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Society for Ambulatory Anesthesia

Section Editor: Peter S. A. Glass

Intravenous Dextrose Administration Reduces Postoperative Antiemetic Rescue Treatment Requirements and Postanesthesia Care Unit Length of Stay
Susan Dabu-Bondoc, MD,* Nalini Vadivelu, MD,* Chantelle Shimono, MSN, APRN, Annette English, PharmD, Boonsri Kosarussavadi, MD,* Feng Dai, PhD, Kirk Shelley, MD, PhD,* and Jessica Feinleib, MD, PhD**
BACKGROUND: Postoperative nausea and vomiting (PONV) remains the most common postoperative complication, and causes decreased patient satisfaction, prolonged postoperative hospital stays, and unanticipated admission. There are limited data that indicate that dextrose may reduce nausea and vomiting. In this trial, we attempted to determine whether the rate of PONV can be decreased by postoperative administration of IV dextrose bolus. METHODS: To test the effect of postoperative dextrose administration on PONV rates, we conducted a double-blind, randomized, placebo-controlled trial. We enrolled 62 nondiabetic, ASA class I or II nonsmoking outpatients scheduled for gynecologic laparoscopic and hysteroscopic procedures. Patients were randomized into 2 groups: the treatment group received dextrose 5% in Ringer lactate solution, and the control (placebo) group received Ringer lactate solution given immediately after surgery. All patients underwent a standardized general anesthesia and received 1 dose of antiemetic a half hour before emergence from anesthesia. PONV scores, antiemetic rescue medications, narcotic consumption, and discharge time were recorded in the postanesthesia care unit (PACU) in half-hour intervals. RESULTS: The 2 groups were similar with regard to age, weight, anxiety scores, prior PONV, non per os status, presurgical glucose, anesthetic duration, intraoperative narcotic use, and total weight-based fluid volume received. Postoperative nausea scores were not significantly different in the dextrose group compared with the control group (P > 0.05) after Bonferroni correction for repeated measurements over time. However, patients who received dextrose 5% in Ringer lactate solution consumed less rescue antiemetic medications (ratio mean difference, 0.56; 95% confidence interval, 0.390.82; P = 0.02), and had a shorter length of stay in the PACU (ratio mean difference, 0.80; 95% confidence interval, 0.660.97; P = 0.03) compared with patients in the control group. CONCLUSION: In this trial, postanesthesia IV dextrose administration resulted in improved PONV management as defined by reductions in antiemetic rescue medication requirements and PACU length of stay that are worthy of further study. In light of its ease, low risk, and benefit to patient care and satisfaction, this therapeutic modality could be considered. (Anesth Analg 2012;117:5916)

O
From the *Department of Anesthesiology, Yale School of Medicine, New Haven, CT; PACU Nursing and Acute Pain Service, Yale New Haven Hospital, New Haven, CT; Pharmacy Department, Yale New Haven Hospital, New Haven, CT; and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, **Veterans Administration Medical Health Systems/Yale School of Medicine. Accepted for publication December 1, 2011. The authors declare no conflicts of interest. This report was previously presented at the ASA 2009 Annual Meeting, NewOrleans, LA, October 17-21. Reprints will not be available from the authors. Address correspondence to Susan Dabu-Bondoc, MD, Department of Anesthesiology, Yale New Haven Hospital/Yale School of Medicine, 333 Cedar St., TMP 3, New Haven, CT 06520. Address e-mail to susan.dabubondoc@yale.edu Copyright 2012 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3182458f9e

