Ramosetron, dexamethasone, and their combination for the prevention of postoperative nausea and vomiting in women undergoing laparoscopic cholecystectomy

What is the impact of dexamethasone on postoperative pain in adults undergoing general anaesthesia for elective abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Previous meta-analysis of heterogeneous surgical cohorts demonstrated reduction in postoperative pain with perioperative intravenous dexamethasone, but none have addressed adults undergoing elective abdominal surgery. The aim of this study was to determine the impact of intravenous perioperative dexamethasone on postoperative pain in adults undergoing elective abdominal surgery under general anaesthesia.

METHODS

This review was prospectively registered on the international prospective register of systematic reviews (CRD42020176202). Electronic databases Medical Analysis and Retrieval System Online (MEDLINE), Exerpta Medica Database (EMBASE), (CINAHL) Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and trial registries were searched to January 28 2021 for randomised controlled trials, comparing dexamethasone to placebo or alternative antiemetic, that reported pain. The primary outcome was pain score, and secondary outcomes were time to first analgesia, opioid requirements and time to post-anaesthesia care unit (PACU) discharge.

RESULTS

Fifty-two studies (5768 participants) were included in the meta-analysis. Pain scores ≤ 4 hour (h) were reduced in patients who received dexamethasone at rest (mean difference (MD), - 0.54, 95% confidence interval (CI) - 0.72 to - 0.35, I2 = 81%) and on movement (MD - 0.42, 95% CI - 0.62 to - 0.22, I2 = 35). In the dexamethasone group, 4-24 h pain scores were less at rest (MD - 0.31, 95% CI - 0.47 to - 0.14, I2 = 96) and on movement (MD - 0.26, 95% CI - 0.39 to - 0.13, I2 = 29) and pain scores ≥ 24 h were reduced at rest (MD - 0.38, 95% CI - 0.52 to - 0.24, I2 = 88) and on movement (MD - 0.38, 95% CI - 0.65 to - 0.11, I2 = 71). Time to first analgesia (minutes) was increased (MD 22.92, 95% CI 11.09 to 34.75, I2 = 98), opioid requirements (mg oral morphine) decreased (MD - 6.66, 95% CI - 9.38 to - 3.93, I2 = 88) and no difference in time to PACU discharge (MD - 3.82, 95% CI - 10.87 to 3.23, I2 = 59%).

CONCLUSIONS

Patients receiving dexamethasone had reduced pain scores, postoperative opioid requirements and longer time to first analgesia. Dexamethasone is an effective analgesic adjunct for patients undergoing abdominal surgery.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects.

OBJECTIVES

• To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded.

DATA COLLECTION AND ANALYSIS

A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo.

MAIN RESULTS

We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Antiemetic efficacy of dexmedetomidine versus dexmedetomidine-dexamethasone combination in patients undergoing breast surgery

Objective

To compare the antiemetic efficacy of dexmedetomidine alone versus combined dexmedetomidine–dexamethasone on incidence of postoperative nausea and vomiting (PONV) in patients undergoing breast surgery.

Methods

A total of 149 patients (aged 20–65 years) were assigned to receive normal saline (control group, n = 50), dexmedetomidine 0.5 μg/kg (DEX group, n = 49), or a combination of dexmedetomidine 0.5 μg/kg and dexamethasone 5 mg (dual group, n = 50) at 30 minutes prior to the end of surgery. The primary outcome measure was the incidence of PONV in the post-anesthesia care unit (PACU).

Results

During the first 24 hours after surgery, the incidence of PONV was significantly higher in the control group than in the DEX and dual groups (70% vs. 20% and 12%, respectively), with no intergroup difference observed between the DEX and dual groups. In the PACU, the incidence of PONV differed significantly among the control, DEX, and dual groups (12%, 4%, and 3%, respectively).

Conclusion

Dexmedetomidine alone and in combination with dexamethasone significantly reduced PONV with similar antiemetic efficacies in female patients during the first 24 hours after breast surgery.

Clinical trial registration: ClinicalTrials.gov (NCT 02550795).

Effect of the Dexamethasone-Ondansetron Combination Versus Dexamethasone-Aprepitant Combination to Prevent Postoperative Nausea and Vomiting

Objective

Postoperative nausea and vomiting (PONV) is a common problem associated with general anaesthesia. The incidence can be as high as 80% in high-risk patients. Our primary objective was to compare the efficacy of the combination of dexamethasone-ondansetron and dexamethasone-aprepitant in patients undergoing laparoscopic surgery.

