The effect of ondansetron on the efficacy of postoperative tramadol: a systematic review and meta-analysis of a drug interaction

The Pharmacological Treatment of Chronic Pain: From Guidelines to Daily Clinical Practice

In agreement with the International Association for the Study of Pain, chronic pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. To date, there are several types of pain: nociceptive, neuropathic, and nociplastic. In the present narrative review, we evaluated the characteristics of the drugs used for each type of pain, according to guidelines, and their effects in people with comorbidity to reduce the development of severe adverse events.

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.

Drug-Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications

Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug-drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug-drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.

Perioperative pain management in COVID-19 patients: Considerations and recommendations by the Saudi Anesthesia Society (SAS) and Saudi Society of Pain Medicine (SSPM)

The COVID-19 pandemic has swept across the world over the past few months. Many articles have been published on the safety of anesthetic medications and procedures used in COVID-19 positive patients presenting for surgery. Several other articles covered the chronic pain management aspect during the pandemic. Our review aimed to focus on perioperative pain management for COVID-19 patients. We conducted a literature search for pertinent recent articles that cover considerations and recommendations concerning perioperative pain management in COVID-19 patients. We also searched the literature for the relevant adverse effects of the commonly used medications in the treatment of COVID-19, and their potential drug-drug interactions with the common medications used in perioperative pain management. Professional societies recommend prioritizing regional anesthesia techniques, which have many benefits over other perioperative pain management options. When neuraxial and continuous peripheral nerve block catheters are not an option, patient-controlled analgesia (PCA) should be considered if applicable. Many of the medications used for the treatment of COVID-19 and its symptoms can interfere with the metabolism of medications used in perioperative pain management. We formulated an up-to-date guide for anesthesia providers to help them manage perioperative pain in COVID-19 patients presenting for surgery.

Long-term stability of an infusion containing paracetamol, alizapride, ketorolac and tramadol in glass bottles at 5±3°C

Background and objective

Infusion containing paracetamol, alizapride, ketorolac and tramadol is used after a general anaesthesia in order to limit pain, fever and nausea. Currently, these infusions are prepared according to demand in the anaesthesia unit, but the preparation in advance could improve quality of preparation and time management. The aim of this study was to investigate the long-term stability of this infusion in glass bottles at 5°C ± 3 °C.

Method

Five bottles of infusion were stored at 5°C ± 3 °C for 60 days. A visual and microscope inspection were performed periodically to observe any particle appearance or colour change. pH and absorbance at three wavelengths were measured. The concentrations were measured by ultra-high performance liquid chromatography - diode array detection.

Results

Multiple verifications were performed during the first 35 days and no crystal, impurity or colour change were observed. At the next time point (42nd day), crystals were visible to the naked eye. pH and absorbance at 350 nm and 550 nm were stable. A slight increase in the absorbance at 410 nm was observed during the study, suggesting that a degradation product could be formed and absorb at this wavelength. The infusion was considered chemically stable while the lower one-sided prediction limit at 95% remains superior to 90% of the initial concentration. Concentration measurements demonstrated that ketorolac and alizapride remained stable in the infusion for 35 days. The stability of tramadol was 28 days. However, degradation of paracetamol was much faster given that concentration has fallen below 90% of the initial concentration after 7 days.

Conclusion

Infusion of paracetamol, alizapride, ketorolac and tramadol remains stable for 7 days in glass bottles at 5°C ± 3 °C and could be prepared in advance with these storage conditions.

Efficacy of ultrasound-guided erector spinae plane block for analgesia after laparoscopic cholecystectomy: a randomized controlled trial†

Background and objectives

The primary aim of this study is to assess the effect of ultrasoung-guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores.

Methods

Patients between 18–70 years old, ASA I-II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US-ESP with 40 ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US-ESP with 40 ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded.

Results

There were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100 ± 19.2 mg in Group ESP, while it was 143 ± 18.6 mg in Group Control (p < 0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p = 0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p < 0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1, 39] = 24.061, p < 0.0005).

Conclusions

Bilateral US-ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.

Patient-controlled intravenous tramadol versus patient-controlled intravenous hydromorphone for analgesia after secondary cesarean delivery: a randomized controlled trial to compare analgesic, anti-anxiety and anti-depression effects

Introduction

This study aimed to compare the postoperative analgesic effects of tramadol and hydromorphone for secondary cesarean delivery (CD) as well as their anti-anxiety and anti-depression properties.