ccurring in approximately one-third of untreated surgical patients,1,2 postoperative nausea and vomiting (PONV) may result in surgical wound dehiscence, delayed hospital stay, unanticipated hospital admissions, and increased aspiration rates. PONV prevention is therefore important to improve patient safety and medical outcomes, enhance patient satisfaction, and contain medical costs. Risk factors predicting the incidence of PONV include sex, history of PONV, gynecologic (GYN) procedure, nonsmoker, and age younger than 40 years; nonsmoking female patients undergoing GYN procedures have up to 75% risk of experiencing PONV.3-5 Multiple trials leading to an array of pharmacologic therapies targeting the multifactorial causes of PONV6,7 have shown a reduction in its incidence by approximately 20% per therapeutic modality.4 Two other proposed therapies include fluid administration and carbohydrate loading. Although results are
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conflicting, several studies have investigated the use of perioperative fluid therapy and its effect on the incidence of PONV.8-17 A study by Dagher et al.8 showed that administration of crystalloid did not decrease PONV and antiemetic use, whereas that of Haentjens et al.9 demonstrated that intraoperative hydration with colloid solution had a minimal effect on the incidence of PONV when compared with normal saline solution. In a review of perioperative fluid management, Chappell et al.10 concluded, however, that although current evidence lacks strength, IV fluid therapy in liberal doses may reduce PONV in outpatients undergoing minor surgery.10-14 Oral D glucose has been used through the ages for the symptomatic relief of nausea and vomiting but clinical studies show mixed results.18-20 The exact mechanism has not been determined, but has been thought to be due to a direct local action on the wall of the gastrointestinal tract that reduces muscle contraction because of the high osmotic pressure exerted by the simple sugar.19 Lauwick et al.20 examined the effects of oral dextrose loading 2 hours before induction of general anesthesia and reported it to have no effect on the rate of PONV. Cook et al.21 and McCaul et al.14 investigated the use of preoperative IV hydration combined with caloric supplementation; the former authors failed to demonstrate a reduction in PONV incidence in the recovery room, whereas the latter showed an increased incidence. In our surgical suite, there is a practice of administering IV boluses of dextrose 5% in Ringer lactate (D5LR) solution in the postanesthesia care unit (PACU) to decrease PONV. We therefore designed a controlled trial to evaluate whether the postoperative IV administration of dextrose decreases PONV in a patient population that is at highest risk: female, nonsmoking patients undergoing GYN procedures.

METHODS

ASA physical status I or II outpatients, aged 18 to 70 years, scheduled for GYN laparoscopic or hysteroscopic surgery requiring general anesthesia were invited to participate in the study. IRB approval and informed written consent from each participant were obtained. Patients with a history of diabetes mellitus, congestive heart failure, renal insufficiency or failure, or currently receiving steroids or antiemetics, and those who were pregnant, were excluded. In the preoperative holding area, patients demographic data and state anxiety scores were collected. The State Anxiety Index is a widely used and well validated self-report anxiety assessment instrument.22-24 To confirm baseline normoglycemia, preoperative blood glucose levels were obtained during IV placement using a portable glucometer (SureStepFlexx; LifeScan, Johnson & Johnson Co., Milpitas, CA). Participants were randomized into 2 groups: the treatment group received D5LR solution, and the control (placebo) group received Ringer lactate (LR) solution. Randomization was performed using the permuted block method with pharmacy-controlled allocation concealment. In the PACU, the intraoperative fluid solution was discontinued and the randomized fluid was initiated. All patients received 1 L of this fluid over 30 minutes. One dose of antiemetic medication (IV ondansetron 4 mg) was administered to all patients a half hour before emergence. Intervention solution bags were placed in sequentially numbered,

sealed, opaque black plastic bags to conceal group assignment from the subject, the anesthesia provider, and the PACU caregiver. All subjects underwent a standardized oxygen-sevoflurane-vecuronium and opioid general anesthesia. Anesthesia was induced with propofol (1.52 mg/kg), fentanyl (12 g/kg) and vecuronium (0.050.1 mg/kg) to facilitate endotracheal intubation. Anesthesia was maintained with oxygen/air (1:2 L/min) and sevoflurane (11.5 minimum alveolar concentration). IV fentanyl and morphine were administered, in 25-g and 1- to 2-mg dose increments, respectively, depending on the change in the patients heart rate and arterial blood pressure from baseline. All patients received LR solution during pre- and intraoperative periods. On arrival to the PACU, patients nausea levels were assessed using an 11-point verbal rating scale (VRS), from 0 to 10, with 0 representing no nausea and 10 representing the worst nausea ever. Nausea VRS scores were obtained every half hour until discharge from the PACU. Standardized rescue antiemetic medications were administered depending on their VRS scores. Patients received no rescue medication when the VRS score was 0 to 2; 1 dose of rescue medication when the VRS score was 3 to 6; and 2 doses for nausea score of 7 to 10, to reduce the nausea score to 0 to 2. First-line rescue medications included (in the following order of administration) IV dimenhydrinate 25 mg, ondansetron 4 mg, dimenhydrinate 25 mg, and promethazine 12.5 mg. If initial rescue medications failed, patients were then given IV droperidol 0.625 to 1.25 mg, dexamethasone 4 to 8 mg, or were admitted overnight if refractory to treatment. A standardized PACU protocol for pain control was used. Patients pain was rated by a verbal numeric pain rating scale, an 11-point scale from 0 to 10, whereby 0 is no pain, and 10 the most intense pain imaginable. Patients were given no fentanyl when the pain (numeric pain rating scale) score was 0 to 3, 25 g of fentanyl for a pain score of 4 to 6, and 50 g of fentanyl for a pain score of 7 to 10. If patients required >100 g of fentanyl, analgesia was then supplemented with morphine or hydromorphone in increments of 1 to 2 mg or 0.1 to 0.2 mg, respectively, until the pain score decreased to 0 to 3. The end point of treatment was to reduce the pain score to 0 to 3. The total number of doses of antiemetics used, amount of analgesics consumed, and episodes of nausea and/or vomiting were obtained every half hour from time of arrival to the PACU until discharge. To avoid interrater variability, an independent observer-investigator who was blinded to group assignment collected data in the PACU. The primary objective of this study was to compare the incidence of PONV (Yes/No) in the study treatment groups. An a priori power analysis suggested that a sample size of 32 in each group (2 groups) yielding a total size of 64 achieved a power of 0.8 ( = 0.05) to detect a difference of 33.2% in the incidence of PONV assuming a baseline incidence of 65% in patients under similar GYN laparoscopic/ hysteroscopic procedures.25,26 The secondary efficacy measures included measurement of nausea VRS scores, antiemetic medication consumption, and PACU length of stay (LOS). The antiemetic medication consumption was defined as all antiemetic medication

