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[Postoperative nausea and vomiting-recommendations for its prevention and therapy in paediatric medicine]. DIE ANAESTHESIOLOGIE 2023; 72:37-47. [PMID: 36602557 DOI: 10.1007/s00101-022-01248-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Post-operative nausea and/or vomiting (PONV/POV) are among the biggest problems occurring in the paediatric recovery room and in the course of the following post-operative period. Apart from pain and emergence delirium, PONV is one of the main causes of post-operative discomfort in children. The DGAI Scientific Working Group on Paediatric Anaesthesia already worked out recommendations for the prevention and treatment of PONV in children years ago. These recommendations have now been revised by a team of experts, the current literature has been reviewed, and evidence-based core recommendations have been consented. Key elements of the new recommendations consist of effective individual measures for prevention and therapy, next to the implementation of a fixed dual prophylaxis in the clinical routine applicable to all children ≥ 3 years of age.
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Drögemöller BI, Wright GEB, Trueman J, Shaw K, Staub M, Chaudhry S, Miao F, Higginson M, Groeneweg GSS, Brown J, Magee LA, Whyte SD, West N, Brodie SM, Jong G', Israels S, Berger H, Ito S, Rassekh SR, Sanatani S, Ross CJD, Carleton BC. A pharmacogenomic investigation of the cardiac safety profile of ondansetron in children and pregnant women. Pharmacotherapy 2022; 148:112684. [PMID: 35149390 DOI: 10.1016/j.biopha.2022.112684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/22/2022] [Accepted: 02/01/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ondansetron is a highly effective antiemetic for the treatment of nausea and vomiting. However, this medication has also been associated with QT prolongation. Pharmacogenomic information on therapeutic response to ondansetron exists, but no investigation has been performed on genetic factors that influence the cardiac safety of this medication. METHODS Three patient groups receiving ondansetron were recruited and followed prospectively (pediatric post-surgical patients n = 101; pediatric oncology patients n = 98; pregnant women n = 62). Electrocardiograms were conducted at baseline, and 5- and 30-min post-ondansetron administration, to determine the effect of ondansetron treatment on QT interval. Pharmacogenomic associations were assessed via analyses of comprehensive CYP2D6 genotyping and genome-wide association study data. RESULTS In the entire cohort, 62 patients (24.1%) met the criteria for prolonged QT, with 1.2% of the cohort exhibiting unsafe QT prolongation. The most significant shift from baseline occurred at five minutes post-ondansetron administration (P = 9.8 × 10-4). CYP2D6 activity score was not associated with prolonged QT. Genome-wide analyses identified novel associations with a missense variant in TLR3 (rs3775291; P = 2.00 × 10-7) and a variant linked to the expression of SLC36A1 (rs34124313; P = 1.97 × 10-7). CONCLUSIONS This study has provided insight into the genomic basis of ondansetron-induced cardiac changes and has emphasized the importance of genes that have been implicated in serotonin-related traits. These biologically-relevant findings represent the first step towards understanding this adverse event with the overall goal to improve the safety of this commonly used antiemetic medication.
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Affiliation(s)
- Britt I Drögemöller
- Department of Biochemistry and Medical Genetics, Rady Faculty of Health Sciences, University of Manitoba, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada; British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada
| | - Galen E B Wright
- British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Canada; Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Canada
| | - Jessica Trueman
- British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada
| | - Kaitlyn Shaw
- British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada
| | - Michelle Staub
- Clinical Research Unit, Children's Hospital Research Institute of Manitoba, Canada
| | - Shahnaz Chaudhry
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Canada
| | - Fudan Miao
- British Columbia Children's Hospital Research Institute, Canada
| | | | - Gabriella S S Groeneweg
- British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada
| | - James Brown
- British Columbia Women's Hospital and Health Centre, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada
| | - Laura A Magee
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College, UK
| | - Simon D Whyte
- British Columbia Children's Hospital Research Institute, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada; Department of Pediatric Anesthesia, British Columbia Children's Hospital, Canada
| | - Nicholas West
- British Columbia Children's Hospital Research Institute, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada; Department of Pediatric Anesthesia, British Columbia Children's Hospital, Canada
| | - Sonia M Brodie
- British Columbia Children's Hospital Research Institute, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada
| | - Geert 't Jong
- Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Canada; Clinical Research Unit, Children's Hospital Research Institute of Manitoba, Canada; Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada
| | - Sara Israels
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada
| | - Howard Berger
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Canada; Epi Methods Consulting, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Canada
| | - Shahrad R Rassekh
- British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada; Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Children's Heart Centre, BC Children's Hospital, University of British Columbia, Canada
| | - Shubhayan Sanatani
- Division of Cardiology, Department of Pediatrics, Children's Heart Centre, BC Children's Hospital, University of British Columbia, Canada
| | - Colin J D Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, Canada; British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada
| | - Bruce C Carleton
- Faculty of Pharmaceutical Sciences, University of British Columbia, Canada; British Columbia Children's Hospital Research Institute, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Canada.