Methods

A total of 106 patients receiving secondary CD under spinal anesthesia were randomly allocated to the tramadol group (n=53) and the hydromorphone group (n=53). Each group received patient-controlled intravenous analgesia using flurbiprofen 4 mg/kg combined with tramadol (4 mg/kg) or hydromorphone (0.04 mg/kg) immediately after the surgery. Postoperative pain numerical rating scale (NRS) for incision and visceral pain, hospital anxiety and depression scale (HADS), early walking time and length of hospital stay were assessed.

Results

Patients in the tramadol and hydromorphone groups exhibited equivalent incision pain NRS at different time points (P>0.05). Visceral pain in the tramadol group was higher than that in the hydromorphone group at postoperative 4 hours (2.9 [1.2] vs 2.3 [1.4], P=0.011) and 8 hours (2.4 [1.1] vs 1.8 [1.1], P=0.028). One week after the surgery, the patients in the tramadol group, as compared to the hydromorphone group, had lower anxiety scores (1.9 [3.5] vs 3.6 [4.1], P=0.033) and depression scores (0.8 [1.3] vs 2.7 [4.1], P=0.023). In addition, early walking time (25.3 [7.0] hours vs 29.3 [9.6] hours, P=0.016) and length of hospital stay (2.9 [0.8] days vs 3.3 [0.8] days, P= 0.008) after the surgery in the tramadol group were less than those in the hydromorphone group.

Conclusion

Postoperative intravenous analgesia with tramadol or hydromorphone for secondary CD provides comparable analgesic effects on incision pain. Tramadol is less effective in controlling visceral pain compared to hydromorphone. However, tramadol can help to alleviate anxiety and depression in the early postpartum period, improve patients’ early mobilization and shorten their hospital stay.

Clinical trial number and registry URL

No: ChiCTR-IIR-17011043; URL: www.chictr.org.cn.

Comparison of Ondansetron versus Clonidine efficacy for prevention of postoperative pain, nausea and vomiting after orthognathic surgeries: A triple blind randomized controlled trial

Background

The aim of this randomized controlled triple blind trial was to compare the efficacy of clonidine with dexamethasone versus ondansetron with dexamethasone for postoperative pain, nausea and vomiting prevention in orthognathic surgery patients.

Material and Methods

In this clinical trial study, 30 consecutive patients with skeletal class III deformities were candidates for orthognathic surgery in Qaem hospital, Mashhad University of medical sciences, Mashhad, Iran from March to November 2017. These subjects were randomly assigned to two equal number groups, ondansetron or clonidine. Patients received either oral ondansetron 8mg or oral clonidine 150μg as premedication, 1 hour before the surgery (both dissolved in 20 cc of water). Also both groups received intravenous dexamethasone 8mg (1 hour preoperatively and every 4 hours intraoperatively).

Results

In this study, a total of 30 patients (14 males and 16 females) with a mean age of 23.9 ± 3.9 were investigated. The incidence of postoperative nausea in women was more than men (p=0.003), also the correlation between the incidence of PON and the surgery duration ≥ 3 hours was statistically significant (p = 0.050). The frequency of postoperative nausea (PON) in the ondansetron group was less than clonidine (53.3% vs 73.3% respectively). There was no postoperative vomiting (POV) in the ondansetron group, but 6.7% of cases in clonidine group suffered POV. Post-operative nausea in ondansetron group occurred significantly later than clonidine (525.0±233.2 vs 100.0±34.0 min; p<0.001). On the other hand, the incidence time of post-operative severe pain or in other word the analgesia time in clonidine group was significantly more than ondansetron one (875/0±68/5 vs 614.3±159.1 min; p<0.001).

Conclusions

Ondansetron with dexamethasone premedication was more effective in controlling PONV after orthognathic surgery compared to clonidine with dexamethasone group.

Key words:Postoperative nausea and vomiting, ondansetron, clonidine.

Seizure-like activity after gadolinium administration in an anaesthetised foal undergoing magnetic resonance imaging

The use of MRI has been recently increasing in veterinary patients, and this modality has been adapted for use in large animals with the concurrent use of gadolinium-based contrast media. Possible adverse reactions to its administration have been described in human and veterinary medicine, but there are no reports in foals. This case report describes the occurrence of seizure-like activity following administration of gadolinium to a 1.5-month old Finnish warmblood foal that was admitted for an MRI scan and cerebral spinal fluid collection. After the administration of contrast media, severe muscle twitching was observed. Prompt intervention, facilitated by constant patient monitoring and administration of propofol and diazepam, resulted in the control of the seizure and a favourable outcome. Since no alterations were found during the diagnostic investigation, it was suspected that the seizure-like activity might have been an adverse reaction to the contrast medium.