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Table 1. Baseline Characteristics of Participants


Variable Age (yr) Weight (kg) Height (in.) Marital status, married (%) State Anxiety Index Prior surgery, yes (%) History of PONV, yes (%) Preoperative blood glucose Intraoperative opioid (IV mE/kg body weight)a IV fluids in OR (mL/kg/NPO-h) IV fluids total (mL/kg/NPO-h)b Anesthetic duration (min) Estimated blood loss (mL) Surgical procedures Hysteroscopic procedures Laparoscopic procedures Dextrose group (n = 30) 37.9 (10.3) 66.9 (10.8) 63.1 (3.3) 22 (73.3%) 43.5 (11.0) 24 (80.0%) 14 (46.7%) 102.1 (15.3) 0.3 (0.1) 1.4 (0.5) 2.3 (1.82.6) 92.5 (75.0130.0) 10.0 (10.050.0) 13 (43.3%) 17 (56.7%) Control group (n = 32) 37.5 (9.8) 71.2 (16.5) 63.6 (2.8) 27 (84.4%) 42.2 (12.1) 25 (78.1%) 15 (46.9%) 106.4 (16.5) 0.3 (0.2) 1.5 (0.6) 2.2 (1.63.1) 107.5 (79.0150.0) 10.0 (10.050.0) 16 (50.0%) 16 (50.0%) P value 0.88* 0.24* 0.50* 0.33 0.69* 1.00 1.00 0.30* 0.38* 0.73* 0.93 0.47 0.71 0.62

PONV = postoperative nausea and vomiting; OR = operating room; NPO = non per os. a IV opioid (fentanyl, morphine) consumed by subjects in the operating room, all doses converted into IV morphine equivalents (mE) per kilogram (kg) body weight. b Total IV fluids in the operating room plus the postanesthesia care unit. *Mean (SD) of normal variable (Shapiro-Wilk test, P > 0.05) and Welch t test P value are listed. Numbers (%) for categorical variable and Fisher exact test P value are listed. Median (interquartile range) of non-normal variable (Shapiro-Wilk test, P < 0.05) and Wilcoxon rank sum test P value are listed.

