Combination therapy for postoperative nausea and vomiting - a more effective prophylaxis?

Effect of herbal medicine on postoperative nausea and vomiting after laparoscopic surgery: A systematic review and meta-analysis

BACKGROUND

Traditionally, herbal medicines have been used to alleviate nausea and vomiting; however, a comprehensive clinical evaluation for postoperative nausea and vomiting (PONV), especially after laparoscopic surgery, remains limited. This review aimed to evaluate the efficacy and safety of herbal medicine as an alternative therapy to prevent and manage nausea and vomiting after laparoscopic surgery compared with untreated, placebo, and Western medicine groups.

METHODS

We searched 11 databases, including EMBASE, PubMed, and the Cochrane Library, to collect randomized controlled trials (RCTs) of herbal medicines on PONV after laparoscopic surgery on July 7, 2022. Two independent reviewers screened and selected eligible studies, extracted clinical data, and evaluated the quality of evidence using the Cochrane risk-of-bias tool. The primary outcome was the incidence of PONV, whereas the secondary outcomes included the frequency and intensity of PONV, symptom improvement time, antiemetic requirement frequency, and incidence of adverse events. Review Manager Version 5.3. was used for the meta-analysis.

RESULTS

We identified 19 RCTs with 2726 participants comparing herbal medicine with no treatment, placebo, and Western medicine. The findings showed that compared with no treatment, herbal medicine demonstrated significant effects on vomiting incidence (risk ratio [RR] = 0.43, 95% confidence interval [CI] 0.32-0.57, P < .00001). Compared with placebo, herbal medicine revealed a significant effect on the severity of nausea 12 hours after laparoscopic surgery (standardized mean difference = -2.04, 95% CI -3.67 to -0.41, P = .01). Herbal medicines showed similar effects with Western medicine on the incidence of postoperative nausea (RR = 0.94, 95% CI 0.63-1.42, P = .77) and vomiting (RR = 0.68, 95% CI 0.25-1.84, P = .45). Furthermore, comparing the experimental group containing herbal medicine and control group excluding herbal medicine, adverse events were considerably lower in the group with herbal medicine (RR = 0.45, 95% CI 0.27-0.72, P = .001).

CONCLUSION

Herbal medicine is an effective and safe treatment for nausea and vomiting secondary to laparoscopic surgery. However, the number of studies was small and their quality was not high; thus, more well-designed RCTs are warranted in the future.

Chinese herbal medicine as adjuvant treatment for postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a protocol for systematic review and meta-analysis

INTRODUCTION

Postoperative nausea and vomiting (PONV) is a distressing symptom that patients often complain of even after less invasive surgery such as laparoscopic surgery (LS). If PONV is not well managed, patient recovery and postoperative quality of life are adversely affected. Although various drugs have been administered to prevent PONV, their effectiveness is limited, and adverse effects are numerous. Although herbal medicines have been widely used to manage various gastrointestinal symptoms, including nausea and vomiting, scientific evidence of their effects is lacking. This protocol is intended for a systematic review to analyse the efficacy and safety of Chinese herbal medicines for PONV after LS through a meta-analysis.

METHODS AND ANALYSIS

Randomised controlled trials, reported until June 2022, will be retrieved from electronic databases such as Medline, EMBASE and Cochrane Library. We will compare the effects of herbal medicine in patients presenting with PONV after LS with those of Western medicine, placebo and no treatment. If sufficient studies are identified, we will evaluate the combined effects of herbal and Western medicine. The incidence of nausea and vomiting will be considered the primary outcome. Secondary outcomes will include the intensity of complaints, quality of life and incidence of adverse events. Two independent reviewers will collect data based on the Preferred Reporting Items for Systematic Review and Meta-Analyses statement, evaluate the quality of each study using the Cochrane risk-of-bias tool and synthesise the results via meta-analysis, if possible.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The results of this study will be disseminated to peer-reviewed journals and posters.

PROSPERO REGISTRATION NUMBER

CRD42022345749.

What is the ideal combination antiemetic regimen?