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Yang H, Jeon W, Ko Y, Jeong S, Lee J. The effect of oral ondansetron on QT interval in children with acute gastroenteritis; a retrospective observational study. BMC Pediatr 2021; 21:501. [PMID: 34758763 PMCID: PMC8579543 DOI: 10.1186/s12887-021-02937-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background In mildly to moderately dehydrated patients with acute gastroenteritis (AGE), oral rehydration therapy (ORT) is the treatment of choice. Though ondansetron is a very effective antiemetics and leads to succeed ORT, there have been reports QT prolongation in patients using it. We investigated the effect of oral ondansetron on QT interval in mildly to moderately dehydrated children with AGE. Methods This retrospective observational study was conducted in a single pediatric emergency department (ED) of a tertiary university hospital. We collected the medical records of patients with a primary diagnosis of AGE who received oral ondansetron and underwent an electrocardiogram between January 2017 and June 2018. A pediatric emergency physician calculated the corrected QT interval (QTc) by Bazett’s method, and the calculations were reviewed by a pediatric cardiologist. QTc values before (preQTc) and after (postQTc) ondansetron administration were analyzed. ΔQTc was calculated as the change from preQTc to postQTc. We also investigated any cardiac complications from oral ondansetron. Results Total 80 patients were included. The mean age of the patients was 53.31 ± 32.42 months, and 45% were male. The mean dose of oral ondansetron was 0.18 ± 0.04 mg/kg. The mean interval from administration of ondansetron to performance of the electrocardiogram was 65 ± 26 min. The mean preQTc was 403.3 ± 24.0 ms, and the mean postQTc was 407.2 ± 26.7 ms. Two patients had a preQTc ≥460 ms, and one patient had a postQTc ≥460 ms. ΔQTc was ≥30 ms in seven patients (8.8%). No ΔQTc was ≥60 ms. No pre- or postQTc was ≥500 ms. No patient had a fatal cardiac arrhythmia after taking ondansetron. Conclusion Oral administration of a single dose of ondansetron in children with AGE did not cause high-risk QTc prolongation or fatal arrhythmia.
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Affiliation(s)
- Heewon Yang
- Department of Emergency Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Woochan Jeon
- Department of Emergency Medicine, Inje University, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Yura Ko
- Department of Emergency Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Sooin Jeong
- Division of Pediatric Cardiology, Department of Pediatrics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jisook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea.
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Abstract
Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.
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Affiliation(s)
- Anthony L Kovac
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS, 66160, USA.
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5
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Safaeian R, Hassani V, Asghari A, Mohseni M, Ashraf H, Koleini ZS. The effects of ondansetron versus dexamethasone on electrocardiographic markers of ventricular repolarization in children undergoing cochlear implant. Int J Pediatr Otorhinolaryngol 2020; 132:109896. [PMID: 32032916 DOI: 10.1016/j.ijporl.2020.109896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/06/2020] [Accepted: 01/18/2020] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Congenital hearing loss is associated with cardiac rhythm disturbances namely long Q-T syndrome. This study was designed to investigate the effect of anti-emetic doses of ondansetron and dexamethasone on ECG recordings in children undergoing cochlear implant surgery. METHODS Sixty-three pediatric patients scheduled for elective cochlear implantation were enrolled in the study. Two patients were excluded as their baseline ECG showed long QT syndrome. Anesthesia was induced with fentanyl, propofol and atracurium and maintained with propofol. Dexamethasone 0.1 mg.kg-1or ondansetron 0.2 mg.kg-1was randomly administered for the participants approximately 30 min before the end of surgery. ECG recording was performed 15 min after induction of anesthesia and 15 min after dexamethasone/ondansetron administration. RR interval, QRS duration, QT interval, and Tp-e interval were measured by a blinded cardiologist. RESULTS Ondansetron resulted in no significant changes in RR, JTc and QTc intervals; while prolongedTp-e interval. Multivariable logistic regression analysis showed that use of ondansetron was an independent predictor of QTc prolongation after adjustment for age, gender and baseline QTc (OR = 17.94, CI 95% 1.97-168.70, p = 0.011). The incidence of postoperative retching/vomiting in ondansetron group was significantly lower than dexamethasone group. (3.2% vs. 26.7%, p = 0.011). CONCLUSION The risk of arrhythmias with the use of ondansetron in otherwise healthy candidates of cochlear implant is very low. However, the drug may induce significant changes in ECG parameters. The clinical significance of these changes in patients with cardiac conduction abnormalities should be investigated in further studies.
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Affiliation(s)
- Reza Safaeian
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | - Valiollah Hassani
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | - Alimohamad Asghari
- Skull Base Research Center, The Five Senses Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Masood Mohseni
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran.
| | - Haleh Ashraf
- Cardiac Primary Prevention Research Center (CPPRC), Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Sadat Koleini
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
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Görges M, Sherwin ED, Poznikoff AK, West NC, Brodie SM, Whyte SD. Effects of Dexmedetomidine on Myocardial Repolarization in Children Undergoing General Anesthesia: A Randomized Controlled Trial. Anesth Analg 2020; 129:1100-1108. [PMID: 30985379 DOI: 10.1213/ane.0000000000004135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Dexmedetomidine is a highly selective α2-adrenergic agonist, which is increasingly used in pediatric anesthesia and intensive care. Potential adverse effects that have not been rigorously evaluated in children include its effects on myocardial repolarization, which is important given that the drug is listed as a possible risk factor for torsades de pointes. We investigated the effect of 3 different doses of dexmedetomidine on myocardial repolarization and transmural dispersion in children undergoing elective surgery with total IV anesthesia. METHODS Sixty-four American Society of Anesthesiologists I-II children 3-10 years of age were randomized to receive dexmedetomidine 0.25 µg/kg, 0.5 µg/kg, 0.75 µg/kg, or 0 µg/kg (control), as a bolus administered over 60 seconds, after induction of anesthesia. Pre- and postintervention 12-lead electrocardiograms were recorded. The interval between the peak and the end of the electrocardiogram T wave (Tp-e; transmural dispersion) and heart rate-corrected QT intervals (myocardial repolarization) were measured by a pediatric electrophysiologist blinded to group allocation. Data were analyzed using an analysis of covariance regression model. The study was powered to detect a 25-millisecond difference in Tp-e. RESULTS Forty-eight children completed the study, with data analyzed from 12 participants per group. There were no instances of dysrhythmias. Tp-e values were unaffected by dexmedetomidine administration at any of the studied doses (F = 0.09; P = .96). Mean (99% CI) within-group differences were all <2 milliseconds (-5 to 8). Postintervention, corrected QT interval increased in the control group, but decreased in some dexmedetomidine groups (F = 7.23; P < .001), specifically the dexmedetomidine 0.5 and 0.75 µg/kg doses. Within groups, the mean (99% CI) differences between pre- and postintervention corrected QT interval were 12.4 milliseconds (-5.8 to 30.6) in the control group, -9.0 milliseconds (-24.9 to 6.9) for dexmedetomidine 0.25 µg/kg, -18.6 milliseconds (-33.7 to -3.5) for dexmedetomidine 0.5 µg/kg, and -14.1 milliseconds (-27.4 to -0.8) for dexmedetomidine 0.75 µg/kg. CONCLUSIONS Of the bolus doses of dexmedetomidine studied, none had an effect on Tp-e and the dexmedetomidine 0.5 and 0.75 µg/kg doses shortened corrected QT intervals when measured at 1 minute after dexmedetomidine bolus injection during total IV anesthesia. There is no evidence for an increased risk of torsades de pointes in this context.