doses consumed by each patient for the entire PACU stay. Equivalency of LOS with management of PONV was defined as a discharge time difference of 10% between the 2 groups. Opioid analgesics consumed (fentanyl, morphine, or hydromorphone) were all converted to IV morphine milligram-equivalents. Continuous measurements were assessed for normality of distribution by the Shapiro-Wilk test with the chosen level of P value 0.05. When not normally distributed, data were summarized as a median and interquartile range; otherwise, a mean and standard deviation were given. Normal continuous data were compared by using 2-sample Welch t test (or unequal variance t test) and non-normal continuous data were compared by using Wilcoxon rank sum test. All categorical data were reported as number and percentage and were compared using the Fisher exact test. Percentage difference in categorical data between 2 groups and its 95% confidence interval (CI) were reported as effect size. For all continuous data, as described in recent studies,27-30 we first calculated the logarithm of the ratio R of mean difference between treatment and control groups and its 95% CI, whose values were transformed by exponential function and reported as effect sizes. The logarithm only transforms the distribution of a ratio toward symmetry and no assumption is made of a lognormal distribution. This ratio mean estimate is unit-free and can be pooled together in meta-analysis.29 The relationships between PONV VRS score at different time points and rescue antiemetics or patients LOS were assessed using Spearman rank correlation coefficients. All statistical analyses were performed with the use of SAS 9.2 (SAS Institute, Cary, NC) with original database prepared by the IBM SPSS statistical software (Chicago, IL). All statistical tests were 2-tailed. The Bonferroni procedure was used to adjust P values only where betweengroup comparisons have been made repeatedly over time. P values of <0.05 were considered to indicate statistical

significance, unless otherwise specified. Aside from the cutoff P value, a 95% CI that does not embrace the value of no difference between treatment and control groups (e.g., 1 for ratio R of mean difference) also indicates that the treatment is significantly different from the control at the 5% level. In addition, the CI provides very useful information for the range of observed effect size that helps in assessing clinical significance of research findings.31

RESULTS

Sixty-four patients were enrolled in the study. Two patients were withdrawn after randomization because of extreme anxiety and abnormal blood glucose. Baseline demographic and personality characteristics of the participants are presented in Table 1. According to the results of the Shapiro-Wilk normality test, the variables IV fluids total, anesthetic duration, and estimated blood loss were not normally distributed (P < 0.05), and the variables age, weight, height, state anxiety status, preoperative blood glucose, intraoperative opioid, and IV fluids in the operating room were normally distributed (P > 0.05). The last column of Table 1 lists the P values for categorical variables (Fisher exact test), non-normal variables (Wilcoxon rank sum test), and normal variable (Welch t test). Both groups were similar with regard to age, weight and height, state anxiety, and whether they had previous surgery, or had a history of PONV/motion sickness. Preoperative glucose levels, intraoperative narcotic consumption, total time in surgery, and IV fluids received did not differ between the groups (P value from 0.24 to 1). Both groups were also homogeneous with regard to surgical procedure types P = 0.62). Table 2 presents the results of between-group comparisons of primary and secondary outcomes. No statistical significance was found for a difference of our primary end point, incidence of PONV (Yes/No) between the 2 groups (Fisher exact test, P = 0.22). Fourteen of 30 participants

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Table 2. Postoperative Outcome Data


Variable Nausea, yes (%) Vomiting, yes (%) Vomiting total episodes, n Rescue Rx, yes (%) Rescue Rx (doses)b Opioid PACUc Length of stay (min) VRS scored T0 VRS score T30 VRS score T60 VRS score T90 VRS score T120 VRS score Td Admission because of PONV Dextrose group (n = 30) 14 (46.7%) 4 (13.3%) 5 12 (40.0%) 1 (12) 0.03 (00.06) 148 (52) 0 (00) 0 (00) 0 (00) 0 (00) 0 (02) 0 (00) 0 Control group (n = 32) 20 (62.5%) 4 (12.5%) 11 18 (56.3%) 2 (24) 0.03 (00.09) 184 (74) 0 (00) 0 (04) 0 (03) 0 (03) 0 (03) 0 (02) 0 Difference (95% CI)a 15.8% (43.6, 11.8) 0.8% (16.7, 18.4) 16.3% (44.0, 11.5) 0.56 (0.39, 0.82) 0.64 (0.33, 1.23) 0.80 (0.66, 0.97) 0.57 (0.19, 1.68) 0.32 (0.12, 0.85) 0.51 (0.16, 1.64) 0.41 (0.16, 1.07) 0.72 (0.32, 1.63) 0.19 (0.07, 0.53) P value 0.31* 1* 0.22* 0.02 0.66 0.03 1e 0.48e 0.48e 0.18e 1e 0.18e

CI = confidence interval; Rx = medication; PACU = postanesthesia care unit; VRS = verbal rating scale; PONV = postoperative nausea and vomiting. a Effective size: for categorical variables, percentage difference and its 95% CI; for continuous variables, ratio mean difference and its 95% CI. b Total number of antiemetic rescue medication doses received by patients who required antiemetic treatment. c Total fentanyl, morphine, or hydromorphone received in the PACU, all units converted to IV morphine equivalents/kg. d VRS nausea scores (010); T0 = at time zero or upon arrival in the PACU; T30 = 30 minutes after arrival in the PACU, etc.; Td = at discharge. e Bonferroni-adjusted P value (original P value * 6, rounded to 1.00 if >1.00). *Fisher exact test P value for categorical variables. Numbers (%) are listed in columns 2 and 3. Wilcoxon rank sum test P value for non-normal variables. Median (interquartile range) is listed in columns 2 and 3. Welch t test P value for normal variables. Mean (SD) is listed in columns 2 and 3.

