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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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Lin Y, Tiansheng S, Zhicheng Z, Xiaobin C, Fang L. Effects of Ramosetron on Nausea and Vomiting Following Spinal Surgery: A Meta-Analysis. CURRENT THERAPEUTIC RESEARCH 2022; 96:100666. [PMID: 35464291 PMCID: PMC9019236 DOI: 10.1016/j.curtheres.2022.100666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/17/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal surgery is associated with severe pain within the first few days after surgery. Opioids are commonly used to control postoperative pain, but these can lead to postoperative nausea and vomiting (PONV). Therefore, use of more effective and better-tolerated agents would be beneficial for these patients. Serotonin receptor antagonists, such as ramosetron, have been used to reduce PONV in patients receiving anesthesia. OBJECTIVE We conducted a meta-analysis of published randomized controlled trials (RCTs) to compare the efficacy and tolerance of ramosetron to prevent PONV after spinal surgery. METHODS Medline, Embase, Cochrane Library, and Science Citation Index databases were systematically searched for relevant RCT articles published between January 1979 and November 2020. Full text articles restricted to English language that described RCTs comparing the use of ramosetron with other serotonin antagonists to treat PONV following spinal surgery in adult patients were considered for meta-analysis. Two reviewers independently performed study selection, quality assessment, and data extraction of all articles. Differences were resolved by a third reviewer. RESULTS The search identified 88 potentially relevant articles, of which only 3 met our selection criteria. Study drugs were administered at the end of spinal surgery in all 3 included articles. The meta-analysis revealed that ramosetron (0.3 mg) reduced the pain score (mean difference = -0.66; 95% CI -1.02 to -0.30), lowered the risk of PONV (risk ratio = 0.86; 95% CI, 0.76-0.97), and postoperative vomiting (risk ratio = 0.32; 95% CI, 0.17-0.60), and limited the use of rescue antiemetics (risk ratio = 0.66; 95% CI, 0.45-0.96) after spinal surgery. However, there were no significant differences in the incidence of postoperative nausea, the use of rescue pain medications, the number of rescue analgesics required, and the risk of discontinuation of patient-controlled analgesia between ramosetron and palonosetron (0.075 mg) or ondansetron (4 mg). There were no statistically significant differences in the risk of adverse events among the 3 medications. CONCLUSIONS This meta-analysis of 3 RCTs showed that ramosetron reduced the risk of PONV and POV, limited the use of rescue antiemetics, reduced the postoperative pain score, and did not increase the risk of discontinuing patient-controlled analgesia compared with palonosetron or ondansetron after spinal surgery in 3 RCTs. Therefore, this meta-analysis indicates that ramosetron is an effective and well tolerated antiemetic that can be used to prevent PONV following spinal surgery in adult patients. PROSPERO identifier: CRD42020223596 (Curr Ther Res Clin Exp. 2022; 83:XXX-XXX)© 2022 Elsevier HS Journals, Inc.
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Affiliation(s)
- Yiyun Lin
- Correspondence to: Lin Yiyun, MD, Department of Orthopedic Surgery, Senior Department of Orthopedics, the Fourth Medical Center of PLA General Hospital, Nanmengcang 5#, Beijing, China, 100700, Tell: + 86 010 84008002; fax: + 86 010 84008002
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3
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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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Lim L, Jang YE, Kim EH, Lee JH, Kim JT, Kim HS. Comparison of the Effects of Sufentanil and Fentanyl in Intravenous Patient-Controlled Analgesia after Pediatric Moyamoya Surgery: A Retrospective Study. Pediatr Neurosurg 2020; 55:36-41. [PMID: 31940654 DOI: 10.1159/000504582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 10/26/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intravenous patient-controlled analgesia (PCA) has been one of the most popular modalities for postoperative pain management in orthopedic surgery, plastic surgery, or neurosurgery in children. OBJECTIVE We compared the effects of fentanyl and sufentanil used in intravenous PCA on postoperative pain management and opioid-related side effects in pediatric moyamoya disease. METHODS This retrospective study included 97 pediatric patients who underwent surgery for moyamoya disease. Preoperative and perioperative parameters were assessed. The PCA regimen was as follows: fentanyl group (0.2 μg/kg/mL, 1 mL of loading volume, 0.1 μg/kg/h of basal infusion, a bolus of 0.2 μg/kg on demand, "lock-out" interval of 15 min); sufen-tanil group (0.04 μg/kg/mL, 1 mL of loading volume, 0.02 μg/kg/h of basal infusion, a bolus of 0.04 μg/kg on demand, 15 min lock-out), 10 μg/kg (up to 300 μg) of ramosetron for prophylaxis of postoperative nausea and vomiting with the same loading dose in both groups. Peripheral nerve blocks were performed. Pain was assessed by numeric rating scale or revised Faces Pain Scale. Side effects were reviewed. RESULTS The two groups showed similar pain scores and incidence of nausea or vomiting during the first 48 h postoperatively. Additional analgesics were more frequent in the fentanyl group, and PCA was discontinued more frequently in the sufentanil group. CONCLUSIONS Postoperatively, sufen-tanil in PCA provided more analgesia than fentanyl with less additional analgesics in moyamoya disease. However, PCA with sufentanil was more frequently discontinued due to nausea or vomiting compared to fentanyl-based PCA.
