appropriate antiemetic prophylaxis. The management of PONV includes a strategy for reducing baseline risks, administration of antiemetic prophylaxis for moderate and high risk patients, and rescue treatment if PONV prophylaxis failed. The patient‘s baseline risk should be objectively assessed using a validated risk score with known predictors. The incidence of PONV predicted by predictive models has moderate accuracy. Althoughcurrent predictive models for PONV are practical tools in PONV risk stratification, a more individual approach to each patient is needed to identify patients with more severe PONV. Anesthesiologists\u27 clinical experience and knowledge on the efficacy and safety of pharmacological and non-pharmacological antiemetic methods improve a patient satisfaction, while reducing postoperative morbidity and medical costs. New research on the role of genes in the response to antiemetic agents suggests that PONV prophylaxis and treatment could be tailored for each patient individually

Nausea and vomiting - the "big little problem" during recovery after anesthesia

Poslijeoperativna mučnina i povraćanje česte su i vrlo neugodne nuspojave u bolesnika nakon primjene anestezije. Unatoč primjeni modernih anestetika i minimalno invazivnih kirurških tehnika, učestalost ove nuspojave još uvijek je velika, te iznosi i do 30% kada se koristi antiemetska profilaksa. Ukoliko nema antiemetske zaštite može biti čak i do 80%. Etiološki, poslijeoperativna mučnina i povraćanje uzrokovane su brojnim čimbenicima koji mogu proizlaziti iz određenih karakteristika i sklonosti pacijenta, anestezioloških lijekova, te vrste operacije i kirurške tehnike. Procjena čimbenika povećanog rizika za nastanak poslijeoperativne mučnine i povraćanja pomaže anesteziolozima u odabiru najprikladnije antiemetske zaštite. Terapijski postupci kod poslijeoperativne mučnine i povraćanja obuhvaćaju procjenu bolesnikovog rizika za njihov nastanak, strategiju smanjenja osnovnog rizika, primjenu antiemetske zaštite kod bolesnika s umjerenim i visokim rizikom, te tretiranje mučnine i povraćanja nakon neuspješne antiemetske zaštite. Osnovni rizik svakog pojedinog bolesnika potrebno je objektivno procijeniti pomoću validiranog bodovnog zbroja koji sadrži nekoliko prediktora. Predviđanje nastanka poslijeoperativne mučnine i povraćanja pomoću prediktivnih modela ima umjerenu pouzdanost. Danas poznati modeli predviđanja za nastanak poslijeoperativne mučnine i povraćanja imaju praktičnu vrijednost za stupnjevanje rizika, no osuvremenjen individualni pristup pojedinom bolesniku potreban je za utvrđivanje klinički važne poslijeoperativne mučnine i povraćanja. Kliničko iskustvo anesteziologa i poznavanje pouzdanosti i sigurnosti farmakoloških i nefarmakoloških antiemetskih metoda može poboljšati zadovoljstvo bolesnika, ujedno smanjujući poslijeoperativni pobol i troškove liječenja. Nova istraživanja o ulozi gena u individualnom odgovoru bolesnika na antiemetske lijekove može pomoći kliničarima u oblikovanju terapije poslijeoperativne mučnine i povraćanja prilagođene svakom pojedinom kirurškom bolesniku.Postoperative nausea and vomiting (PONV) are the most common and very unpleasant side effects after general anesthesia. Despite modern anesthetics and non-invasive surgical techniques, the overall incidence still remains high. It is about 30% even with PONV prophylaxis, but can go as high as 80% without prophylaxis. The etiology of PONV is complex and has a multifactorial cause, including patients, anesthetic and surgical risk factors. An assessment of the PONV risk factors helps anesthesiologists to use appropriate antiemetic prophylaxis. The management of PONV includes a strategy for reducing baseline risks, administration of antiemetic prophylaxis for moderate and high risk patients, and rescue treatment if PONV prophylaxis failed. The patient‘s baseline risk should be objectively assessed using a validated risk score with known predictors. The incidence of PONV predicted by predictive models has moderate accuracy. Althoughcurrent predictive models for PONV are practical tools in PONV risk stratification, a more individual approach to each patient is needed to identify patients with more severe PONV. Anesthesiologists\u27 clinical experience and knowledge on the efficacy and safety of pharmacological and non-pharmacological antiemetic methods improve a patient satisfaction, while reducing postoperative morbidity and medical costs. New research on the role of genes in the response to antiemetic agents suggests that PONV prophylaxis and treatment could be tailored for each patient individually

Lokalni anestetici i steroidi: kontraindikacije i komplikacije - trenutni klinički pregled