(46.7%) in the D5LR group experienced nausea, versus 20 of 32 participants (62.5%) in the LR group (percentage difference, 15.8%; 95% CI, 43.6% to 11.8%; Fisher exact test, P = 0.31), whereas 4 of 30 participants (13.3%) in the D5LR group experienced vomiting, versus 4 of 32 participants (12.5%) in the LR group (percentage difference, 0.8%; 95% CI, 16.7% to 18.4%; Fisher exact test, P = 1.00). However, of those participants who vomited, there were fewer total episodes in the D5LR group (5 episodes among 4 patients) than those (11 episodes among 4 patients) in the LR group. Twelve of 30 participants (40.0%) in the D5LR group versus 18 of 32 participants (56.3%) in the LR group needed rescue antiemetic (percentage difference,16.3%; 95% CI, 44.0% to 11.5%; Fisher exact test, P = 0.22). Notably, of the patients who required rescue treatment in the PACU, the antiemetic rescue medication dose consumed by patients in the D5LR group was less than that in the LR group (ratio mean difference, 0.56; 95% CI, 0.390.82; Wilcoxon rank sum test, P = 0.02), i.e., dextrose in the treatment group reduced the rescue medication dose by 44%. LOS was determined, and patients in the D5LR group had a modestly shorter stay in the PACU (148 52 minutes) compared with that (184 74 minutes) in patients in the LR group (ratio mean difference, 0.80; 95% CI, 0.660.97; Welch t test, P = 0.03), i.e., a 20% reduction in LOS. Postoperatively, PONV VRS scores were recorded beginning on arrival in the PACU and every 30 minutes thereafter. No statistical significance between the 2 groups was found after Bonferroni correction for repeated measurements of VRS over time (Wilcoxon rank sum test, P 0.18, corrected for tests at 6 time points, Table 2). There were no unplanned admissions because of PONV. We identified a positive correlation between rescue antiemetic dose and PONV VRS scores at different time points (Spearman rank correlation coefficient, > 0.40, P

Figure 1. Scatter plot of log10 length of stay (LOS) and number of rescue medication doses. The loess line is added with a smoothness parameter of 0.6.

< 0.001), between LOS and VRS score from at 60 minutes to at discharge time ( > 0.40, P < 0.001). Specifically at the time of discharge, the correlations between VRS scores and rescue antiemetics, and between VRS scores and LOS, were 0.67 and 0.56, respectively (P < 0.001). A scatter plot of rescue antiemetics and LOS, 2 variables shown to have reduced measurements in the D5LR group, is shown in Figure 1.

DISCUSSION

PONV has many significant effects on both medical outcomes and the final cost for a given procedure. Furthermore, the most common prophylactic modalities are based on treating patients with additional medications, exposing them to more potential side effects. In contrast, treatment of nausea with oral dextrose (Emetrol) has been a well-established remedy associated with very low risk for nondiabetic patients.19