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after surgery. PONV and PDNV have been associated with postoperative complications and hospital discharge delays. Despite the extensive evidence describing the use of several regimens in different surgical populations, the ideal regimen has not been established. Several antiemetic drugs have been evaluated in more than 1000 clinical controlled trials for management of this complex emetogenic pathway, including the 5-hydroxytryptamine (5-HT₃) receptor antagonists, dopamine receptor antagonists, neurokinin-type receptor antagonists, antihistaminics, anticholinergics, and corticosteroids, with the 5-HT₃ receptor antagonists being the most commonly used for PONV prophylaxis. Because of the complex emetogenic pathway and multifactorial etiology of PONV, a multimodal approach using two or more drugs that act at different neuro-receptor sites is suggested in patients with one or more risk factors to successfully address PONV and reduce its incidence. Nevertheless, the most studied regimens in randomized clinical trials (RCTs) are the combination of serotonin 5-HT3 receptor antagonists with dexamethasone or dopamine receptor antagonists (droperidol). Therefore, the safest and more effective combination regimen appears to be the use of serotonin 5-HT3 receptor antagonist antiemetic drugs with dexamethasone.

A Single Prophylactic Dose of Ondansetron Given at Cessation of Postoperative Propofol Sedation Decreases Postoperative Nausea and Vomiting in Cardiac Surgery Patients: A Randomized Controlled Trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common occurrence after cardiac surgery. However, in contrast to other surgical populations, routine PONV prophylaxis is not a standard of care in cardiac surgery. We hypothesized that routine administration of a single prophylactic dose of ondansetron (4 mg) at the time of stopping postoperative propofol sedation before extubation in the cardiac surgery intensive care unit would decrease the incidence of PONV.

METHODS

With institutional human ethics board approval and written informed consent, we conducted a randomized controlled trial in patients ≥19 years of age with no history of PONV undergoing elective or urgent cardiac surgery procedures requiring cardiopulmonary bypass. The primary outcome was the incidence of PONV in the first 24 hours postextubation, compared by the χ test. Secondary outcomes included the incidence and times to first dose of rescue antiemetic treatment administration, the incidence of headaches, and the incidence of ventricular arrhythmias.

RESULTS

PONV within the first 24 hours postextubation occurred in 33 of 77 patients (43%) in the ondansetron group versus 50 of 82 patients (61%) in the placebo group (relative risk, 0.70 [95% confidence interval {CI}, 0.51-0.95]; absolute risk difference, -18% [95% CI, -33 to -2]; number needed to treat, 5.5 [95% CI, 3.0-58.4]; χ test, P = .022). Kaplan-Meier "survival" analysis of the times to first rescue antiemetic treatment administration over 24 hours indicated that patients in the ondansetron group fared better than those in the placebo group (log-rank [Mantel-Cox] test; P = .028). Overall, 32 of 77 patients (42%) in the ondansetron group received rescue antiemetic treatment over the first 24 hours postextubation versus 47 of 82 patients (57%) in the placebo group (relative risk, 0.73 [95% CI, 0.52-1.00]; absolute risk difference, -16% [95% CI, -31 to 1]); P = .047. There were no significant differences between the groups in the incidence of postoperative headache (ondansetron group, 5 of 77 patients [6%] versus placebo group, 4 of 82 patients [5%]; Fisher exact test; P = .740) or ventricular arrhythmias (ondansetron group, 2 of 77 patients [3%] versus placebo group, 4 of 82 patients [5%]; P = .68).

CONCLUSIONS

These findings support the routine administration of ondansetron prophylaxis at the time of discontinuation of postoperative propofol sedation before extubation in patients following cardiac surgery. Further research is warranted to optimize PONV prophylaxis in cardiac surgery patients.

A review of nausea and vomiting in the anaesthetic and post anaesthetic environment

Postoperative nausea and vomiting (PONV) has long been known as a complication of anaesthesia and surgery. This paper focuses on the assessment of the risk factors related to PONV along with the strategies and interventions which can be put in place to manage the condition. The pharmacological and multi-modal treatment methods of managing the risk factors that contribute to PONV are discussed.

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.

Triple Therapy with Scopolamine, Ondansetron, and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Moderate to High-Risk Patients Undergoing Craniotomy Under General Anesthesia: A Pilot Study

Introduction

Postoperative nausea and vomiting (PONV) is one of the most common complaints from patients and clinicians after a surgical procedure. According to the current Society of Ambulatory Anesthesia Consensus Guidelines, the general incidence of vomiting and nausea is around 30 and 50%, respectively; and up to 80% in high-risk patients. In previous studies, the reported incidence of PONV at 24 h after craniotomy was 43–70%. The transdermal scopolamine (TDS) delivery system contains a 1.5-mg drug reservoir, which is designed to deliver a continuous slow release of scopolamine through intact skin during the first 72 h of patch application. Therefore, we designed this single arm, non-randomized, pilot study to assess the efficacy and safety of triple therapy with scopolamine, ondansetron, and dexamethasone to prevent PONV.