The objective of this clinical update, based on recently published literature, was to discuss incidence and characteristics of the most relevant clinical adverse effects associated with local anesthetic and steroid use in regional anesthesia and treatment of acute or chronic pain. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from 2015 to 2018 was performed. This narrative review provides anesthesia practitioners with updated evidences on complications and contraindications of local anesthetic and steroid use with emphasis on current points of view regarding prevention, early diagnosis and treatment of adverse events.Cilj rada je analizirati učestalost i karakteristike klinički važnijih nusučinaka lokalnih anestetika i kortikosteroida u regionalnoj anesteziji te liječenju akutne i kronične boli temeljem medicinske literature objavljene unatrag pet godina. Pretražene su baze medicinskih podataka na engleskom jeziku pomoću PubMed, Ovid Medline®i Google Scholara za razdoblje od početka 2015. do kraja 2018. godine. Ovaj narativni pregledni članak donosi pregled komplikacija i kontraindikacija za lokalne anestetike i kortikosteroide s naglaskom na sadašnje stavove u pogledu prevencije, rane dijagnoze i liječenja nuspojava

Extracorporeal membrane oxygenation in the treatment of acute respiratory distress syndrome – results of the Croatian Referral Center for Respiratory Extracorporeal Membrane Oxygenation (ECMO)

U jesen 2009. godine krenula je pandemija influence uzrokovana H1N1 virusom. Novi virus gripe uzrokovao je tešku primarnu pneumoniju s posljedičnim akutnim respiratornim distres sindromom (ARDS). Težina bolesti je bila takva da konvencionalna mehanička ventilacija često nije bila dostatna za oksigenaciju organizma. U takvoj situaciji je Zavod za intenzivnu medicinu i neuroinfektologiju Klinike za infektivne bolesti \u27\u27Dr. Fran Mihaljević\u27\u27 u Zagrebu bio prisiljen uvesti terapiju izvantjelesnom oksigenacijom. Nakon višegodišnjeg iskustva u listopadu 2013. godine, Zavod je postao Referentni centar Ministarstva zdravlja RH za izvantjelesnu oksigenaciju akutno respiratorno ugroženih bolesnika. Posljedično tomu, danas bolesnici oboljeli od najtežeg oblika ARDS-a u Hrvatskoj imaju dodatnu terapijsku opciju i šansu za preživljenje, bez obzira na etiologiju samog ARDS-a.During the fall of 2009 H1N1 influenza pandemic hit the world. This new virus caused severe influenza pneumonia with acute respiratory distress syndrome (ARDS) in significant portion of patients. Conventional mechanical ventilation frequently failed to achieve adequate oxygenation in these patients. In those circumstances, the Department for Intensive Care Medicine and Neuroinfectology of the "Dr. Fran Mihaljević" University Hospital for Infectious Diseases in Zagreb, Croatia started using extracorporeal membrane oxygenation (ECMO) treatment. After acquired experience, in 2013 the aforementioned Department became the Croatian Referral Centar for Respiratory ECMO. Consequently, today the patients with the most severe form of ARDS in Croatia have a new treatment option and improved chance for survival regardless of the ARDS etiology

Effects of high intraoperative inspired oxygen on postoperative nausea and vomiting in gynecologic laparoscopic surgery

Study objective: To assess the efficacy of intraoperative different inspired oxygen fractions (FIO2) of 0.8 and 0.5 when compared with standard FIO2 0.3 in prevention of postoperative nausea and vomiting (PONV). Design: A prospective, controlled, randomized, double-blind study. Setting: General hospital, postanesthesia care unit (PACU) and gynecologic floor room. Patients: 120 ASA physical status I and II women, aged 21 to 76 y, undergoing elective gynecologic laparoscopic surgery. Interventions: Patients were randomized to receive gas mixture of 30% oxygen in air (FI O2=0.3, group G30), 50% oxygen in air (FIO2=0.5, group G50) or 80% oxygen in air (FIO2=0.8, group G80), n=36 in each group. A standardized sevoflurane general anesthesia, postoperative pain management and antiemetic regimen were used. Measurements: The incidence of nausea, vomiting or both was assessed for early (0-2h) and late PONV (2-24h) along with the use of rescue antiemetic, degree of nausea and severity of pain. Main results: There was no overall difference in the incidence of PONV at early and late assessment periods among the three groups. Patients in G80 had significantly less vomiting than G30 at 2 hours, 3% (1/36) vs. 22% (8/36), respectively, P=0.028. Nausea scores, rescue antiemetic use, pain scores and opioid consumption were not different among the groups. Conclusion: High intraoperative FIO2 of 0.8 and FIO2 of 0.5 does not prevent PONV in patients without antiemetic prophylaxis. Intraoperative FIO2 of 0.8 has beneficial effect on early vomiting only