Effect of Goreisan, a traditional Japanese Kampo medicine, on postoperative nausea and vomiting in gynecological patients

Background

Goreisan, a traditional Japanese Kampo medicine, may prevent postoperative nausea and vomiting (PONV). The purpose of this study was to evaluate the effect of Goreisan on PONV in a high-risk population in a randomized, double-blind, placebo-controlled manner.

Findings

Patients undergoing gynecological surgery were randomly allocated to the Goreisan and the control groups. General anesthesia was induced with propofol and remifentanil. After endotracheal intubation, anesthesia was maintained with sevoflurane, fentanyl, and remifentanil. Goreisan 7.5 g dissolved in water (Goreisan group) or water (control group) in a volume of 20 ml was administered through a nasogastric tube approximately 1 h before completion of surgery. The primary outcome of this study was the incidence of PONV during the first 2 h after extubation. In the interim analysis, it was apparent that Goreisan has no effect. Therefore, we discontinued recruiting patients and present results based on data from 83 patients. The incidence of PONV during the first 2 h after extubation was 45% in the Goreisan group (n = 40) and 46.5% in the control group (n = 43) (p = 0.89). There was no significant difference in PONV incidence or severity during the first 24 h post-extubation.

Conclusion

Goreisan has little potency in preventing PONV in high-risk patients.

Are postoperative intravenous fluids in patients undergoing elective laparoscopic cholecystectomy a necessity? A randomized clinical trial

BACKGROUND

Intravenous (IV) fluid therapy should be individualized according to each patient's weight, disease, and comorbidities, as well as the type and duration of the operative procedure. Laparoscopic cholecystectomy represents one of the most common, short-duration operations; thus, the aim of this study was to assess the necessity of postoperative administration of IV fluids.

METHOD

A randomized clinical trial with patients undergoing elective laparoscopic cholecystectomy was performed. Patients were randomly assigned to control group (IV fluids at the surgeon's discretion) and study group (no IV fluids after the operation). Body weight and composition, total intravenous fluids, urinary output, creatinine levels, and the presence of thirst and hunger were assessed. Costs related to the administration of postoperative IV fluids were measured.

RESULTS

The study and control groups were similar with regard to sex distribution, age, and general characteristics. There was a significant difference in the amount of infused IV fluids (1,600 mL vs 3,000 mL), directly related to the amount offered postoperatively to the control group. Weight, extracellular water, and urinary output (1,257 ± 736 mL vs 888 ± 392 mL; P < .05) were increased in the control group, and this was positively correlated with the volume of infused fluids (r = 0.333). There were no differences in creatinine levels, thirst, hunger, and well-being features. An average of 10.7 minutes per patient of nursing time was required for IV administration. Cost related to IV fluids was increased in the control group.

CONCLUSION

Postoperative intravenous fluids are not necessary in patients undergoing laparoscopic cholecystectomy, and their use is associated with increased nursing time and costs.

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.

Efficacy of palonosetron in postoperative nausea and vomiting (PONV)-a meta-analysis

INTRODUCTION

Palonosetron is a second-generation 5-HT3 receptor antagonist with proposed higher efficacy and sustained action for prophylaxis of postoperative nausea and vomiting (PONV).

METHODS

Randomized controlled trials involving adult population undergoing elective surgery under general anesthesia comparing palonosetron to placebo, ramosetron, granisetron, and ondansetron were included. Data were extracted for vomiting incidence (VI), complete response (no nausea/vomiting; Complete Response [CR]), and rescue antiemetic need. This was categorized as early phase (24 hours postoperative for ramosetron and 6 hours for rest) and delayed phase (48 hours for ramosetron and 24 hours for rest). VI and CR were used as markers of drug efficacy. Any adverse effects were evaluated.