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Affiliation(s)
- Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea, .,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea,
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Hajdini H, Steurer LM, Balakas K, Ercole PM. A Randomized Controlled Trial to Compare Pain Medications in Children Undergoing Strabismus Surgery. J Perianesth Nurs 2019; 34:1196-1204. [PMID: 31280990 DOI: 10.1016/j.jopan.2019.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 01/08/2019] [Accepted: 01/28/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate optimal intraoperative combinations of analgesia for children undergoing strabismus surgery. DESIGN A randomized controlled trial was employed to compare the difference in pain after administration of hydromorphone versus fentanyl. METHODS Participants were randomly assigned to either arm of the study. Pain was measured by the revised Faces, Legs, Activity, Cry, and Consolability Scale (rFLACC) tool postoperatively, and the parent was asked about the presence or absence of pain after discharge. FINDINGS A total of 135 children were included in the study. The rFLACC pain score was found to be significantly higher postoperatively among patients receiving fentanyl (P = .011). Pain after discharge was reported more often among patients who received fentanyl (P < .001). CONCLUSIONS Results of this study can be used to change practice to minimize the pain levels both postoperatively and after discharge for children undergoing strabismus surgery.
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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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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The Fragility of Statistically Significant Results in Pediatric Orthopaedic Randomized Controlled Trials as Quantified by the Fragility Index: A Systematic Review. J Pediatr Orthop 2018; 38:e418-e423. [PMID: 29979332 DOI: 10.1097/bpo.0000000000001201] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The randomized controlled trial (RCT) is the gold standard study design allowing critical comparison of clinical outcomes while minimizing bias. Traditionally clinical trials are evaluated through statistical significance, expressed by P-values and confidence intervals. However, until recently, the robustness of a study's conclusions has been given little attention. A new metric, the fragility index, quantifies the number of patients theoretically required to switch outcomes in order to reverse the study conclusions. The primary aim of our work was to determine the fragility index of RCTs in the pediatric orthopaedic literature. The secondary aim was to determine study factors associated with lower fragility index. METHODS Pubmed and Embase were systematically searched for pediatric orthopaedic RCTs published September 1, 2006 to September 1, 2016. Two independent reviewers screened titles, abstracts, and manuscripts to identify studies published in English involving 2 treatment arms. Trials without dichotomous primary or secondary outcomes or with patients >18 years were excluded. Data were extracted from each eligible article in duplicate and the fragility index was determined using Fisher exact test, with previously published methods. Univariate analysis was used to determine factors associated with lower fragility index. RESULTS Seventeen trials were eligible for inclusion. The median treatment arm size was 58 and overall sample size was 116 patients. The median fragility index was 3 (range, 0 to 18). A fragility index of 3 means that just 3 patients would need to switch treatment outcomes in order for the trial results to become statistically nonsignificant. In 1 study, the number of patients lost to follow-up exceeded the fragility index, such that the study conclusions could be completely reversed purely depending on the outcomes of the patients lost to follow-up. Lower fragility index was associated with smaller patient sample sizes and greater P-values. CONCLUSIONS The fragility index is a useful adjunct metric to the P-value and confidence intervals, allowing analysis of the robustness of study conclusions. RCTs in pediatric orthopaedics often have small sample sizes, many with low fragility indices. Future efforts could focus on encouraging institutional collaboration and patient recruitment with the ultimate goal of improving RCT sample sizes, and potentially improving the robustness of RCT results. LEVEL OF EVIDENCE Level I.