Materials and methods

In the preoperative area, subjects received an active TDS 1.5 mg that was applied to a hairless patch of skin in the mastoid area approximately 2 h prior to the operation. Immediately after anesthesia induction, all patients received a single 4 mg dose of ondansetron IV and a single 10 mg dose of dexamethasone IV. Patients who experienced nausea and/or vomiting received ondansetron 4 mg IV as the initial rescue medication. Postoperative nausea and vomiting assessments were performed for up to 120 h after surgery.

Results

A total of 36 subjects were analyzed. The overall incidence of PONV during the first 24 h after neurological surgery was 33% (n = 12). The incidence of nausea and emesis during the first 24 h after surgery was recorded as 33% (n = 12) and 16% (n = 6), respectively.

Conclusion

Our data showed that this triple therapy regimen may be an efficient alternative regimen for PONV prophylaxis in patients undergoing neurological surgery with general anesthesia. Further studies using regimens affecting different receptor pathways should be performed to better prove the efficacy and safety in the prevention or delay of PONV.

Postoperative nausea and vomiting prophylaxis: A comparative study of ondansetron, granisetron and granisetron and dexamethasone combination after modified radical mastectomy

BACKGROUND

Post-operative nausea and vomiting (PONV) is commonly seen after modified radical mastectomy (MRM). In this randomized double-blind prospective study we compared the efficacy of ondansetron, granisetron and granisetron and dexamethasone combination for prevention of PONV following MRM in female patients.

MATERIALS AND METHODS

A total of 75 patients (20-60 years of age) undergoing elective MRM were randomly allocated to one of the three groups of 25 patients each. Group O received ondansetron 4 mg, Group G received granisetron 40 mcg/kg and group granisetron and dexamethasone (G + D) received granisetron 40 mcg/kg + dexamethasone 8 mg prior to induction. All episodes of PONV within 24 h after induction of anesthesia were recorded.

STATISTICAL ANALYSIS

Statistical analysis was done using Kruskal-Wallis test (nonparametric ANOVA).

RESULTS

The incidence of complete response (no PONV, no rescue medication) was 96% with G+D, as compared with 86% with granisetron and 4% with ondansetron during 0-3h after surgery which was clinically significant (P < 0.05). Similarly clinically significant response was seen during 3-6, 6-9, 9-12 and 12-24 h of surgery.

CONCLUSION

Granisetron and dexamethasone combination is more effective for prevention of PONV in comparison to individual ondansetron and granisetron in MRM.

Comparison of the antiemetic effect of ramosetron with the combination of dexamethasone and ondansetron in middle ear surgery: A double-blind, randomized clinical study

Background:

Postoperative nausea and vomiting (PONV) is a frequent complication of middle ear surgery. Ondansetron has been shown to be effective for early PONV and dexamethasone has been shown to be effective for late PONV. Therefore, a combination of dexamethasone and ondansetron is commonly used for middle ear surgery. This study was conducted to compare the combination of ondansetron and dexamethasone with ramosetron for early and late PONV up to 48 h after middle ear surgery.

Methods:

One hundred and twenty adults scheduled for middle ear surgery were allocated to receive either dexamethasone 8 mg and ondansetron 4 mg (n=60) or ramosetron 0.3 mg (n=60). General anesthesia with inhalation agents was used for all the patients. The incidence and severity of PONV, administration of rescue antiemetic, and the side effects of the antiemetic were documented during the first 48 h after surgery.

Results:

The incidence of nausea was significantly lower in the dexamethasone and ondansetron group compared to the ramosetron group between 2 and 24 h. The complete response, which is patients with no nausea or vomiting, was significantly more in dexamethasone and ondansetron group compared to ramosetron group between 2 and 24 h and between 24 and 48 h (76% vs. 56%, P=0.02, 93% vs. 81%, P=0.05, respectively). Overall, complete response was more in dexamethasone and ondansetron group compared to ramosetron group (71% vs. 40%, P=0.01).

Conclusion:

The combination of dexamethasone and ondansetron is superior to ramosetron for prevention of PONV after middle ear surgeries.