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Affiliation(s)
- Matthias Görges
- From the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.,Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Andrew K Poznikoff
- From the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Pediatric Anesthesia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Nicholas C West
- From the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonia M Brodie
- From the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Simon D Whyte
- From the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.,Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.,Department of Pediatric Anesthesia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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Nakajima D, Kawakami H, Mihara T, Sato H, Goto T. Effectiveness of intravenous lidocaine in preventing postoperative nausea and vomiting in pediatric patients: A systematic review and meta-analysis. PLoS One 2020; 15:e0227904. [PMID: 31990953 PMCID: PMC6986726 DOI: 10.1371/journal.pone.0227904] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/26/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intravenous lidocaine in adults undergoing general anesthesia has been shown to reduce the incidence of postoperative nausea and vomiting (PONV). However, the anti-postoperative vomiting (POV) effect of lidocaine in pediatric patients remains unclear. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of intravenous lidocaine on prevention of POV/PONV. METHODS Six databases including trial registration sites were searched. Randomized clinical trials evaluating the incidence of POV/PONV after intravenous lidocaine compared with control were included. The primary outcome was the incidence of POV within 24 hours after general anesthesia. The incidence of POV was combined as a risk ratio with 95% confidence interval using a random-effect model. We used the I2 to assess heterogeneity. We evaluated the quality of trials using the Cochrane methodology, and we assessed quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events. RESULTS AND DISCUSSION Six trials with 849 patients were included, of whom 433 received intravenous lidocaine. Three trials evaluated the incidence of POV, and 3 evaluated the incidence of PONV. The overall incidence of POV within 24 hours after anesthesia was 45.9% in the lidocaine group and 63.4% in the control group (risk ratio, 0.73; 95% confidence interval, 0.53-1.00; I2 = 32%; p = 0.05). The incidence of PONV within 24 hours after anesthesia was 3.73% in the lidocaine group and 4.87% in the control group (RR, 0.76; 95% CI, 0.36-1.59; I2 = 0%; p = 0.47). The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, imprecision, and possible publication bias. CONCLUSION Our meta-analysis suggests that intravenous lidocaine infusion may reduce the incidence of POV, however, the evidence quality was "very low." Further trials with a low risk of bias are necessary.
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Affiliation(s)
- Daisuke Nakajima
- Intensive Care Department, Yokohama City University Medical Center, Yokohama, Japan
- * E-mail:
| | - Hiromasa Kawakami
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Takahiro Mihara
- Education and Training Department, YCU Center for Novel and Exploratory Clinical Trials, Yokohama City University Hospital, Yokohama, Japan
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Hitoshi Sato
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Takahisa Goto
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
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9
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Patel P, Paw Cho Sing E, Dupuis LL. Safety of clinical practice guideline-recommended antiemetic agents for the prevention of acute chemotherapy-induced nausea and vomiting in pediatric patients: a systematic review and meta-analysis. Expert Opin Drug Saf 2019; 18:97-110. [DOI: 10.1080/14740338.2019.1568988] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Priya Patel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Pediatric Oncology Group of Ontario, Toronto, Canada
| | - Edric Paw Cho Sing
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
| | - L. Lee Dupuis
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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Abstract
OBJECTIVE Ondansetron improves the success of oral rehydration in children with gastroenteritis. In postoperative adults, ondansetron has been shown to prolong the corrected QT (QTc). The aim of the study was to evaluate the effect of ondansetron on the QT at peak effect and at 1-hour postpeak effect in pediatric patients. METHODS This was an observational study looking at patients aged 6 months to 18 years receiving intravenous ondansetron for nausea, vomiting, or the inability to take fluids in the emergency department. Patients had electrocardiogram performed at baseline, at ondansetron's peak effect, and 1 hour postpeak effect. A paired samples Student t test compared QTc change at peak effect to zero. Peak effect of intravenous ondansetron is 3 minutes. RESULTS One hundred patients were included. Fifty-five percent of patients were female with a mean age of 8.3 years. The mean (range) baseline QTc was 435 (388 to 501) milliseconds. The mean (range) change in QTc at peak effect of ondansetron was 3 (-40 to 65) milliseconds (P = 0.072). The change in QTc 1-hour postpeak effect of ondansetron was 3 (-43 to 45) milliseconds (P = 0.082). No change at peak effect or 1-hour postpeak effect was clinically significant. CONCLUSIONS Ondansetron does not affect the QTc of pediatric patients receiving the medication for nausea, vomiting, or inability to take fluids in the emergency department. No changes in the QTc are clinically significant. To date, there have been no studies evaluating the effect of ondansetron in this acutely ill population; therefore, a larger study should be completed to confirm these data.
