Efficacy of prophylactic droperidol, ondansetron or both in the prevention of postoperative nausea and vomiting in major gynaecological surgery. A prospective, randomized, double-blind clinical trial

Efficacy of 5-HT3 receptor antagonists (ondansetron) vs dopamine receptor antagonists (droperidol) for preventing postoperative nausea, vomiting and headache: a meta-analysis

Objective To investigate the effects of 5-hydroxytryptamine 3 receptor antagonists (ondansetron [OND]) versus dopamine receptor antagonists (droperidol [DRO]) in the prevention of postoperative nausea, vomiting (PONV) and headache by pooling data from open published studies. Methods Performed systematic electronic searches of PubMed, Embase, Google scholar and CNKI, to identify open-published prospective randomized controlled trials (RCTs) relevant to the comparison of OND versus DRO for preventing PONV and headache to be included in the present study. The pooled PONV, headache, dizziness and drowsiness were calculated based on the original data of each included study. The pooled data was presented with risk ratio (RR) and 95% confidence interval (95%CI). Results Thirteen prospective randomized clinical trials were included in this meta-analysis. The pooled PONV, post-operative nausea (PON) and positive operative vomiting (POV) were 0.67 (95%CI:0.48-0.93, p<0.05), 0.88 (95%CI:0.67-1.14, p>0.05) and 0.56 (95%CI:0.39-0.82,p<0.05) respectively for OND vs. DRO. And the overall pooled positive operative nausea and vomiting was 0.71(95%CI:0.60-0.86) by fixed effects model for OND vs. DRO. The pooled risk of postoperative headache, dizziness and drowsiness were 4.33 (95%CI:0.76-24.69, p>0.05), 0.63 (95%CI:0.21-1.87, p>0.05) and 0.48(0.28-0.81,p<0.05) respectively by fixed effect model for OND vs. DRO. Conclusion The post-operative nausea, vomiting and dizziness risks were significant decreased for patients receiving OND compared to patients receiving DRO.

Predisposing factors for postoperative nausea and vomiting in gynecologic tumor patients

PURPOSE

To evaluate the predictors of postoperative nausea and vomiting (PONV) in women with gynecologic tumor.

METHODS

The analysis was based on prospectively collected data of 82 adult patients with gynecologic tumor, who were submitted to open surgical treatment and undergoing general anesthesia. The predictors included were age ≥50 years, non-smoker, use of postoperative opioids, mechanical bowel preparation, intraoperative intravenous hydration (IH) ≥10 mL/kg/h, and IH in the immediate postoperative, first and second postoperative days (PO1 and PO2) ≥30 mL/kg. A score with predictor variables was built. A multiple logistic regression was fitted. To estimate the discriminating power of the chosen model, a receiver operating characteristic (ROC) curve was plotted and the area under the ROC curve (AUC) was calculated. Statistical significance was set at p value <0.05 and the confidence interval at 95 %.

RESULTS

The incidence (%) of nausea, vomiting and both, in the general population, was 36.6, 28.1, 22.0, respectively. The highest incidences of PONV were found in non-smokers and in patients who received >30 mL/kg of IH in the PO2. The results of the adjusted model showed an increased risk of PONV for each 1-point increase in the score punctuation. The relative risk was higher than 2.0 for vomiting in all period and in the PO1. The ROC curve showed great discrimination of postoperative nausea and vomiting from the proposed score (AUC >0.75).

CONCLUSIONS

The study population was at high risk of PONV. Therefore, institutional guidelines abolishing modificable variables following temporal evaluation of the effectiveness should be undertaken.

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.

RETRACTED ARTICLE: Combination Antiemetic Regimens for Prevention of Postoperative Nausea and Vomiting : Focus on High-Risk Patients

None of the available antiemetics is entirely effective, perhaps because most of them act through the blockade of one receptor. There is a possibility that a combination of antiemetics with different sites of activity would be more effective than one drug alone for prophylaxis against postoperative nausea and vomiting (PONV).The clinical use of combined traditional antiemetics, including antihistamines (e.g. diphenhydramine), butyrophenones (e.g. droperidol) and benzamides (e.g. metoclopramide), for the prevention of PONV is limited because of the possibility of additive central nervous system toxicity, such as delayed emergence, drowsiness and extrapyramidal reactions. The efficacy of a combination of a serotonin 5-HT₃ receptor antagonist (ondansetron, granisetron or tropisetron) and dexamethasone is superior to that of 5-HT₃ receptor antagonists alone for the prevention of PONV, suggesting that dexamethasone enhances the antiemetic efficacy of 5-HT₃ receptor antagonists. The combination of a 5-HT₃ receptor antagonist with a traditional antiemetic (droperidol, metoclopramide or promethazine) acting at a different emetogenic receptor is more effective in reducing the incidence of PONV than each antiemetic alone acting at one receptor site. The risk of undesirable adverse effects does not increase with the combination of a 5-HT₃ receptor antagonist and a traditional antiemetic at the doses commonly used for PONV, because of the absence of drug interactions. The combination of a 5-HT₃ receptor antagonist (ondansetron) with other agents (propofol and CP-122721) reduces the incidence of PONV to a greater degree than monotherapy. However, no data are available for the combination of 5-HT₃ receptor antagonists and small doses of propofol for the prevention of PONV.Further studies are needed to evaluate the efficacy and safety of combination antiemetic regimens for PONV. Knowledge regarding combinations of these antiemetic drugs may be necessary to completely prevent PONV.

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

The problem of postoperative nausea and vomiting (PONV) remains far from being resolved. Despite the introduction of new classes of antiemetics and a vast amount of published research, there is a general impression that there has been little progress in this area. The multifactorial etiology of PONV might be better addressed using a combination of drugs acting at different receptor sites. This approach of balanced antiemesis may be the answer towards achieving a significant improvement in the management of PONV. This article will cover the different strategies used to prevent PONV with particular emphasis on combination antiemetics. A review of the currently available methods to manage PONV as well as the physiological and pharmacological basis of combination therapy is presented.