RESULTS

Twenty-two trials (4 with 3 groups) were included (comparing palonosetron to placebo in 5, ramosetron in 5, granisetron in 4, and ondansetron in 12 subgroups). Palonosetron demonstrated statistical superiority over placebo for VI and CR, both early/delayed PONV prevention. For delayed phase, palonosetron surpassed ramosetron in all 3 variables; however, none of the variables attained statistical significance during early phase. In early phase, palonosetron had better VI and CR than did granisetron; however, variables other than CR (better for palonosetron) failed to achieve statistical significance for delayed phase. All 3 outcomes were significantly better for palonosetron compared with ondansetron in delayed phase, but statistical superiority could only be demonstrated for VI in early phase. Being inconsistently documented across trials, nausea scores could not be evaluated.

CONCLUSION

Palonosetron is as safe as and more effective than placebo, ramosetron, granisetron, and ondansetron in preventing delayed PONV. For early PONV, it has higher efficacy over placebo, granisetron, and ondansetron.

Novel citation-based search method for scientific literature: application to meta-analyses

Background

Finding eligible studies for meta-analysis and systematic reviews relies on keyword-based searching as the gold standard, despite its inefficiency. Searching based on direct citations is not sufficiently comprehensive. We propose a novel strategy that ranks articles on their degree of co-citation with one or more “known” articles before reviewing their eligibility.

Method

In two independent studies, we aimed to reproduce the results of literature searches for sets of published meta-analyses (n = 10 and n = 42). For each meta-analysis, we extracted co-citations for the randomly selected ‘known’ articles from the Web of Science database, counted their frequencies and screened all articles with a score above a selection threshold. In the second study, we extended the method by retrieving direct citations for all selected articles.

Results

In the first study, we retrieved 82 % of the studies included in the meta-analyses while screening only 11 % as many articles as were screened for the original publications. Articles that we missed were published in non-English languages, published before 1975, published very recently, or available only as conference abstracts. In the second study, we retrieved 79 % of included studies while screening half the original number of articles.

Conclusions

Citation searching appears to be an efficient and reasonably accurate method for finding articles similar to one or more articles of interest for meta-analysis and reviews.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-015-0077-z) contains supplementary material, which is available to authorized users.

Toward standardized reporting of drug interactions: the READI checklist for anecdotal reports

Anecdotal reports contribute 30% of the literature on adverse drug reactions and interactions. However, the quality of such reports has not been uniformly high. Standardized reporting of clinical studies is of increasing interest, including the CARE guidelines on reporting anecdotal cases in general. Although there are guidelines on evaluating and managing drug-drug interactions, there are none recommending methods for reporting suspected drug interactions. Here, based on published guidelines for reporting suspected adverse drug reactions, I propose a checklist for reporting details of suspected drug interactions, the REporting Anecdotal Drug Interactions (READI) checklist, hoping to stimulate discussion and improve reporting of suspected drug interactions. The checklist includes items relating, among others, to the patient affected, the drugs involved, and the outcome.

Role of CYP2D6 Polymorphisms in the Outcome of Postoperative Pain Treatment

OBJECTIVE

To investigate the role of CYP2D6 phenotype in the outcome of postoperative (PO) pain (POP) treatment.

DESIGN

Longitudinal cohort study. Open-label trial with post hoc analysis.

SETTING

General Hospital Surgery and Recovery Units.

PATIENTS

Ninety unrelated Caucasians submitted to abdominal/thoracic surgery.

INTERVENTIONS

Standard multimodal POP treatment including opioids (tramadol) and nonsteroidal anti-inflammatory drugs (ketoprofen) at different dosages and infusion rates according to the predicted mild, moderate, or severe POP.

OUTCOME MEASURES

Pain (Numeric Rating Scale-NRS) and sedation (Ramsay Sedation Scale-RSS) up to 24 hours after surgery. By genotyping 16 CYP2D6 alleles, the four CYP2D6 phenotypes poor metabolizer (PM), intermediate metabolizers (IM), extensive metabolizers (EM) and ultrarapid metabolizers (UM) were predicted.

RESULTS

As compared with the CYP2D6-EM phenotype, in the early PO time (30 min) a higher RSS mean score in IM was observed (P = 0.035). A suggestion towards higher mean score in PM (P = 0.091) and a minor mean score in UM (P = 0.091) was also detected. No difference in the outcome of pain across the CYP2D6 phenotypes was observed.

CONCLUSIONS

In respect to the normal CYP2D6 phenotype, our results suggested that slowly metabolizers (IMs and PMs) might have a major sedation, whereas more rapid metabolizers (UM) a minor sedation, in the early time after surgery. A minor role of CYP2D6 phenotype in PO analgesia may be suggested.