Methods

Seventy 18 to 60 years old patients scheduled for laparoscopic surgery were included in the study. Sixty-seven patients completed the study. Patients in the dexamethasone-aprepitant group (group DA, n=35) received 40 mg of aprepitant orally 1-2 hours before the induction of anaesthesia and 2 mL saline intravenously (iv) within the last 30 minutes of surgery; patients in the dexamethasone-ondansetron group (group DO, n=35) received oral placebo identical to aprepitant 1-2 hours before the induction of anaesthesia and 4 mg ondansetron iv within the last 30 minutes of surgery. All patients received 8 mg dexamethasone iv after the induction of anaesthesia. The primary outcome was a complete response (no postoperative nausea, retching and vomiting and no need for rescue antiemetic); the secondary outcomes were the incidence of nausea, retching, vomiting, the need of rescue antiemetic and opioid consumption within 24 hours after surgery.

Results

A complete response was not significantly different between the groups (group DO: 67%, DA: 69%) at 24 hours (p=0.93). The incidence of PONV and postoperative opioid consumption was similar between the groups.

Conclusion

The study was designed to evaluate whether the combination of dexamethasone-aprepitant is better than the combination of dexamethasone-ondansetron regarding the complete response for PONV in patients undergoing laparoscopic surgery. The results however showed that dexamethasone-aprepitant has not improved the complete response for PONV compared to dexamethasone-ondansetron.

Effect of the Dexamethasone-Ondansetron Combination Versus Dexamethasone-Aprepitant Combination to Prevent Postoperative Nausea and Vomiting

Objective

Postoperative nausea and vomiting (PONV) is a common problem associated with general anaesthesia. The incidence can be as high as 80% in high-risk patients. Our primary objective was to compare the efficacy of the combination of dexamethasone-ondansetron and dexamethasone-aprepitant in patients undergoing laparoscopic surgery.

Methods

Seventy 18 to 60 years old patients scheduled for laparoscopic surgery were included in the study. Sixty-seven patients completed the study. Patients in the dexamethasone-aprepitant group (group DA, n=35) received 40 mg of aprepitant orally 1-2 hours before the induction of anaesthesia and 2 mL saline intravenously (iv) within the last 30 minutes of surgery; patients in the dexamethasone-ondansetron group (group DO, n=35) received oral placebo identical to aprepitant 1-2 hours before the induction of anaesthesia and 4 mg ondansetron iv within the last 30 minutes of surgery. All patients received 8 mg dexamethasone iv after the induction of anaesthesia. The primary outcome was a complete response (no postoperative nausea, retching and vomiting and no need for rescue antiemetic); the secondary outcomes were the incidence of nausea, retching, vomiting, the need of rescue antiemetic and opioid consumption within 24 hours after surgery.

Results

A complete response was not significantly different between the groups (group DO: 67%, DA: 69%) at 24 hours (p=0.93). The incidence of PONV and postoperative opioid consumption was similar between the groups.

Conclusion

The study was designed to evaluate whether the combination of dexamethasone-aprepitant is better than the combination of dexamethasone-ondansetron regarding the complete response for PONV in patients undergoing laparoscopic surgery. The results however showed that dexamethasone-aprepitant has not improved the complete response for PONV compared to dexamethasone-ondansetron.

Continuous administration of ramosetron with patient-controlled analgesia after laparoscopic distal gastrectomy does not delay postoperative bowel function recovery: A prospective, randomized, double-blinded study

BACKGROUND

Currently, 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are indicated to slow gastrointestinal motility in the diarrhea-predominant subtype of irritable bowel syndrome. They are commonly used to prevent or treat postoperative nausea and vomiting (PONV) and opioid-induced nausea and vomiting (OINV). We conducted a prospective, randomized, double-blinded study to investigate whether the continuous administration of ramosetron, a selective 5-HT3 receptor antagonist, for preventing PONV and/or OINV after laparoscopic distal gastrectomy (LDG) might influence bowel function recovery.

METHODS

Patients scheduled to undergo LDG were randomly assigned to 1 of 3 treatment regimens: no prophylactic ramosetron (Group C); ramosetron 0.6 mg added to 2-day intravenous patient-controlled analgesia (IV-PCA) (Group R0.6); and ramosetron 1.2 mg added to 2-day IV-PCA (Group R1.2). Postoperative recovery profiles of bowel function, incidence of postoperative nausea/vomiting and pain, and perioperative data that affected bowel function recovery were evaluated.