Efficacy of dexamethasone added to ramosetron for preventing postoperative nausea and vomiting in highly susceptible patients following spine surgery

Background

Opioid-based patient controlled analgesia (PCA) provides adequate pain control following spinal surgeries at the expense of increased risk of postoperative nausea and vomiting (PONV). We evaluated the efficacy of dexamethasone added to ramosetron, which is a newly developed five-hydroxytryptamine receptor 3 antagonist with a higher receptor affinity and longer action duration compared to its congeners, on preventing PONV in highly susceptible patients receiving opioid-based IV PCA after spinal surgery.

Methods

One hundred nonsmoking female patients undergoing spinal surgery were randomly allocated to either a ramosetron group (group R) or a ramosetron plus dexamethasone group (group RD)., Normal saline (1 ml) or 5 mg of dexamethasone was injected before anesthetic induction, while at the end of the surgery, ramosetron (0.3 mg) was administered to all patients and fentanyl-based IV PCA was continued for 48 hrs. The incidence and severity of PONV, pain score and the amount of rescue antiemetics were assessed for 48 hours after surgery.

Results

The number of patients with moderate to severe nausea (20 vs. 10, P = 0.029), and overall incidence of vomiting (13 vs. 5, P = 0.037) were significantly lower in the group RD than in the group R, respectively. Rescue antiemetic was used less in the RD group without significance.

Conclusions

Combination of ramosetron and dexamethasone significantly reduced the incidence of moderate to severe nausea and vomiting compared to ramosetron alone in highly susceptible patients receiving opioid-based IV PCA after surgery.

Multimodal therapies for postoperative nausea and vomiting, and pain

Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.

An overview of the clinical use of ondansetron in preschool age children

The introduction of 5-HT₃ receptor antagonist has revolutionized the prevention and treatment of nausea and vomiting in preschool aged children. These distressing symptoms, arising from multiple etiologies such as anesthesia, chemotherapy, and viral infection, are a major concern of patients and their families. Clinical research has demonstrated the antiemetic effectiveness of ondansetron in children. Although most of these studies focus primarily on preventing vomiting across the pediatric age group, they provide strong evidence for the use of ondansetron in preschool age children. For children at high risk, pediatric practice guidelines recommend ondansetron in conjunction with other antiemetics to achieve complete control of symptoms.

Prophylactic antiemetic effects in gynecologic patients receiving fentanyl IV-patient controlled analgesia: comparison of combined treatment with ondansetron and dexamethasone with metoclopramide and dexamethasone

Background

This study was conducted to compare the efficacy of a combination of ondansetron and dexamethasone with that of metoclopramide and dexamethasone for prevention of postoperative nausea and vomiting (PONV) in gynecologic patients receiving fentanyl IV-patient controlled analgesia.

Methods

One hundred patients were divided into two groups at random. In Group O, 5 mg of dexamethsone was administered after tracheal intubation, while 4 mg of ondansetron was administered at the end of surgery. In Group M, 5 mg of dexamethsone was administered after tracheal intubation and 20 mg metoclopromide was administered at the end of surgery. During the experiment, the PONV was evaluated at regular intervals. In addition, the incidence of nausea, and vomiting and the numerical rating scale (NRS) of nausea was measured (range, 0-10).

Results

The overall incidence of PONV in Group O was 22/50 (44%) while that in Group M was 19/50 (38%). There were no significant differences in the incidence of nausea, moderate to severe nausea (NRS of nausea, 4-10), or vomiting between groups.

Conclusions

Treatment with a combination of 20 mg metoclopramide and 5 mg dexamethasone is an effective, safe, and inexpensive way to prevent PONV when compared to treatment with 4 mg ondansetron and 5 mg dexamethasone.

[Prophylaxis of postoperative nausea and vomiting in morbidly obese patients undergoing laparoscopic gastroplasties: a comparative study among three methods]

BACKGROUND AND OBJECTIVES

Videolaparoscopic bariatric surgeries are associated with a high incidence of postoperative nausea and vomiting. Those events can lead to significant morbidity, increase hospitalization costs, as well as patient dissatisfaction. The objective of this study was to compare different prophylaxis protocols of postoperative nausea and vomiting in videolaparoscopic gastroplasties.