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Ataro G. Anesthesia for children with long QT syndrome: Challenges and solutions from pediatric studies. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kitaura A, Nakao S, Hamasaki S, Houri K, Tsujimoto T, Kimura S, Matsushima M. Sevoflurane prolonged the QTc interval and increased transmural dispersion of repolarization in a patient with long QT syndrome 3: a case report. JA Clin Rep 2017; 3:29. [PMID: 29457073 PMCID: PMC5804612 DOI: 10.1186/s40981-017-0093-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 05/02/2017] [Indexed: 02/02/2023] Open
Abstract
We report that sevoflurane not only caused marked QTc interval prolongation but also increased transmural dispersion of repolarization in a patient with long QT syndrome 3 (LQT3). A 16-year-old male with LQT3 underwent a shoulder operation. He experienced no episode of syncope or cardiac arrest, but his preoperative electrocardiography (ECG) showed marked QTc interval prolongation (631 ms) and Tp-e interval prolongation (126 ms). Anesthesia was induced with propofol and maintained with 2% sevoflurane and remifentanil. Although no lethal arrhythmias occurred in the perioperative period, not only the QTc interval but also Tp-e interval was further prolonged by sevoflurane. While sevoflurane has been recognized as a safe anesthetic in terms of QT interval prolongation, even in patients with long QT syndromes, we believe that sevoflurane might be avoided for poorly controlled LQT3 patients.
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Affiliation(s)
- Atsuhiro Kitaura
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Shinichi Hamasaki
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Kei Houri
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Takatoshi Tsujimoto
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Seishi Kimura
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Mayuka Matsushima
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
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Moeller JR, Gummin DD, Nelson TJ, Drendel AL, Shah BK, Berger S. Risk of Ventricular Arrhythmias and Association with Ondansetron. J Pediatr 2016; 179:118-123.e1. [PMID: 27665040 DOI: 10.1016/j.jpeds.2016.08.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/18/2016] [Accepted: 08/17/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the use of ondansetron in a tertiary care pediatric health system, assess the incidence of ventricular tachyarrhythmia within 24 hours of ondansetron, and identify the characteristics of children experiencing a ventricular tachyarrhythmia after ondansetron, to identify potential risk factors. STUDY DESIGN This retrospective chart review identified children ≤18 years of age who received ondansetron within 24 hours prior to a ventricular tachyarrhythmia. Those identified were evaluated for other diagnoses, concomitant medication use, electrolyte abnormalities, or underlying conduction abnormalities that may have contributed to the arrhythmia. RESULTS A total of 199 773 doses of ondansetron were administered to 37 794 patients over 58 009 visits. Average dose was 0.13 mg/kg/dose (range 0.005-0.86 mg/kg/dose). Seven patients received ondansetron within 24 hours prior to a ventricular arrhythmia. All 7 patients had underlying congenital cardiac conduction abnormalities (n = 3) or other major cardiac diagnoses (n = 4). In clinical review, torsades de pointes was found in only 1 of the 7 patients. CONCLUSIONS This retrospective study found the risk of ventricular arrhythmia within 24 hours after ondansetron administration was 3 in 100 000 patients treated annually (0.003%). Children with major cardiac conditions could be considered for electrocardiogram screening and continuous cardiac monitoring while receiving ondansetron. Our findings do not support recommendations for electrocardiogram screening or continuous monitoring of other pediatric populations receiving ondansetron.
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Affiliation(s)
- Jaclyn R Moeller
- Department of Pharmacy, Children's Hospital of Wisconsin, Milwaukee, WI
| | - David D Gummin
- Wisconsin Poison Center, Children's Hospital of Wisconsin, Milwaukee, WI; Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
| | - Tom J Nelson
- Department of Pharmacy, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Amy L Drendel
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Breanne K Shah
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Stuart Berger
- Department of Pediatrics, Northwestern University, Chicago, IL; Lurie Children's Hospital of Chicago, Chicago, IL
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Abstract
INTRODUCTION Ondansetron is commonly used to treat vomiting in gastroenteritis, but has a United States Food and Drug Administration black box warning for risk of Q wave to T wave time interval (QT) prolongation. We report 2 pediatric cases of fatal refractory cardiac arrest after administration of ondansetron. CASES A 10-year-old previously healthy boy presented to the emergency room with gastroenteritis symptoms. After intravenous fluids, morphine, antibiotics, and 2 doses of ondansetron, the patient became unresponsive with agonal respirations and a wide complex tachycardia consistent with ventricular tachycardia. In a second case, an 86-day-old infant with previously unidentified congenital cardiomyopathy presented to our emergency department with gastroenteritis symptoms. The patient received ondansetron and subsequently experienced repeated bouts of supraventricular tachycardia which progressed to ventricular fibrillation. Resuscitation efforts failed in each case, and both patients expired. DISCUSSION Ondansetron can cause dose-dependent QT prolongation effects, which are more clinically relevant when other proarrhythmic elements are present. There is very limited published experience on use of ondansetron in children younger than 2 years. Our 2 cases join 2 previous case reports of death after ondansetron administration for gastroenteritis. The pharmacology of ondansetron's cardiac effects and drug-induced QT prolongation is discussed. CONCLUSIONS Patients may have hidden risk factors that, together with ondansetron, could result in a proarrhythmic state that could lead to adverse effects, such as arrhythmias. Administration of ondansetron should be individualized and used cautiously in patients with risk factors for arrhythmia.