RESULTS

Seventy-three patients completed the study protocol. Parameters associated with postoperative recovery of bowel function, such as time to first flatus, time to first bowel movement, time to first defecation, and time to commencement of soft diet, were not significantly different between the 3 groups. The incidence of nausea 2 to 24 hours after surgery was significantly lower in Group R0.6 (20.0%) and Group R1.2 (12.5%) than in Group C (45.8%) (P < .022). The ratio of complete response 2 to 24 hours after surgery was significantly higher in Group R0.6 (80.0%) and Group R1.2 (87.5%) than in Group C (54.2%) (P < .022). The incidence of retching 24 to 48 hours after surgery was significantly lower in Group R0.6 (0.0%) and Group R1.2 (4.2%) than in Group C (16.7%) (P < .043).

CONCLUSION

Continuous administration of ramosetron with patient-controlled analgesia to prevent PONV and OINV after LDG did not delay postoperative bowel function recovery.

Intravenous palonosetron compared with a combination of ramosetron and dexamethasone in preventing post operative nausea and vomiting in patients undergoing gynaecological surgeries under spinal anaesthesia, a randomised study

Background and Aims:

Post-operative nausea and vomiting (PONV) is one of the most common complications in patients undergoing gynaecological surgeries under spinal anaesthesia (SA). Palonosetron has the unique property of controlling 'delayed chemotherapy-induced nausea and vomiting' when compared to older serotonin antagonists. This study compared the effectiveness of palonosetron with a combination of ramosetron and dexamethasone in preventing PONV.

Methods:

Sixty patients undergoing gynaecological surgeries under SA were randomly allocated into two groups of thirty each, to receive either a combination of 0.3 mg of ramosetron and 8 mg of dexamethasone intravenously (IV) (Group RD) or 0.075 mg of palonosetron IV (Group P). The incidence of PONV, number of complete responders (no nausea, vomiting or use of rescue anti-emetics) and severity of nausea were evaluated during intra- and post-operative period.

Results:

The incidence of complete responders during intraoperative period was 80.0% in Group RD and 76.7% in Group P (P = 0.074) whereas postoperatively at 0–2 h and 2–6 h, it was 73.3% and 83.3% in Group RD respectively as compared to 46.6% and 56.6% in Group P respectively (P = 0.016 and P = 0.024). The incidence of PONV during 24 h of post-operative period was 30.00% in Group RD as compared to 60.00% in Group P (P = 0.0195). Nausea severity score and use of rescue anti-emetics did not vary between the groups.

Conclusion:

Combination of ramosetron and dexamethasone is more effective than palonosetron alone in preventing PONV in patients undergoing gynaecological surgeries under SA.

5HT3 Antagonists versus Dexamethasone in the Prevention of PONV in Patients Undergoing Laparoscopic Cholecystectomy: A Meta-Analysis of RCTs

Background. 5HT3 antagonist, an antiemetic alternative to dexamethasone, is an effective drug for the prevention of postoperative nausea and vomiting (PONV). Methods. PubMed and The Cochrane Library (from inception to June 2016) were searched for relevant RCTs (randomized controlled trials). Results. Seven trials, totaling 682 patients, were included in this meta-analysis. This meta-analysis demonstrated that 5HT3 antagonist was as effective as dexamethasone in preventing PONV (RR, 1.12; 95% CI, [0.86, 1.45]; P = 0.40) within 24 hours of laparoscopic cholecystectomy, and no significant heterogeneity was observed among the studies (I² = 0%; P = 0.98). During the early postoperative period (0-6 h), 5HT3 antagonists were superior to dexamethasone in reducing POV (RR, 0.31; 95% CI, [0.11, 0.93]; P = 0.04), while, in other postoperative stages (6-12 h, 12-24 h, and 0-24 h), it was not more effective in the prevention of POV than dexamethasone. And no significant difference was found in the prevention of PON between 5HT3 antagonists and dexamethasone at different postoperative periods (0-6 h, 6-12 h, 12-24 h, and 0-24 h). Conclusions. As a result, it is advisable to encourage 5HT3 antagonists as an alternative to dexamethasone for the prevention of PONV in patients undergoing laparoscopic cholecystectomy.

Dexamethasone combined with other antiemetics versus single antiemetics for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: An updated systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis of published randomized controlled trials was performed to update the present evidence about the safety and efficacy of dexamethasone combined with other antiemetics versus single antiemetics for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy.

METHODS

A computer literature search of PubMed, Scopus, Web of Science and Embase was conducted to identify the relevant randomized controlled trials. In addition, a manual search of reference lists of the retrieved articles was conducted. Relevant outcomes were pooled as odds ratio (OR) by RevMan version 5.3 for windows.