METHODS

This is a randomized prospective study with 77 patients undergoing videolaparoscopic gastroplasty. Patients were divided into four groups as follows: Cont group, control (n = 19) where antiemetics were not administered; Dexa group (n = 16), patients received dexamethasone; Onda group (n = 20), patients received ondansetron; and Dexa+Onda group (n = 22), patients received dexamethasone and ondansetron. All patients underwent standardized anesthesia and postoperative analgesia with intravenous morphine. Patients who were taking gastric protectors or antiemetics and those with hiatal hernia were excluded. Demographic data, duration of the surgery, doses of morphine, and development of nausea and vomiting in the immediate postoperative period (up to six hours) were recorded.

RESULTS

Demographic data and doses of morphine administered did not differ among the groups (One-way ANOVA). The incidence of nausea and/or vomiting in the different groups was: Cont group - 78.94%; Dexa group - 62.25%; Onda group - 50%; and Dexa+Onda group - 18.8% (p = 0.0002).

CONCLUSIONS

The incidence of postoperative nausea and vomiting in videolaparoscopic gastroplasties was more effectively reduced with the association of ondansetron and dexamethasone than with each drug separately.

Acupressure and acupuncture in preventing and managing postoperative nausea and vomiting in adults

This literature review sets out to investigate the effectiveness of acupressure and acupuncture in preventing and managing postoperative nausea and vomiting (PONV) in adult patients. PONV is problematic, affecting patient satisfaction, delayed discharge and even patient re-admission. Current treatment of PONV constitutes a variety of drug therapies, which are only partially effective. With the integration of complementary and alternative medicines in healthcare, this review examined 10 research studies investigating the use of acupressure and acupuncture in treating PONV. Three studies found acupressure to be effective in preventing PONV. However, population samples were small and the research designs had numerous anomalies. Overall the article suggests that acupuncture and acupressure are ineffective in preventing and managing PONV in adult patients. Further investigation of the effectiveness of acupressure and acupuncture, combined with current drug therapies, using well designed and adequately powered studies is needed. Published studies predominantly examined the use of P6 as the pressure point. Further studies should examine other 'acupoint' sites, to ascertain whether these are effective dependent upon the operative site.

Combination of antiemetics for the prevention of postoperative nausea and vomiting in high-risk patients

It was previously reported that the Korean predictive model could be used to identify patients at high risk of postoperative nausea and vomiting (PONV). This study investigated whether PONV in the high-risk and very high-risk patients identified by the Korean predictive model could be prevented by multiple prophylactic antiemetics. A total of 2,456 patients were selected from our previous PONV study and assigned to the control group, and 374 new patients were recruited consecutively to the treatment group. Patients in each group were subdivided into two risk groups according to the Korean predictive model: high-risk group and very high-risk group. Patients in the treatment group received an antiemetic combination of dexamethasone 5 mg (minutes after induction) and ondansetron 4 mg (30 min before the end of surgery). The incidences of PONV were examined at two hours after the surgery in the postanesthetic care unit and, additionally, at 24 hr after the surgery in the ward, and were analyzed for any differences between the control and treatment groups. The overall incidence of PONV decreased significantly from 52.1% to 23.0% (p< or =0.001) after antiemetic prophylaxis. Specifically, the incidence decreased from 47.3% to 19.4% (p< or =0.001) in the high-risk group and from 61.3% to 28.3% (p< or =0.001) in the very high-risk group. Both groups showed a similar degree of relative risk reductions: 59.0% vs. 53.8% in the high-risk and very high-risk groups, respectively. The results of our study showed that the antiemetic prophylaxis with the combination of dexamethasone and ondansetron was effective in reducing the occurrence of PONV in both high-risk and very high-risk patients.

The nurse's role in day surgery: a literature review

AIM

This paper reports a literature review to synthesize the evidence on day surgery, demonstrating its usefulness for innovative nurses.

BACKGROUND

Day surgery growth has developed rapidly in recent years. Such a rapid growth has triggered a shift in nursing roles and interventions. Nursing roles are taking shape within modern day surgical units but have not been widely reviewed in developing countries.

METHODS

The RCN library, BNI, CINAHL and Medline databases were searched using the terms 'day surgery and technological advantages', 'financial/economic benefits', 'patient experiences/satisfaction', 'day surgery/international comparisons', 'day surgery and developing countries'. Only papers in the English language from 1990 to 2005 were reviewed, with a predominantly adult focus. The papers examined mainly used research techniques and some opinion papers, policy documents and textbooks were examined for additional information.