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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Culver MA, Richards EC, Jarrell DH, Edwards CJ. Use of Prophylactic Ondansetron with Intravenous Opioids in Emergency Department Patients: A Prospective Observational Pilot Study. J Emerg Med 2017; 53:629-634. [PMID: 28987314 DOI: 10.1016/j.jemermed.2017.06.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/21/2017] [Accepted: 06/29/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The current literature suggests that the prophylactic use of antiemetics is ineffective at preventing nausea or vomiting caused by opioids in the emergency department (ED). While there is no data evaluating ondansetron's efficacy for preventing opioid-induced nausea and vomiting, this practice remains common despite a lack of supporting evidence. OBJECTIVES This study aimed to identify if prophylactic ondansetron administered with intravenous (IV) opioids prevents opioid-induced nausea or vomiting. METHODS This prospective observational study was conducted in the ED at two academic medical institutions. Patients were eligible for enrollment if they were prescribed an IV opioid with or without IV ondansetron and absence of baseline nausea. Patients' level of nausea was evaluated at baseline, 5 min, and 30 min after an IV opioid was administered and then observed for 2 hours. RESULTS One hundred thirty-three patients were enrolled, with 90% of patients presenting with a chief complaint of pain. Sixty-four (48.1%) patients received an IV opioid alone and 69 (51.9%) patients received both IV ondansetron and an IV opioid. Twenty-three (17.3%) patients developed nausea caused by opioid administration. One (0.75%) patient had an emetic event and 3 (2.3%) patients required rescue antiemetics during their observation period. Rate of nausea was similar between treatment groups 5 min after the opioid was administered (p = 0.153). There was no statistical difference in emesis, rescue medication requirements, or nausea severity between treatment groups. CONCLUSION Our trial found that ondansetron did not appear to be effective at preventing opioid-induced nausea or vomiting. These findings and previous literature suggest prophylactic ondansetron should not be given to ED patients who are receiving IV opioids.
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Affiliation(s)
- Mark A Culver
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Emily C Richards
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Daniel H Jarrell
- Department of Pharmacy, Banner University Medical Center Tucson, Tucson, Arizona
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Yokoi A, Mihara T, Ka K, Goto T. Comparative efficacy of ramosetron and ondansetron in preventing postoperative nausea and vomiting: An updated systematic review and meta-analysis with trial sequential analysis. PLoS One 2017; 12:e0186006. [PMID: 28977021 PMCID: PMC5627966 DOI: 10.1371/journal.pone.0186006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/22/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postoperative nausea and vomiting is a distressing complication of surgery, and 5-HT3 receptor antagonists are often prescribed to prevent it. Ondansetron is the agent typically administered to prevent postoperative nausea and vomiting. Although ramosetron has a longer duration of action than ondansetron, it remains unclear whether ramosetron is the more effective medication. We performed an updated meta-analysis on the comparative efficacy of ramosetron and ondansetron in preventing postoperative nausea and vomiting. METHODS We searched six databases for all trials that randomly assigned patients to ramosetron or ondansetron groups. The primary outcome was postoperative nausea or vomiting in the early, late, and next-day periods. The secondary outcomes were side effects of the medications. We used the random-effects model to combine the results. Trial sequential analyses were performed to correct for repetitive testing in the updated meta-analysis. RESULTS Twenty-seven randomized controlled trials with 3,811 patients were included in the meta-analysis. The combined results of ramosetron vs. ondansetron efficacy in preventing postoperative nausea and vomiting were as follows: Risk ratio [95% confidence interval] = 0.82 [0.69-0.98] for early postoperative nausea, 0.76 [0.65-0.89] for late postoperative nausea, 0.69 [0.57-0.84] for next-day postoperative nausea, 0.78 [0.63-0.98] for early postoperative vomiting, 0.57 [0.45-0.72] for late postoperative vomiting, and 0.61 [0.43-0.86] for next-day postoperative vomiting. Dizziness was significantly lower in ramosetron groups than in ondansetron groups (risk ratio [95% confidence interval] = 0.81 [0.66-0.98]). Trial sequential analysis revealed that the results for late postoperative nausea, late postoperative vomiting, and next-day postoperative nausea were conclusive. CONCLUSIONS Ramosetron is more effective in preventing late postoperative nausea, late postoperative vomiting, and next-day postoperative nausea than ondansetron. The incidence of dizziness may be lower in patients receiving ramosetron than in patients receiving ondansetron. TRIAL REGISTRATION University hospital Medical Information Network Clinical Trials Registry: UMIN000022980.