RESULTS

Pooled data from 14 RCTs (1542 patients) favored dexamethasone combined with other antiemetics over single antiemetics as a prophylaxis against postoperative nausea and vomiting after laparoscopic cholecystectomy in the early postoperative period (OR = 0.39, 95% CI [0.27 to 0.54], p < 0.00001), late postoperative period (OR = 0.36, 95% CI [0.23 to 0.56], p < 0.00001), and overall postoperative period (OR = 0.34, 95% CI [0.23 to 0.51], p < 0.00001). Subsequently, rescue antiemetic usage was significantly lower in the combination group (OR = 0.25, 95% CI [0.16 to 0.41], p < 0.00001). Subgroup analysis showed that all combinations of dexamethasone and other antiemetics were superior to corresponding singel antiemetics except for the combination of dexamethasone and ramosetron which was not superior to ramosetron alone in all postoperative periods and the combination of dexamethasone and granisetron which was not superior to granisetron alone in the early postoperative period (OR = 0.26, 95% CI [0.07 to 1.01], p = 0.05). For all adverse events, there was no significant difference between the two groups.

CONCLUSION

Dexamethasone combined with other antiemetics provided better prophylaxis than single antiemetics against postoperative nausea and vomiting after laparoscopic cholecystectomy. The underlying mechanism of dexamethasone action and its optimal dose should be further investigated.

Effect of Palonosetron, Dexamethasone, or Palonosetron and Dexamethasone in Postoperative Nausea and Vomiting in Highly Susceptible Thyroidectomy Patients: A Randomized Trial

Our study aimed to compare the efficacy of dexamethasone added to palonosetron to both palonosetron and dexamethasone monotherapy for preventing postoperative nausea and vomiting in highly susceptible patients receiving opioid-based, intravenous patient-controlled analgesia after thyroidectomy. Nonsmoking women who underwent total thyroidectomy were randomly allocated to either the dexamethasone group (Group D), the palonosetron group (Group P), or to the dexamethasone plus palonosetron group (Group DP). The severity of nausea and pain, the number of episodes of vomiting, the administrations of rescue anti-emetics, and the side effects of the antiemetics were documented in the recovery room at 2, 4, 8, 12, 24, and 48 hours after surgery. The severity of nausea was lowest in Group DP, followed by Group P and Group D. But there was an overall difference only between Group D and Group DP. The overall differences in the time to the first administration of the rescue antiemetic were observed in a Kaplan-Meier analysis (P = 0.017), noting a significant difference between Group D and Group DP (P = 0.003). The combination of dexamethasone and palonosetron decreased the severity of nausea and increased the time to the first antiemetic dose compared with using dexamethasone or palonosetron alone in nausea-susceptible patients undergoing thyroidectomy.

Comparison of ramosetron plus dexamethasone with ramosetron alone on postoperative nausea, vomiting, shivering and pain after thyroid surgery

BACKGROUND

Postoperative nausea and vomiting (PONV), postanesthetic shivering and pain are common postoperative patient complaints that can result in adverse physical and psychological outcomes. Some antiemetics are reported to be effective in the management of postoperative pain and shivering, as well as PONV. We evaluated the efficacy of dexamethasone added to ramosetron on PONV, shivering and pain after thyroid surgery.

METHODS

One hundred and eight patients scheduled for thyroid surgery were randomly allocated to three different groups: the control group (group C, n = 36), the ramosetron group (group R, n = 36), or the ramosetron plus dexamethasone group (group RD, n = 36). The patients were treated intravenously with 1 and 2 ml of 0.9% NaCl (group C); or 2 ml of 0.15 mg/ml ramosetron plus 1 ml of 0.9% NaCl (group R); or 2 ml of 0.15 mg/ml ramosetron plus 1 ml of 5 mg/ml dexamethasone (group RD) immediately after anesthesia.

RESULTS

Incidence of nausea and the need for rescue antiemetics, verbal rating scale (VRS) 1 hour pain value, ketorolac consumption, and incidence of shivering were significantly lower in group R and group RD, than in group C (P < 0.05). Moreover, these parameters were significantly lower in group RD than in group R (P < 0.05).

CONCLUSIONS

Combination of ramosetron and dexamethasone significantly reduced not only the incidence of nausea and need for rescue antiemetics, but also the VRS 1 hour pain value, ketorolac consumption, and the incidence of shivering compared to ramosetron alone in patients undergoing thyroid surgery.