FINDINGS

The key strengths of day surgery are cost-effectiveness, increased patient satisfaction and low infection rates. Patients indicated that effective information provision and psychological preparation helped them cope with the experience. The use of music, story telling and distraction reduced pre-operative anxiety. Contrastingly, the deficits included poor information giving and psychological preparation resulting in high anxiety levels. Many patients encountered variable pain and nausea management and education strategies.

CONCLUSION

This review highlights the importance of adequate preparation and continuous psychological support for patients undergoing day surgery. The challenges faced by practitioners involved with innovation are also emphasized.

Risk factors for prolonged stay after ambulatory surgery: economic considerations

The risk factors that prolong length of stay of ambulatory patients can be classified as preoperative, intraoperative, and postoperative. Preoperative factors include the type of surgery, ear, nose and throat and strabismus surgery, old age and pre-existing congestive heart failure. Intraoperative factors include increasing length of surgery, and general anesthesia, while postoperative factors include postoperative nausea and vomiting, excessive pain and adverse cardiovascular events. The factors that anesthesiologists can address to reduce length of stay are postoperative nausea and vomiting and excessive pain. Multimodal management of postoperative nausea and vomiting and pain can minimize adverse events and thereby reduce length of stay in the postanesthetic care unit, but will not necessarily lead to a reduction in staffing levels. As personnel costs contribute the majority of postanesthetic care unit costs, more than 95%, direct financial savings may not be possible from eliminating adverse events alone. Optimizing the use of the postanesthetic care unit and reducing total hours in the unit with higher operating room turnover may lead to indirect financial benefits.

Intravenous droperidol: a review of its use in the management of postoperative nausea and vomiting

Droperidol (Dehydrobenzperidol, Dehidrobenzoperidol, Dridol, Droleptan, Inapsine) is a dopamine D(2) receptor antagonist that has been widely used in adults and children for the prevention and treatment of postoperative nausea and vomiting (PONV) over several decades and, more recently, for the prevention of opioid-induced PONV during patient-controlled analgesia (PCA) in adults. In well controlled clinical trials of patients undergoing surgery, the efficacy of single-dose intravenous (IV) droperidol in preventing PONV was similar to that of ondansetron and dexamethasone. Droperidol significantly reduced opioid-induced PONV in adults during PCA and had a morphine-sparing effect. Droperidol is generally well tolerated and the incidence of adverse effects is similar to that observed with placebo and the serotonin 5-HT(3) receptor antagonists (setrons). Guidelines recommend that, in adults, droperidol monotherapy be considered for those at moderate risk of PONV, and droperidol in combination with a setron and/or dexamethasone be considered for patients at moderate or high risk of PONV. In children with moderate or high risk of PONV, droperidol is recommended for first-line use in some countries, and second-line use in others.

Randomized comparison of two anti-emetic strategies in high-risk patients undergoing day-case gynaecological surgery

BACKGROUND

Postoperative nausea and vomiting (PONV) is a significant cause of morbidity among patients undergoing general anaesthesia. The optimal strategy for prevention of PONV, however, remains unclear. This study compared two commonly used prophylactic strategies in high-risk, day-case, gynaecological surgery patients.

METHODS

We conducted a randomized trial comparing sevoflurane combined with dolasetron (SD), with propofol-based total intravenous anaesthesia (TIVA) in 126 high-risk patients undergoing day-case gynaecological surgery. The primary endpoints included the incidence and severity of nausea or vomiting before discharge and the incidence of nausea or vomiting between discharge and 24 h. To identify the factors most predictive of a complete response (no PONV at any time within the 24 h period), multiple logistic regression models were fitted.

RESULTS

Before discharge, there was no significant difference between the two treatment groups with respect to nausea and vomiting outcomes (P = 0.3). Post-discharge nausea and vomiting (PDNV), however, were significantly more common for patients in the TIVA group (nausea, P = 0.004 and vomiting, P = 0.03). Type of anaesthetic, adjusted for weight and anaesthesia duration was significantly associated with complete response (odds ratio = 2.7, 95% confidence interval = 1.15 to 6.4).

CONCLUSIONS

Although both TIVA and dolasetron prophylaxis reduce the predicted rate of PONV in the early postoperative period, the anti-emetic effects of propofol are short-lived. A longer-acting drug such as dolasetron may therefore be necessary to prevent PDNV.

Postoperative nausea and vomiting (PONV) after orthognathic surgery: a retrospective study and literature review

PURPOSE

Postoperative nausea and vomiting (PONV) is the most common postoperative complication after surgery and general anesthesia. PONV occurs primarily within the first 24 hours and can lead to significant morbidity, delayed hospital discharge, increased hospital costs and perhaps most importantly, poor patient satisfaction. We sought, in this study, to determine the prevalence of PONV and to identify risk factors in patients who underwent orthognathic surgery.