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Affiliation(s)
- Ayako Yokoi
- Department of Anesthesiology, Kanagawa Children’s Medical Center, Minami-ku, Yokohama, Japan
| | - Takahiro Mihara
- Department of Anesthesiology, Kanagawa Children’s Medical Center, Minami-ku, Yokohama, Japan
- Department of Anesthesiology and Critical Care Medicine, Kanazawa-ku, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- * E-mail:
| | - Koui Ka
- Department of Anesthesiology, Kanagawa Children’s Medical Center, Minami-ku, Yokohama, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Kanazawa-ku, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Pinsornsak P, Teeyaphudit M, Ruetiwarangkoon C, Chaiwuttisak A. Comparison of Ramosetron With Ondansetron for Prevention of Intrathecal Morphine-Induced Nausea and Vomiting After Primary Total Knee Arthroplasty: A Randomized Control Trial. J Arthroplasty 2017; 32:1040-1043. [PMID: 27816366 DOI: 10.1016/j.arth.2016.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/04/2016] [Accepted: 09/09/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Spinal anesthesia with intrathecal morphine is a reliable, easy to apply, and cost effective method for controlling pain after total knee arthroplasty (TKA). However, postoperative nausea and vomiting (PONV) is a major concern. 5-Hydroxytryptamine receptor 3 (5-HT3) antagonists like ondansetron and ramosetron are commonly used for preventing PONV, but the optimal choice remains unclear. We conducted a study to assess the effectiveness of ramosetron and ondansetron, hypothesizing that the longer acting ramosetron may be better than ondansetron in the first 48 hours after TKA, performed with spinal anesthesia and intrathecal morphine. METHODS Patients were randomized preoperatively to either intravenous ondansetron (8 mg) or ramosetron (0.3 mg). The primary outcomes were the incidence rates of PONV. Secondary outcomes were the need for a rescue antiemetic (metoclopramide), pain score, patient satisfaction, and adverse drug reactions (ADRs) at 0-6, 6-12, 12-24, and 24-48 hours. RESULTS Ninety patients were evaluable; 45 patients/arm. Compared with ondansetron, ramosetron was associated with significantly lower incidence rates of nausea at: (1) 12-18 hours: 3/45 vs 11/45 (P = .016), (2) 18-24 hours: 1/45 vs 9/45 (P = .005), and vomiting at 18-24 hours: 1/45 vs 6/45 (P = .044). There were no significant differences in the use of rescue-antiemetic medicine, pain score, patient satisfaction, and ADRs. CONCLUSION Preoperative ramosetron provided more prolonged PONV prophylaxis than ondansetron after TKA in our setting, and had a similar ADR profile. Other trials are needed to confirm our results before ramosetron is adopted widely.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Mungkorn Teeyaphudit
- Department of Orthopaedic Surgery, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Chaivet Ruetiwarangkoon
- Department of Orthopaedic Surgery, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Adisai Chaiwuttisak
- Department of Orthopaedic Surgery, Thammasat University, Khlong Luang, Pathum Thani, Thailand
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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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15
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Mihara T, Goto T. Is ramosetron superior to ondansetron? Paediatr Anaesth 2013; 23:464. [PMID: 23577824 DOI: 10.1111/pan.12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine; Yokohama City University Graduate School of Medicine; Yokohama; Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine; Yokohama City University Graduate School of Medicine; Yokohama; Japan
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