Ramosetron, midazolam, and combination of ramosetron and midazolam for prevention of postoperative nausea and vomiting: A prospective, randomized, double-blind study

Objective

To compare the efficacy of ramosetron, midazolam, and the combination of ramosetron and midazolam in the prevention of postoperative nausea and vomiting (PONV) in female patients undergoing thyroidectomy.

Methods

Patients were randomized to receive 0.3 mg ramosetron (Group R), 75 µg/kg midazolam (Group M) or 0.3 mg ramosetron combined with 75 µg/kg midazolam (Group RM) before the induction of anaesthesia. PONV, use of rescue antiemetics, pain severity and fentanyl consumption were assessed for 24 h after thyroidectomy.

Results

A total of 100 patients were enrolled; 94 patients completed the study. The severity of nausea was statistically significantly reduced at 0–2 h in Group RM compared with Groups R and M, and at 2–6 h in Group RM compared with Group M. The incidence of retching and vomiting was significantly lower at 0–2 h, 2–6 h, 6–12 h in Group RM than in Group M, and lower in Group R than Group M at 6–12 h. The requirement for rescue antiemetics was significantly lower at 0–2 h in group RM than in group M.

Conclusion

The combination therapy of ramosetron and midazolam provided superior antiemetic efficacy compared with midazolam single therapy, but did not show any significant additional benefits compared with ramosetron single therapy.

Reevaluation of the effectiveness of ramosetron for preventing postoperative nausea and vomiting: a systematic review and meta-analysis

BACKGROUND

Ramosetron has been shown to have a very strong effect for preventing postoperative nausea and vomiting (PONV) in previous meta-analyses. However, these previous meta-analyses included a number of studies by Fujii et al. which have now been proven to have been fabricated. In the present meta-analysis, we reevaluated the effectiveness of ramosetron in preventing PONV after excluding Fujii et al.'s randomized controlled trials.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Web of Science. All double-blind randomized controlled trials that tested the efficacy of ramosetron compared with a placebo or other drugs as a control in the prophylaxis of PONV were considered to be eligible. The first postoperative 24 hours were divided into early (0-6 hours) and late (6-24 hours) time periods, and we collected these data separately.

RESULTS

A total of 1372 patients were included in the final analysis. Compared with a placebo, ramosetron reduced the incidence of early postoperative nausea (PON) (relative risk [RR] [95% confidence interval] 0.59 [0.47-0.73]: number needed to treat [NNT] [95% confidence interval] 6.0 [4.3-9.7]), late PON (RR 0.65 [0.49-0.85]: NNT 7.2 [4.6-16.6]), early postoperative vomiting (POV) (RR 0.48 [0.31-0.74]: NNT 14.8 [8.3-70.4]), and late POV (RR 0.50 [0.35-0.73]: NNT 12.3 [7.1-47.6]). Compared with ondansetron, ramosetron reduces early POV (RR 0.50 [0.28-0.90]: NNT 24.1 [10.7-98.0]) and late POV (RR 0.53 [0.34-0.81]: NNT 27.2 [12.0-102.0]) but not PON.

CONCLUSIONS

Ramosetron has a significant effect for preventing PONV compared with a placebo, but less than that reported in previous analyses. Ramosetron also has statistically significant differences in preventing early and late POV compared with ondansetron, but the clinical significance may be questioned because the NNTs are large.

The comparative study to evaluate the effect of palonosetron monotherapy versus palonosetron with dexamethasone combination therapy for prevention of postoperative nausea and vomiting

Background

5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are effective and safe on postoperative nausea and vomiting (PONV). Palonosetron, the newest 5-HT3 antagonist, has potent antiemetic property. We hypothesized that a combination of palonosetron and dexamethasone could more decrease PONV than palonosetron alone.

Methods

Among the patients scheduled to undergo laparoscopic gynecologic surgery, mastoidectomy with tympanoplasty or thyroidectomy under general anesthesia, eighty four female patients with at least two PONV risk factors were enrolled in this study. They were received randomly 0.075 mg palonosetron and 4 mg dexamethasone (group C) or 0.075 mg palonosetron alone (group P). The severity of PONV using Rhodes index and the percentage of complete response during postoperative 24 hours were compared between groups.

Results

The frequency of mild/moderate/great/severe PONV based on Rhodes index were 9.8%/0%/0%/0% and 9.3%/2.3%/2.3%/0% in group P and group C, respectively. Complete response for PONV was observed in 90.2% and 86% of patients in group P and group C, respectively. The overall incidence of PONV in group P and C was 9.8% and 14%, respectively. There was no significant difference between the two groups.

Conclusions

There were no differences between palonosetron monotherapy and combination therapy of palonosetron and dexamethasone in patients with high emetogenic risk.