Prophylaxis of postoperative nausea and vomiting: controversies in the use of serotonin 5-hydroxytryptamine subtype 3 receptor antagonists

The Effect of Ondansetron on the Analgesic Efficacy of Tramadol in Patients Undergoing Laparoscopic Cholecystectomy

Purpose

Investigating the effect of ondansetron on the efficacy of tramadol in patients undergoing laparoscopic cholecystectomy.

Methods

Sixty American Society of Anesthesiologists (ASA) I-II patients over the age of 18 who underwent laparoscopic cholecystectomy were included in this study. All patients were given 1 mg/kg tramadol intravenously (iv) during the intraoperative period. Patients were randomly assigned to receive either 4 mg ondansetron (Group O) or 2 mL saline (Group S). Postoperative tramadol consumption, pain score (NRS), intensity of nausea (NRS), presence of vomiting, consumption of rescue analgesics and antiemetics, and patient satisfaction were recorded.

Results

A total of 60 patients were enrolled in the study; five patients were excluded due to deviation from the protocol. Data from 55 patients (Group O: 28 patients, Group S: 27 patients) were evaluated in the study. No differences between the two groups were detected for postoperative consumption of tramadol, pain score (NRS), intensity of nausea (NRS), presence of vomiting, consumption of rescue analgesics and antiemetics, and patient satisfaction.

Conclusions

The results showed that coadministration of tramadol and ondansetron did not change tramadol consumption during the postoperative 24 hours after laparoscopic cholecystectomy. Clinical trial registration number is as follows: https://clinicaltrials.gov/ct2/show/NCT04745273-01/31/2021.

Comparison of ondansetron, tropisetron, and palonosetron for the prevention of postoperative nausea and vomiting after middle ear surgery

Background

Postoperative nausea and vomiting (PONV) are 2 of the most frequent adverse effects of anesthesia. PONV prolongs hospital stays and also delays the recovery of patients.

Objective

In this study, the effects of ondansetron, tropisetron, and palonosetron on PONV in patients who had undergone middle ear surgeries such as mastoidectomy or tympanoplasty were compared.

Methods

The study included 165 American Society of Anesthesiologists grade 1 and 2 patients aged 18 to 65 years. Patients were randomized into 3 groups by a closed envelope method. Neither the patients nor the nurses administering the treatments knew which patient belonged to which group. The anesthetic technique was standardized for all groups. During skin closure, 0.075 mg palonosetron, 5 mg tropisetron, and 8 mg ondansetron were administered intravenously to the palonosetron, tropisetron, and ondansetron groups, respectively. After completion of the surgery, the patients were followed for 48 hours. Diclofenac sodium (100 mg IM) was administered to patients experiencing pain and metoclopramide chloride (10 mg IM) was administered to patients with nausea or vomiting. Potential side effects such as headache and constipation were recorded in the postanesthesia care unit and ear, nose, and throat clinic.

Results

There was no significant difference in the effects of all 3 antiemetic agents on the severity of PONV (P = 0.081). At 48 hours postoperatively, the incidence of PONV was significantly lower in the palonosteron group (38.2%) than the ondansetron group (63.6%) and tropisetron group (61.8%) (P = 0.011). At 48 hours postoperatively, the incidence of postoperative nausea was significantly lower in the palonosetron group (32.7%) than in the ondansetron group (63.6%) and the tropisetron group (56.4%) (P = .003). The incidence of PONV between hours 12 and 24 postoperatively was significantly higher in the ondansetron group (27.3%) than in the palonosetron group (9.1%) (P = 0.013). The antiemetic requirement in the first hour after surgery was significantly higher in the tropisetron group (25.5%) than in the palonosetron group (7.3%) (P = .019).

Conclusions

The results of the current study support those of earlier studies that suggest that palonosetron was statistically more effective than the other 2 formulations in the prevention of PONV in patients who have undergone middle ear surgery. (Curr Ther Res Clin Exp. 2019; 80:XXXXXX).

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.

Comparative Pharmacology and Guide to the Use of the Serotonin 5-HT3 Receptor Antagonists for Postoperative Nausea and Vomiting

Since the introduction of the serotonin 5-hydroxy tryptamine 3 (5-HT₃) receptor antagonists in the early 1990s, the incidence of postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) has decreased, yet continues to be a problem for the surgical patient. The clinical application of the 5-HT₃ receptor antagonists has helped define the approach and role of these antiemetics in the prevention and treatment of PONV and PDNV. Pharmacological and clinical differences exist among these medications resulting in corresponding differences in effectiveness, safety, optimal dosage, time of administration, and use as combination and rescue antiemetic therapy. The clinical application of the 5-HT₃ receptor antagonist antiemetics has improved the prevention and treatment of PONV and PDNV. The most recent consensus guidelines for PONV published in 2014 outline the use of these antiemetics. The 5-HT₃ receptor antagonists play an important role to help prevent PONV and PDNV in perioperative care pathways such as Enhanced Recovery After Surgery (ERAS). Comparisons and guidelines for use of the 5-HT₃ receptor antagonists in relation to the risk for PONV and PDNV are reviewed.