PATIENTS AND METHODS

We conducted a retrospective cross-sectional analytic survey of 553 consecutive patients over 14 years of age, who underwent maxillary and/or mandibular osteotomies at Kaiser Permanente Hospital (Oakland, CA), between January 2003 and March 2004. Patient-, anesthesia- and surgery-related factors that were considered to have a possible effect on the prevalence of PONV events were evaluated.

RESULTS

A total of 514 patients met the inclusion criteria. Among these patients, 40.08% experienced PONV during the first 24 hours after surgery. The most important predictive factors associated with an increased risk of PONV were female gender, young patients (15 to 25 years old), nonsmoking status, presence of predisposing factors (ie, prior history of motion sickness and/or PONV, vertigo or migraine headaches), use of volatile general anesthetics, maxillary surgery, postoperative pain level (PACU) and the use of postoperative analgesic opioid drugs. We found a directly proportional relationship between the number of risk factors and the prevalence of PONV.

CONCLUSION

We found PONV had a high prevalence among patients undergoing orthognathic surgery. Further studies are needed to develop effective protocols for preventing this common and unpleasant problem.

Dissecting the myths of day surgery: the anaesthetist's view

Although day surgery is now well established, its practice varies enormously between various parts of the country and even between different practitioners (Audit Commission 2001). Some of these differences may be explained by a number of lingering myths which persist from the earlier, pioneering days of day surgery. The purpose of this short review is to discuss some of these myths from an anaesthetist's perspective and to try to dispel them using the available evidence.

Antiemetic and analgesic-sparing effects of diphenhydramine added to morphine intravenous patient-controlled analgesia

BACKGROUND

This study was designed to examine the analgesic and dose-related antiemetic efficacy of diphenhydramine-morphine mixture for intravenous patient-controlled analgesia (PCA).

METHODS

Healthy women, undergoing abdominal total hysterectomy were recruited to this double-blinded randomized placebo-controlled study. Patients were randomly allocated to one of three groups (n=40 each). In group 1, patients received saline at induction and morphine 1 mg ml(-1) alone for postoperative PCA. Patients in groups 2 and 3 received diphenhydramine 30 mg i.v. at induction and were given a 1.2:1 or a 4.8:1 ratio, respectively, of diphenhydramine-morphine mixture for postoperative PCA.

RESULTS

A total of 112 patients completed the study. The incidence of postoperative nausea (31.6% vs 67.6%, P<0.01) and vomiting (15.8% vs 40.5%, <0.05) was significantly lower in group 3 than in group 1. Furthermore, the incidence of severe nausea was significantly lower in group 3 than in group 1 (2.6% vs 24.3%, P<0.05). The rescue antiemetic requirements were also significantly less in group 3 than in group 1 (5.3% vs 24.3%, P<0.05). However, there was no significant difference between group 2 and group 1 in any of the comparisons. Pain intensity, 24-h morphine consumption and diphenhydramine-related side-effects, such as sedation or dry mouth, did not differ among the three groups.

CONCLUSION

An initial bolus of diphenhydramine 30 mg at anaesthetic induction followed by postoperative PCA with a 4.8:1, but not 1.2:1, diphenhydramine-morphine mixture provides an effective antiemetic efficacy without morphine-sparing effects.

The efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexamethasone. A meta-analysis of randomized controlled trials

PURPOSE

The aim of this quantitative systematic review is to compare the efficacy and side effects of combining one of the 5-HT(3) receptor antagonists (5-HT) with droperidol or dexamethasone for postoperative nausea and vomiting (PONV) prophylaxis.

METHODS

We performed a systematic search (Medline, Embase, and the Cochrane Library) for randomized controlled trials that compared the antiemetic efficacy of combining one of the 5-HT with droperidol or dexamethasone vs 5-HT alone. Relevant endpoints were prevention of early (0 to 6 hr), and overall (0 to 24 hr) PONV, and side effects. The articles that could meet the inclusion criteria were scored for inclusion and methodological validity using the three-item, five-point, Oxford-scale. Relative risk and numbers needed-to-treat with 95% confidence intervals were calculated for each combination vs 5-HT alone. The two combinations were then indirectly compared. A random effects model was used.