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Pharmacologic PONV treatment comes with financial cost. Our study demonstrates a novel effect of perioperative administration of dextrose-containing fluid in reducing the number of antiemetic doses (44% reduction) required in the PACU in healthy female patients undergoing GYN hysteroscopic and laparoscopic procedures. The sole difference between the LR and D5LR group was the addition of 50 g of dextrose in the fluid bolus. Additionally, time spent by the patient or LOS in the PACU is both onerous to the patient and costly to the careproviding institution. The current study demonstrates a 20% reduction in LOS in patients from the D5LR group compared with those in the LR group. However, whether this reduction would be seen in a nonacademic center is also worth investigating. From our data, we identified positive correlations between PONV VRS scores and rescue antiemetic, or LOS. Although this suggests the high convergent validity of VRS as a tool of rating nausea to other efficacy measures (e.g., rescue antiemetic use, LOS) of dextrose, the choice of a best measure as a primary end point for controlled trials similar to ours is still debatable. For example, we only found the number of antiemetics (a secondary outcome) required to achieve the same VRS score was reduced in the D5LR group. This secondary outcome, despite its importance, is nevertheless not the absolute proof of the dextrose intervention. Nonetheless, there are a few limitations in our study. First, we purposefully selected patients at highest risk for PONV and enrolled only healthy, nondiabetic, nonsmoking female patients undergoing relatively minor hysteroscopic and laparoscopic procedures. Although this produced, albeit with a relatively small study population, certain meaningful reductions in the time to discharge and rescue dosing with our intervention, it, however, was also perhaps a major limitation, that of generalizability. Extrapolating the results of this study to patients with major medical comorbidities, or those who are undergoing major abdominal or thoracic procedures, would be tenuous. Certainly, the implementation of this therapeutic modality in diabetic patients would be questionable. That being said, these data suggest that further study of the effects of dextrose-containing fluid in other nondiabetic populations that are less susceptible to PONV is alluring. A second limitation of this study is its sample size. Our current study produced results that were interesting in terms of PONV incidence reduction but were not significant most likely because of the relatively small number of study subjects. A third limitation of this study is the measurement of a subjects blood glucose only before surgery and not after the completion of IV fluid therapy. Whether the positive effects of dextrose administration on PONV were correlated solely to simple caloric supplementation, or to an otherwise more complex mechanism that such treatment provides, would be beyond the scope of this study and requires further investigation. Finally, we applied Bonferroni correction for multiple testings only for VRS score, which was measured at 6 time points. Our findings on reduced antiemetic rescue medication requirement and LOS in the D5LR group would appear statistically nonsignificant (P > 0.05) if we extend
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the correction to all secondary end points. However, this statistical nonsignificance (by P value) does not necessarily mean clinically as no-effect. CIs of observed differences are much more useful than simple P values in interpreting research findings.30,31 In our study, a ratio mean difference of 0.56 with a 95% CI ranging from 0.39 to 0.82 was observed for antiemetic rescue. Thus, the true reduction may be as much as 61% or as little as 28%, and we are 95% certain that overall antiemetic rescue dose is reduced in the D5LR group. The relatively wide range of this 95% CI is probably attributable to the small sample size of the current study. Similarly, we are 95% certain that the overall LOS was reduced in the D5LR group with the true reduction possibly being as much as 34% or as little as 3%. In summary, under the conditions of this study, perioperative administration of dextrose-containing IV fluids reduced the number of antiemetics required and shortened the LOS in the PACU in healthy female patients undergoing GYN hysteroscopic and laparoscopic procedures. This form of PONV therapy has a low side effect profile, is easily accessible, and is inexpensive. However, further larger studies are required to confirm our results, expand to other patient populations, and to elucidate a mechanism by which dextrose may exert this antiemetic effect. E
DISCLOSURES

Name: Susan Dabu-Bondoc, MD. Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript. Attestation: Susan Dabu-Bondoc has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files. Name: Nalini Vadivelu, MD. Contribution: This author helped write the manuscript and collect the data. Attestation: Nalini Vadivelu has seen the original study data and approved the final manuscript. Name: Chantelle Shimono, MSN, APRN. Contribution: This author helped design the study and write the IRB (HIC) protocol, write the manuscript, and collect the data. Attestation: Chantelle Shimono has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Name: Annette English, PharmD. Contribution: This author helped write the manuscript and perform randomization/group allocation-concealment and preparation of intervention solutions. Attestation: Annette English has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Name: Boonsri Kosarussavadi, MD. Contribution: This author helped with data collection and editing. Attestation: Boonsri Kosarussavadi has seen the original study data and approved the final manuscript. Name: Feng Dai, PhD. Contribution: This author helped analyze the data and edit the manuscript. Attestation: Feng Dai has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

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Name: Kirk Shelley, MD, PhD. Contribution: This author helped design the study and edit the manuscript. Attestation: Kirk Shelley has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Name: Jessica Feinleib, MD, PhD. Contribution: This author helped design the study and prepare IRB (HIC) protocol, analyze the data, and write the manuscript. Attestation: Jessica Feinleib has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. This manuscript was handled by: Peter S. A. Glass, MB, ChB.
ACKNOWLEDGMENTS

We are grateful to all the study participants, nurses, and other staff who made the study possible. We thank our editor and reviewers for their insights and comments that greatly improved the manuscript.
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