Factors associated to post-operative nausea and vomiting following oral and maxillofacial surgery: a prospective study

AIM

This study aims to address and assess possible factors associated with nausea and vomiting (NV) following oral and maxillofacial surgery.

MATERIAL AND METHODS

A prospective study was carried out in the period from December 2013 to January 2016 targeting all attended cases in that period. For statistical analysis, Pearson chi-square and Fisher tests were used to verify association and ANOVA and Student's t tests to test for significant difference, p was defined as ≤0.05. The sample group consisted of 207 patients with an average age of 33.56 years (±13.23), and 70.5% of subjects were male.

RESULTS

Calculations based on the predictive model showed that a female patient with prior history of nausea and vomiting who used opioids and had intra-oral surgical access would have a 96% chance of experiencing a nausea and vomiting episode. Other factors like age, being overweight, anesthesia, surgery duration, and duration of hospital stay also contribute so that these aspects must be paid careful attention prior to surgery to ensure a suitably orientated treatment that will avoid disturbances caused by post-operative nausea and vomiting.

CONCLUSION

The occurrence of post-operative nausea and vomiting after oral and maxillofacial surgery was found to be more higher incidence associated to female patients who used opioids, who had a prior history of NV, whose surgery involved intra-oral access, who were in the second or third decades of their lives, who have above average weight, and who have long anesthesia when undergoing surgery, resulting in a long hospital stays.

Comparison of palanosetron with ondansetron for postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy under general anesthesia

BACKGROUND:

Post-operative nausea and vomiting (PONV) is a ‘big little’ problem especially after laparoscopic surgeries. Palanosetron is a new potent 5 hydroxy tryptamine 3 antagonists. In this randomized double blind clinical study we compared the effects of i.v. ondansetron and palanosetron administered at the end of surgery in preventing post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy under general anesthesia.

MATERIALS AND METHODS:

A total of 100 subjects between 18–60 years with Apfel score ≥2, were randomly assigned into one of the two groups, containing 50 patients each. Group A received ondansetron 4 mg i.v. and Group B received palanosetron 0.07 5mg i.v. both as bolus before induction. The incidence of nausea, retching and vomiting, incidence of total PONV, requirement of rescue antiemetics and adverse effects were evaluated during the first 24 h following end of surgery.

RESULTS:

The incidence of nausea was significantly lower in patients who had received palanosetron (16%) as compared to ondansetron (24%). Need of rescue antiemetics was significantly higher in patients receiving ondansetron (32%) as compared to palanosetron (16%). The incidence of total PONV was also significantly lower in group receiving palanosetron (20%) as compared to ondansetron (50%). Among the side effects, headache was noted significantly higher with ondansetron (20%) as compared to palanosetron (6%).

CONCLUSION:

Palanosetron has got better anti-nausea effect, less need of rescue antiemetics, favourable side effect profile and a decrease in the incidence of total PONV as compared to ondansetron in 24 h post operative period in patients undergoing laproscopic cholecystectomy under general anesthesia.

Anesthetic premedication: new horizons of an old practice

The practice of anesthetic premedication embarked upon soon after ether and chloroform were introduced as general anesthetics in the middle of the 19(th) century. By applying opioids and anticholinergics before surgery, the surgical patients could achieve a less anxious state, and more importantly, they would acquire a smoother course during the tedious and dangerous induction stage. Premedication with opioids and anticholinergics was not a routine practice in the 20(th) century when intravenous anesthetics were primarily used as induction agents that significantly shorten the induction time. The current practice of anesthetic premedication has evolved into a generalized scheme that incorporates several aspects of patient care: decreasing preoperative anxiety, dampening intraoperative noxious stimulus and its associated neuroendocrinological changes, and minimizing postoperative adverse effects of anesthesia and surgery. Rational use of premedication in modern anesthesia practice should be justified by individual needs, the types of surgery, and the anesthetic agents and techniques used. In this article, we will provide our readers with updated information about premedication of surgical patients with a focus on the recent application of second generation serotonin type 3 antagonist, antidepressants, and anticonvulsants.

A randomized, double-blind trial of palonosetron compared with ondansetron in preventing postoperative nausea and vomiting after gynaecological laparoscopic surgery

This randomized, double-blind study evaluated the relative efficacy of palonosetron (a new, selective 5-hydroxytryptamine type 3 [5-HT(3)] receptor antagonist) and ondansetron in preventing postoperative nausea and vomiting (PONV) in patients undergoing gynaecological laparoscopic surgery. Patients received either palonosetron 0.075 mg (n = 45) or ondansetron 8 mg (n = 45), intravenously, immediately before induction of general anaesthesia. The occurrence of nausea and vomiting and the severity of nausea according to a visual analogue scale were monitored immediately after the end of surgery and during the following 24 h. The incidence of PONV was significantly lower in the palonosetron group compared with the ondansetron group (42.2% vs 66.7%, respectively). There were no significant statistical differences in the visual analogue scale for nausea. In conclusion, palonosetron 0.075 mg was more effective than ondansetron 8 mg in preventing PONV.