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15
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Abstract
OBJECTIVES There is no evidence regarding the effect of ondansetron on the QT interval in pediatric patients in the ICU. This study aimed to describe the effect of ondansetron on the corrected QT interval in patients cared for in the PICU. DESIGN Retrospective cohort, consecutive enrollment study. SETTING Single-center, tertiary-level, medical/surgical PICU. PATIENTS All patients less than 8 years old who received ondansetron over an 11-month period were included. Exclusion criteria were atrial arrhythmia, bundle-branch block, known congenital long QT syndrome, and concomitant administration of proarrhythmic antiarrhythmic agents. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 210 doses of ondansetron were administered to 107 patients, with a mean age 10.5 ± 4.8 years; 49% were men. Corrected QT interval increased to 460-500 ms in 29% and to more than 500 ms in 11% of events of ondansetron administration. The mean baseline corrected QT interval even before ondansetron administration was higher for these groups (460-500 and > 500 ms; 457 ± 33 and 469 ± 45, respectively; p ≤ 0.05). In multivariate analysis, both groups were associated significantly with underlying electrolyte abnormalities (odds ratio, 2.2; 95% CI, 1.1-4.4 and odds ratio, 5.1; 95% CI, 1.8-15.7, respectively); the group with corrected QT interval more than 500 ms was also significantly associated with organ dysfunction (odds ratio, 3.2; 95% CI, 1.1-9.4). As the numbers of risk factors increased from only ondansetron to three additional QT aggravating factors (electrolyte abnormalities, administration of other QT-prolonging drugs, and organ dysfunction), the likelihood of being associated with corrected QT interval more than 500 ms increased. CONCLUSIONS Prolonged QT interval is observed commonly in PICUs following the administration of ondansetron. Underlying risk factors, such as electrolyte abnormalities and organ dysfunction, seem to pose the highest risk of prolongation of QT interval in these patients. The awareness of prevalent risk factors for increased corrected QT interval may help identify patients at high risk for arrhythmias.
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Tracz K, Owczuk R. Small doses of droperidol do not present relevant torsadogenic actions: a double-blind, ondansetron-controlled study. Br J Clin Pharmacol 2015; 79:669-76. [PMID: 25293524 DOI: 10.1111/bcp.12527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM Drugs used for postoperative nausea and vomiting prophylaxis are believed to provoke torsadogenic changes in cardiac repolarization. The aim of this study was to assess the effect of small doses of droperidol on the parameters of cardiac repolarization, including the QTc interval and transmural dispersion of repolarization. METHODS A total of 75 patients were randomly allocated to receive 0.625 or 1.25 mg droperidol or 8 mg ondansetron. The QTc interval was calculated using Bazett's formula and the Framingham correction. The transmural dispersion of repolarization was determined as Tpeak -Tend time. RESULTS Transient QT prolongation, corrected with both formulae, followed 1.25 mg of droperidol 10 min after administration. No change in the QTc value was observed in the other groups. When corrected with Bazett's formula, QTc was prolonged above 480 ms in two patients receiving 1.25 mg droperidol (at the 10(th) and 20(th) minute of the study) and in one receiving ondansetron. No patients developed a QTc B prolongation over 500 ms. No increase above 480 ms was observed relative to the Framingham correction method. There were no significant differences in the Tpeak -Tend time either between or within the groups. CONCLUSION In men without cardiovascular disorders small doses (1.25 mg) of droperidol prophylaxis induced transient QTc prolongation without changes in transmural dispersion of repolarization. The apparently low risk of the drug applies only in low risk male patients with a low pro-QTc score.
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Affiliation(s)
- Krzysztof Tracz
- Department of Anaesthesiology and Intensive Therapy, Copernicus Medical Centre, Gdańsk, Poland
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17
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Agámez Medina GL, González-Arévalo A, Gómez-Arnau JI, García del Valle S, Rubio JA, Esteban E, Pérez E. Effects of droperidol and ondansetron on dispersion of ventricular repolarization: A randomized double-blind clinical study in anesthetized adult patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:495-501. [PMID: 25887095 DOI: 10.1016/j.redar.2015.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Droperidol and ondansetron prolong QT interval, a circumstance that has raised some concerns regarding the possibility of inducing torsades de pointes (TdP). However drug-induced spatial dispersion of ventricular repolarization has been shown to be the principal arrhythmogenic substrate for TdP. The aim of this study is to explore the effects of droperidol and ondansetron on the dispersion of repolarization, measured using the T peak-to-end interval (Tp-e) and Tp-e/QT and Tp-e/RR(1/2) ratios in surgical anesthetized patients. METHODS A randomized, double-blind study carried out on sixty-three adult patients without cardiac disease or factors favoring QT prolongation and undergoing non-cardiac surgery were randomly assigned to the droperidol or ondansetron group. Under propofol anesthesia, a 12-lead EKG was obtained, and 1.25mg droperidol or 4mg ondansetron was injected. Five minutes later, a new 12-lead EKG was recorded. EKG analyses were independently performed by two cardiologists blinded to the state of the traces or group allocation. QT, RR and Tp-e intervals were measured by averaging five successive beats in leadII (QT) or V5 (Tp-e). The mean value for each measurement was calculated for statistical analysis. RESULTS Thirty-two patients (19 women) received droperidol, and 31 (22 women) ondansetron. Droperidol and ondansetron prolonged the QTcF interval (Fridericia formula) by 6.8 and 7.2ms (mean values) respectively, but neither droperidol nor ondansetron increased the Tp-e interval or Tp-e/QT and Tp-e/RR(1/2) ratios. CONCLUSION At antiemetic doses, neither ondansetron (4mg) nor droperidol (1.25mg) increases the dispersion of ventricular repolarization in healthy adult patients anesthetized with propofol.
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Affiliation(s)
- G L Agámez Medina
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | - A González-Arévalo
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - J I Gómez-Arnau
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - S García del Valle
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - J A Rubio
- Unidad de Cardiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - E Esteban
- Unidad de Cardiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - E Pérez
- Research Institute, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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Tricco AC, Soobiah C, Blondal E, Veroniki AA, Khan PA, Vafaei A, Ivory J, Strifler L, Ashoor H, MacDonald H, Reynen E, Robson R, Ho J, Ng C, Antony J, Mrklas K, Hutton B, Hemmelgarn BR, Moher D, Straus SE. Comparative safety of serotonin (5-HT3) receptor antagonists in patients undergoing surgery: a systematic review and network meta-analysis. BMC Med 2015; 13:142. [PMID: 26084332 PMCID: PMC4472408 DOI: 10.1186/s12916-015-0379-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 05/19/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Serotonin (5-HT3) receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients, but these agents may be harmful. We conducted a systematic review on the comparative safety of 5-HT3 receptor antagonists. METHODS Searches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or other antiemetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by two reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. PROSPERO registry number: CRD42013003564. RESULTS Overall, 120 studies and 27,787 patients were included after screening of 7,608 citations and 1,014 full-text articles. Significantly more patients receiving granisetron plus dexamethasone experienced an arrhythmia relative to placebo (odds ratio (OR) 2.96, 95 % confidence interval (CI) 1.11-7.94), ondansetron (OR 3.23, 95 % CI 1.17-8.95), dolasetron (OR 4.37, 95 % CI 1.51-12.62), tropisetron (OR 3.27, 95 % CI 1.02-10.43), and ondansetron plus dexamethasone (OR 5.75, 95 % CI 1.71-19.34) in a NMA including 31 randomized clinical trials (RCTs) and 6,623 patients of all ages. No statistically significant differences in delirium frequency were observed across all treatment comparisons in a NMA including 18 RCTs and 3,652 patients. CONCLUSION Granisetron plus dexamethasone increases the risk of arrhythmia.