RESULTS

We considered 41 trials for analysis but subsequently excluded eight. Thirty-three trials with data from 3,447 patients were analyzed. Except for early nausea with the 5-HT plus droperidol, both combinations were significantly more effective than 5-HT in preventing early and overall PONV. There was no difference in antiemetic efficacy between the two combinations. The incidence of commonly reported side effects was also similar in the two combination groups.

CONCLUSION

We conclude that there is no statistically significant difference in antiemetic efficacy or side effects profile when one of the 5-HT is combined with either droperidol or dexamethasone and that both combination regimens are significantly more effective than 5-HT alone.

Evidence-based management of postoperative nausea and vomiting: a review

PURPOSE

To provide evidence-based guidelines for the prophylaxis and treatment of postoperative nausea and vomiting (PONV).

SOURCE

Literature from randomized controlled trials, systematic reviews, logistic regression analyses and expert opinion in the management of PONV.

PRINCIPAL FINDINGS

The etiology of PONV is multifactorial. Patient, anesthesia, and surgery related risk factors have been identified. Universal PONV prophylaxis is not cost-effective. Identification of patients at high-risk of PONV allows targeting prophylaxis to those who will benefit most from it. No prophylaxis is needed for patients at low risk for PONV. For patients at moderate risk for PONV, prophylaxis using a single antiemetic or a combination of two agents should be considered. Double and triple antiemetic combinations should be considered for patients at high risk for PONV. Furthermore, a multimodal approach should be adopted incorporating steps to keep the baseline risk of PONV low. The optimum cost-effective approach to the management of PONV will differ between an ambulatory centre and an inpatient hospital setting. For the treatment of established PONV in patients who failed prophylaxis, patients should not receive a repeat dose of the prophylactic antiemetic. Rather, a drug acting at a different receptor should be used. Beyond six hours after surgery, patients can be treated with any of the agents used for prophylaxis, except dexamethasone and transdermal scopolamine.

CONCLUSION

PONV are common after anesthesia and surgery. We provided evidence-based guidelines for the management of this problem based on the available literature.

Morbidity and mortality related to anaesthesia outside the operating room

PURPOSE OF REVIEW

The purpose of this review is to provide information related to morbidity and mortality associated with anaesthesia outside the operating room.

RECENT FINDINGS

There is an increasing demand for anaesthesia at remote locations. Because of its specific characteristics, resulting from the location and the patient, morbidity and mortality rates of remote location anaesthesia could differ from conventional operating room anaesthesia. However, no studies are currently available. On the basis of morbidity and mortality data from conventional operating room anaesthesia, we reached some important conclusions with regard to the safety of anaesthesia outside the operating room. A well-equipped anaesthesia machine, standard monitoring (electrocardiogram, oxygen saturation and non-invasive blood pressure), trained personnel and adequate planning should be standard for all out of the operating room procedures. When all these are in place, the incidence of morbidity or mortality should be comparable to that of anaesthesia provided in the operating room.

SUMMARY

There is certainly a need for studies concerning morbidity and mortality at remote location anaesthesia. Special care for the prevention of hypothermia should be given to those patients undergoing long-lasting diagnostic procedures, e.g. magnetic resonance imaging scans or cardiological investigations.

Consensus guidelines for managing postoperative nausea and vomiting

IMPLICATIONS

We present evidence-based guidelines developed by an international panel of experts for the management of postoperative nausea and vomiting.

Management of postoperative nausea and vomiting in ambulatory surgery

The management of PONV has improved significantly over the years but remains a frequent occurrence in postoperative patients. Evaluation of individual patient risk and the consideration for prophylactic antiemetic in high-risk populations should reduce these unpleasant symptoms and help direct appropriate clinical strategies. Treatment following failure of prophylactic antiemetic therapy requires knowledge of previously used antiemetics and the time of their administration.

Pharmacotherapy of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) are two of the most common and unpleasant side effects following anaesthesia and surgery. Despite the development of new anti-emetics and a vast amount of published research, PONV continues to be a problem, especially in high-risk patients. Recent interest has focused on the use of a combination of agents, acting on different receptors and the adoption of a multimodal approach to tackle this problem. The search for the most cost-effective strategy has also been a major goal. This article will discuss the risk factors and physiology of PONV, currently available therapies, the use of a multimodal approach and the cost-effectiveness of PONV management. Finally, recommendations for the prophylaxis and treatment of PONV will be discussed.