Palonosetron: A novel approach to control postoperative nausea and vomiting in day care surgery

Background:

Postoperative nausea and vomiting (PONV) is one of the complications which hamper the successful implementation of day care surgical procedure in spite of the availability of so many antiemetic drugs and regimens for its prevention. The aim was to compare the prophylactic effects of intravenously (IV) administered ondansetron and palonosetron on PONV prevention in patients undergoing laparoscopic gynecological surgery under general anesthesia.

Methods:

A prospective double-blind study comprised of 60 ASAI/II female patients between the age group of 25 and 40 years was carried out in the Departments of Anesthesiology and Obstetrics and Gynecology of our institute. Patients were randomly divided into two groups of 30 patients each in a double-blind manner. Group I received 8 mg of inj. ondansetron IV while group II received inj. palonosetron 0.075 mg IV 5 minutes before the induction of anesthesia. The need for rescue antiemetics, episodes of PONV and other side effects were observed for 6 hours in the postanesthesia care unit and thereafter complaints were received on phone after the discharge. At the end of study, results were compiled and statistical data was subjected to statistical analysis using Student two-tailed ‘t’ and χ² test and value of P<0.05 was considered significant.

Results:

The demographical profile of the patients was comparable. Twenty and 13.33% of the patients in group I had nausea and vomiting episodes postoperatively as compared to 6.67% and 3.33%, respectively, in group II which was statistically significant (P<0.05). Twenty percent of the patients in group I experienced significant post-op headache as compared to 6.67% in group II. The mean rescue dose of antiemetic was significantly higher (10.6 mg) in the group I as compared to group II (6.4 mg) (P=0.036). The rest of parameters were comparable and statistically nonsignificant.

Conclusions:

Palonosetron is a comparatively better drug to prevent the PONV in patients undergoing day care surgical procedures as compared to ondansetron as it has got a prolonged duration of action and favorable side-effects profile.

[Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment]

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Española de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.

Comparison of azasetron and ondansetron for preventing postoperative nausea and vomiting in patients undergoing gynecological laparoscopic surgery

PURPOSE

We compared the prophylactic effects of intravenously administered azasetron (10 mg) and ondansetron (8 mg) on postoperative nausea and vomiting (PONV) in patients undergoing gynecological laparoscopic surgery under general anesthesia.

MATERIALS AND METHODS

We studied 98 ASA physical status I or II 20-65 years old, female patients, in this prospective, randomized, double blind study. Patients were randomly divided into two groups and received ondansetron 8 mg (group O) or azasetron 10 mg (group A) 5 min before the end of surgery. The incidence of PONV, Visual Analogue Scale (VAS) for pain, need for rescue antiemetic and analgesics, and adverse effects were checked at 1, 6, 12, 24, and 48 h postoperatively.

RESULTS

The overall incidence of PONV was 65% in group O and 49% in group A. The incidence of PONV was significantly higher in group O than in group A at 12-24 h postoperatively (nausea; 24% vs. 45%, p = 0.035, vomiting; 2% vs. 18%, p = 0.008), but there were no significant differences at 0-1, 1-6, 6-12 or 24-48 h.

CONCLUSION

In conclusion, azasetron (10 mg) produced same incidence of PONV as ondansetron (8 mg) in patients undergoing general anesthesia for gynecological laparoscopic surgery. Azasetron was more effective, in the intermediate post-operative period, between 12 and 24 h.

Antinociceptive and side-effects of hydromorphone after subcutaneous administration in cats

The subcutaneous (SC) route is often chosen for drug administration in cats because it is easier to perform than intravenous (IV) injection and is perceived as less painful than intramuscular (IM) injection. However, little is known of how the route of administration influences the pharmacodynamics of drugs. This study measured the changes in skin temperature and thermal threshold (TT) and recorded the side-effects after SC injection of 0.1mg/kg of hydromorphone in six cats. Time to peak TT was 105min. Skin temperature was elevated at 15min and between 45 and 360min. Five cats vomited and two exhibited marked dysphoria. Compared to previously published studies of IV and IM administration of hydromorphone, the SC route results in a slower onset of peak effect, a shorter duration of antinociception and is associated with more undesirable side-effects. As with IV and IM injections, SC administration of hydromorphone at 0.1mg/kg is associated with a significant elevation in skin temperature. Overall, the SC route appears to have the least utility.