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 6th floor, 155 College St, Toronto, ON, M5T 3M7, Canada.
| | - Charlene Soobiah
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Institute for Health Policy Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON, M5T 3M6, Canada.
| | - Erik Blondal
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Areti A Veroniki
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Paul A Khan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Afshin Vafaei
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - John Ivory
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Lisa Strifler
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Huda Ashoor
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Heather MacDonald
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Emily Reynen
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Reid Robson
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Joanne Ho
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Carmen Ng
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Kelly Mrklas
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Departments of Community Health Sciences, Faculty of Medicine, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive, Calgary, AB, T2N 4Z6, Canada.
| | - Brian Hutton
- Clinical Epidemiology Program, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Brenda R Hemmelgarn
- Departments of Community Health Sciences, Faculty of Medicine, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive, Calgary, AB, T2N 4Z6, Canada.
| | - David Moher
- Clinical Epidemiology Program, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada.
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19
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Abstract
PURPOSE OF REVIEW Postoperative nausea and vomiting (PONV) has a high incidence in children and requires prophylactic and therapeutic strategies. RECENT FINDINGS PONV can be reduced by the avoidance of nitrous oxide, volatile anesthetics, and the reduction of postoperative opioids. The use of dexamethasone, 5-HT3 antagonists, or droperidol alone is potent, but combinations are even more effective to reduce PONV. Droperidol has a Food and Drug Administration warning. Hence, dexamethasone and 5-HT3 antagonists should be preferred as prophylactic drugs. It is further reasonable to adapt PONV prophylaxis to different risk levels. Prolonged surgery time, inpatients, types of surgery (e.g. strabismus and ear-nose-throat surgery), and patients with PONV in history should be treated as high risk, whereas short procedures and outpatients are to be treated as low risk. SUMMARY Concluding from the existing guidelines and data on the handling of PONV in children at least 3 years, the following recommendations are given: outpatients undergoing small procedures should receive a single prophylaxis, outpatients at high risk a double prophylaxis, inpatients with surgery time of more than 30 min and use of postoperative opioids should get double prophylaxis, and inpatients receiving a high-risk surgical procedure or with other risk factors a triple prophylaxis (two drugs and total intravenous anesthesia). Dimenhydrinate can be used as a second choice, whereas droperidol and metoclopramide can only be recommended as rescue therapy.
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Effect of ramosetron on the QT interval during sevoflurane anaesthesia in children: a prospective observational study. Eur J Anaesthesiol 2014; 32:330-5. [PMID: 25485883 DOI: 10.1097/eja.0000000000000200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated the effects of concomitant administration of sevoflurane and ramosetron on the QT interval, the interval between the peak and end of the T wave (Tpe) and Tpe/QT ratio in children. OBJECTIVES To compare the effects of concomitant administration of ramosetron and sevoflurane on heart rate corrected interval with Bazett's formula (QTc), Tpe interval and Tpe/QT ratio. DESIGN A prospective observational study. SETTING Elective orthopaedic surgery with patient-controlled analgesia. PATIENTS Forty children aged between 3 and 12 years. INTERVENTION ECG recordings were collected before induction (BASE), before sevoflurane administration (SEVO) and after the administration of ramosetron (SEVO and R). MAIN OUTCOME MEASURES The heart rate corrected interval with Bazett's formula (QTc), Tpe interval and Tpe/QT ratio were calculated and the changes were analysed using repeated-measures analysis of variance (ANOVA). RESULTS The QTc interval at BASE was 388.5 ± 29.3 ms. It increased with sevoflurane anaesthesia to 414.9 ± 21.4 ms and did not change with the administration of ramosetron (418.2 ± 23.0 ms). The Tpe interval and Tpe/QT ratio did not differ between measurements. No ventricular arrhythmias occurred during the study. CONCLUSION Ramosetron was not associated with prolongation of the QTc interval when it was given concomitantly with sevoflurane in children. No ventricular arrhythmias or other adverse effects occurred during the study.
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Whyte SD, Nathan A, Myers D, Watkins SC, Kannankeril PJ, Etheridge SP, Andrade J, Collins KK, Law IH, Hayes J, Sanatani S. The safety of modern anesthesia for children with long QT syndrome. Anesth Analg 2014; 119:932-938. [PMID: 25076102 DOI: 10.1213/ane.0000000000000389] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with long QT syndrome (LQTS) may experience a clinical spectrum of symptoms, ranging from asymptomatic, through presyncope, syncope, and aborted cardiac arrest, to sudden cardiac death. Arrhythmias in LQTS are often precipitated by autonomic changes. This patient population is believed to be at high risk for perioperative arrhythmia, specifically torsades de pointes (TdP), although this perception is largely based on limited literature that predates current anesthetic drugs and standards of perioperative monitoring. We present the largest multicenter review to date of anesthetic management in children with LQTS. METHODS We conducted a multicentered retrospective chart review of perioperative management of children with clinically diagnosed LQTS, aged 18 years or younger, who received general anesthesia (GA) between January 2005 and January 2010. Data from 8 institutions were collated in an anonymized database. RESULTS One hundred three patients with LQTS underwent a total of 158 episodes of GA. The median (interquartile range) age and weight of the patients at the time of GA was 9 (3-15) years and 30.3 (15.4-54) kg, respectively. Surgery was LQTS-related in 81 (51%) GA episodes (including pacemaker, implantable cardioverter-defibrillator, and loop recorder insertions and revisions and lead extractions) and incidental in 77 (49%). β-blocker therapy was administered to 76% of patients on the day of surgery and 47% received sedative premedication. Nineteen percent of patients received total IV anesthesia, 30% received total inhaled anesthesia, and the remaining 51% received a combination. No patient received droperidol. There were 5 perioperative episodes of TdP, all in neonates or infants, all in surgery that was LQTS-related, and none of which was overtly attributable to anesthetic regimen. Thus the incidence (95% confidence interval) of perioperative TdP in incidental versus LQTS-related surgery was 0/77 (0%; 0%-5%) vs 5/81 (6.2%; 2%-14%). CONCLUSIONS With optimized perioperative management, modern anesthesia for incidental surgery in patients with LQTS is safer than anecdotal case report literature might suggest. Our series suggests that the risk of perioperative TdP is concentrated in neonates and infants requiring urgent interventions after failed first-line management of LQTS.
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Affiliation(s)
- Simon D Whyte
- From the Department of Pediatric Anesthesia, BC Children's Hospital and Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada; Pediatric Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Pediatric Cardiac Anesthesia, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee; Pediatric Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee; Pediatric Cardiology, University of Utah School of Medicine and Primary Children's Medical Center, Salt Lake City, Utah; Montreal Heart Institute, Montreal, Quebec, Canada; Cardiology, Children's Hospital Colorado, Aurora, Colorado; Division of Cardiology, University of Iowa Children's Hospital, Iowa City, Iowa; Pediatric Anesthesia, The Hospital for Sick Children, Toronto, Ontario, Canada; and Children's Heart Centre, BC Children's Hospital and Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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22
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Abstract
This case report describes a 10-year-old female patient who underwent ketamine sedation for fracture reduction and experienced asymptomatic ventricular tachycardia after the sedation. She had no history of syncope, chest pain, palpations, or light-headedness and had a normal physical examination. This is the first reported case of a patient experiencing ventricular tachycardia after ketamine use for sedation. This case demonstrates a serious and potentially harmful possible adverse effect of ketamine administration.
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Erdil F, Begeç Z, Kayhan GE, Yoloğlu S, Ersoy MÖ, Durmuş M. Effects of sevoflurane or ketamine on the QTc interval during electroconvulsive therapy. J Anesth 2014; 29:180-5. [DOI: 10.1007/s00540-014-1899-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 07/23/2014] [Indexed: 11/29/2022]
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Lee JH, Park YH, Kim JT, Kim CS, Kim HS. The effect of sevoflurane and ondansetron on QT interval and transmural dispersion of repolarization in children. Paediatr Anaesth 2014; 24:421-5. [PMID: 24372925 DOI: 10.1111/pan.12339] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study evaluated the prolongation of QT interval by the combination of sevoflurane and ondansetron in pediatric patients. Additionally, transmural dispersion of repolarization as interval between the peak and end of the T wave (Tp-e) and Tp-e/QT ratio was also measured to assess the risk of ventricular arrhythmia. METHODS The 3-lead electrocardiography (ECG) in lead II was sampled at three stages: at preinduction, just before (Sevo alone) and finally, after administration of ondansetron (Sevo+Ondansetron) in 41 children aged from 3 to 12 years. The QT interval was corrected for heart rate using Bazett's formula. And, Tp-e interval was obtained, and Tp-e/QT ratio was calculated. For analysis of the changes of parameters, a repeated-measures analysis of variance was used to identify significant differences in QTc, Tp-e interval and Tp-e/QT ratio at the three epochs. RESULTS The mean QTc at preinduction period was 413.8 (20.8) ms. The mean Sevo alone and Sevo+Ondansetron QTcs were 432.5 (28.1) and 439.2 (27.6) ms, and the differences in QTc prolongation between stages were all significant (P < 0.01). Ondansetron increased Tp-e interval significantly; however, Tp-e/QT ratio was not different among three stages. There were no ECG abnormalities such as atrial or ventricular arrhythmia and T-wave abnormality in any patient. CONCLUSIONS Sevoflurane prolongs the QTc interval and its combination with ondansetron further increased this effect in children. However, the dispersion of ventricular repolarization was not significantly affected, and there were no adverse events such as ventricular arrhythmia in this study. The combination of sevoflurane and ondansetron may be clinically safe, but careful ECG monitoring is still advisable.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul, Korea
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25
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Abstract
The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.
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Does low-dose droperidol increase the risk of polymorphic ventricular tachycardia or death in the surgical patient? Anesthesiology 2013; 118:382-6. [PMID: 23291623 DOI: 10.1097/aln.0b013e31827dde8d] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes. METHODS The primary objective of this retrospective study was to determine if low-dose (0.625 mg) droperidol administration was associated with episodes of torsade de pointes in the general surgical population during the 3-yr period following the reinstitution of droperidol to our institutional formulary. RESULTS The authors identified 20,122 surgical patients who received 35,536 doses of droperidol. These patients were cross-matched with an electrocardiogram database and an adverse outcome database. The charts of 858 patients were reviewed, including patients with documentation of prolonged QTc (>440 ms) from March 2007 to February 2011, polymorphic ventricular tachycardia (VT) within 48 h of receiving droperidol, or death within 7 days of receiving droperidol. Twelve surgical patients had VT (n = 4) or death (n = 8) documented within 48 h of droperidol administration. No patients developed polymorphic VT or death due to droperidol administration (n = 0). The eight patients that died were on palliative care. The four patients with documented VT had previous cardiac conditions: two had pre-existing implantable cardiac defibrillators, three had episodes of VT before receiving droperidol, and another had pre-existing hypertrophic obstructive cardiomyopathy. The authors found 523 patients with a documented QTc >440 ms before receiving droperidol. No patients developed VT or death as a direct result of droperidol administration. CONCLUSIONS Our evidence suggests that low-dose droperidol does not increase the incidence of polymorphic VT or death when used to treat postoperative nausea and vomiting in the surgical population.
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Johnston J, Pal S, Nagele P. Perioperative torsade de pointes: a systematic review of published case reports. Anesth Analg 2013; 117:559-564. [PMID: 23744954 DOI: 10.1213/ane.0b013e318290c380] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Torsade de pointes is a rare but potentially fatal arrhythmia. More than 40 cases of perioperative torsade de pointes have been reported in the literature; however, the current evidence regarding this complication is very limited. To improve our understanding, we performed a systematic review and meta-analysis of all published case reports of perioperative torsade de pointes. METHODS MEDLINE was systematically searched for cases of perioperative torsade de pointes. We included patients of all age groups and cases that occurred from the immediate preoperative period to the third postoperative day. Patient and case characteristics as well as QT interval data were extracted. RESULTS Forty-six cases of perioperative torsade de pointes were identified; 29 occurred in women (67%), and 2 episodes were fatal (case fatality rate: 4%). Craniotomies and cardiac surgery accounted for 40% of all cases. Preceding events identified by the authors were hypokalemia (12/46, 26%; 99% confidence interval [CI], 9%-43%) and bradycardia (7/46, 15%; 99% CI, 2%-28%). Drugs were implicated in approximately one third of the events (14/46, 30%; 99% CI, 13%-48%). The mean corrected QT (QTc) at baseline was 457 ± 67 milliseconds (minimum 320 milliseconds; maximum 647 milliseconds; data available in 27/46 patients). At the time of the event, the mean QTc increased to 575 ± 77 milliseconds (minimum 413 milliseconds; maximum 766 milliseconds; data available in 33/46 patients). On average, QTc increased by +118 milliseconds (99% CI, 70-166 milliseconds; P < 0.001) between baseline and after the torsade de pointes event. All patients, except for 2, had a substantial prolongation of their QTc interval at the time of the event. CONCLUSIONS This systematic review identified several common risk factors for perioperative torsade de pointes. Given the nearly uniform presence of a substantial QTc interval prolongation at the time of a torsade de pointes episode, increased vigilance for perioperative QTc interval prolongation may be warranted.
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Affiliation(s)
- Joshua Johnston
- From the Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
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Edson E, Chen L, Augoustides JG. Trigger-free anesthetic management in congenital long QT syndrome. J Clin Anesth 2013; 25:345-7. [DOI: 10.1016/j.jclinane.2013.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 12/25/2012] [Accepted: 01/17/2013] [Indexed: 10/26/2022]
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Doggrell SA, Hancox JC. Cardiac safety concerns for ondansetron, an antiemetic commonly used for nausea linked to cancer treatment and following anaesthesia. Expert Opin Drug Saf 2013; 12:421-31. [DOI: 10.1517/14740338.2013.780026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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[Low-dose droperidol in children: rescue therapy for persistent postoperative nausea and vomiting]. Anaesthesist 2012; 61:30-4. [PMID: 22234576 DOI: 10.1007/s00101-011-1962-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 10/24/2011] [Accepted: 10/25/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Droperidol had been used as an effective antiemetic since the 1970s but was withdrawn from the market in 2001 because of a black box warning about QT prolongation and possible cardiac arrhythmia after high doses. In the meantime the black box warning has seriously been questioned and parenteral droperidol has again been licensed in 2008. Because droperidol acts on dopaminergic receptors different to 5-HT(3) antagonists and dexamethasone, it could possibly serve as a rescue drug after failed postoperative nausea and vomiting (PONV) prophylaxis. Persistent PONV after the recommended prophylaxis is a significant problem in pediatric anesthesia but a satisfactory strategy has not yet been defined. Therefore a retrospective audit was performed in order to evaluate whether low-dose droperidol (10 µg/kgBW) would be an effective rescue drug for failed antiemetic prophylaxis. PATIENTS AND METHODS The electronic anesthesia patient data base of the University Children's Hospital Zurich was searched from 2004-2009 for patients who received low-dose droperidol in the postanesthesia care unit as rescue therapy for persistent PONV after antiemetic prophylaxis. Based on the recorded electronic data the effectiveness of low-dose droperidol as PONV rescue therapy and possible side effects were analyzed. RESULTS A total of 338 patients who received droperidol were found from a total of 34,032 patients and the charts were analyzed. Of these patients 134 were excluded because they had received droperidol for indications other than PONV, 43 patients were excluded because they had not received antiemetic prophylaxis before droperidol and in 17 patients the data were incomplete, leaving 144 patients with an average age of 12.3 years (interquartile range IQR 9.5-15.2 years) for analysis. The upper range of ages resulted from patients with chronic diseases who were still being treated in the Children's Hospital. Low-dose droperidol was given because of persistent nausea to 59 patients (41%) and to 85 patients (59%) for persistent vomiting. Initial antiemetic prophylaxis and/or therapy had consisted of dexamethasone plus tropisetrone in 80 patients and tropisetrone or dexamethasone alone in 64 patients. In 128 patients (89%) rescue therapy with a median dose of 10.9 µg/kgBW droperidol was effective but vomiting persisted in 16 patients (11%). Sedation was the only side effect recorded and this was observed in 39 patients (27%). CONCLUSIONS Low-dose droperidol (10 µg/kgBW) was found to be effective as rescue medication in pediatric patients experiencing PONV despite various prophylactic antiemetic regimens. No neurological or cardiopulmonary side effects were recorded after this low dosage.
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