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Ortiz E, González AI, Jaime V, Guzmán JA, Esparza I, Orozco JO, Guerrero MA, Ramos A, Zerrweck C. The impact of Aprepitant on Nausea and Vomiting following Laparoscopic Sleeve Gastrectomy: A Blinded Randomized Controlled Trial. Obes Surg 2024; 34:1316-1323. [PMID: 38429485 DOI: 10.1007/s11695-024-07129-0] [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: 12/07/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is associated with postoperative nausea and vomiting (PONV). We aimed to compare the effects of aprepitant on the incidence of PONV after LSG. METHODS In this double-blind, randomized controlled trial, the case group received the standard care regimen for PONV (dexamethasone 10 mg, ondansetron 4 mg, and metoclopramide 10 mg) plus prophylactic oral aprepitant 80 mg 1 h preoperatively. The control group received standard care plus a placebo. Comparative analyses using the Rhodes index were performed at 0, 6, 12, and 24 h postoperatively. RESULTS A total of 400 patients (201 in the aprepitant group and 199 in the placebo group) underwent LSG. The groups were homogeneous. The aprepitant group experienced less PONV: early, 69 (34.3%) vs. 103 (51.7%), p ≤ 0.001; 6 h, 67 (33.3%) vs. 131 (65.8%), p ≤ 0.001; 12 h, 41 (20.4%) vs. 115 (57.8%), p ≤ 0.001; and 24 h, 22 (10.9%) vs. 67 (33.7%), p ≤ 0.001. Fewer patients in the aprepitant group vomited: early, 3 (1.5%) vs. 5 (2.5%), p = 0.020; 6 h, 6 (3%) vs. 18 (9%), p = 0.020; 12 h, 2 (1%) vs. 17 (8.5%), p = 0.006; and 24 h, 1 (0.5%) vs. 6 (3%), p = 0.040. Patients in the aprepitant group required less additional PONV medication: early, 61 (30.3%) vs. 86 (43.2), p = 0.008; 6 h, 7 (3.5%) vs. 34 (17%), p = 0.001; 12 h, 6 (3%) vs. 31 (15.6%), p ≤ 0.001; and 24 h, 5 (2.5%) vs. 11 (5.5%), p ≤ 0.001. CONCLUSIONS Prophylactic aprepitant improved PONV between 0 h (early) and 24 h postoperatively in patients undergoing LSG.
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Affiliation(s)
- Elías Ortiz
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - Alberto I González
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - Valeria Jaime
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - José A Guzmán
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - Isaac Esparza
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - José O Orozco
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - Manuel A Guerrero
- Anesthesiology department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - Almino Ramos
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico
| | - Carlos Zerrweck
- Bariatric Surgery Department, Baja Hospital, Ernesto Sarmiento 2308, Burócrata, Ruiz Cortines, 22046, Tijuana, BCN, Mexico.
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Alam M, Shakeri A, Khorsand A, Nasseri K, Nasseri S. Assessing the impact of aprepitant and ondansetron on postoperative nausea and vomiting in orthognathic surgeries: a randomized controlled trial. BMC Anesthesiol 2023; 23:412. [PMID: 38093201 PMCID: PMC10717277 DOI: 10.1186/s12871-023-02371-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common side effect associated with general anesthesia. Both ondansetron and aprepitant been effectively used to prevent PONV. However, there is a disagreement of opinions regarding the superiority of these two drugs. This study aims to compare the efficacy of aprepitant with ondansetron in preventing PONV following orthognathic surgeries. METHODS In this double-blinded clinical trial, 80 patients scheduled for orthognathic surgery at Imam Hossein Hospital, Tehran, Iran, were randomly assigned to two groups. A standardized anesthesia protocol was used for all patients. The first group received a placebo capsule administered one hour before the surgical procedure along with 4 mg (2 ml) of ondansetron intravenously after anesthesia induction. The second group was given 80 mg aprepitant capsules one hour before the surgery, followed by an injection of 2 ml intravenous distilled water after anesthesia induction. The occurrence and severity of PONV, the amount of rescue medication required, and the complete response of patients assessed within 24 h after the surgery. RESULTS There were no significant differences in demographic data between the two groups. Patients in the aprepitant group had a significantly lower incidence and severity of nausea (2.5% versus 27.5%), vomiting (5% versus 25%), and required fewer rescue medications (7.5% versus 62.5%) compared to the ondansetron group. Additionally, the aprepitant group showed a higher complete response rate (90% versus 67.5%) in the 0-2 and 12-24 postoperative hours. CONCLUSION According to the findings of this study, aprepitant has demonstrated a greater efficacy in preventing PONV following orthognathic surgery, when compared to ondansetron. TRIAL REGISTRATION Iranian Registry of Clinical Trials (IRCT code: IRCT20211205053279N3), date of registration: 16/12/2022.
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Affiliation(s)
- Mostafa Alam
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Shakeri
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ardeshir Khorsand
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Karim Nasseri
- Department of Anesthesiology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Sadaf Nasseri
- Research Institute of Dental Sciences-Shahid Beheshti University of Medical Sciences, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Department of Oral and Maxillofacial Medicine, Health Service, Medical University of Kurdistan, Sanandaj, Iran.
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Lee DJ, Douglas JE, Chang J, Wilensky J, Jackson C, Lee JYK, Grady MS, Yoshor D, Kohanski MA, Palmer JN, Atkins JH, Adappa ND. The use of aprepitant for the prevention of postoperative nausea and vomiting in endoscopic transsphenoidal pituitary surgery. Int Forum Allergy Rhinol 2023; 13:2180-2186. [PMID: 37302141 DOI: 10.1002/alr.23208] [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: 03/17/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) are adverse effects after surgery, which may increase the risk of complications. Aprepitant is a neurokinin-1 receptor blocker and has been shown to reduce chemotherapy-related nausea and vomiting and PONV. However, its role in endoscopic skull base surgery remains unclear. The purpose of this study was to evaluate the effect of aprepitant in reducing PONV in endoscopic transsphenoidal (TSA) pituitary surgery. METHODS A retrospective chart review between July 2021 and January 2023 of 127 consecutive patients who underwent TSA was performed at a tertiary academic institution. Patients were divided into 2 groups based on preoperative aprepitant use. Two groups were matched based on known risk factors of PONV (age, sex, nonsmoking, and history of PONV). The primary outcome was the incidence of PONV. Secondary outcome measures included the number of anti-emetic use, length of stay, and postoperative cererebrospinal fluid (CSF) leak. RESULTS After matching, 48 patients were included in each group. The aprepitant group demonstrated a significantly lower incidence of vomiting than the non-aprepitant group (2.1% vs 22.9%, p = 0.002). The number of nausea episodes and anti-emetic use decreased with aprepitant use (p < 0.05). There was no difference in the incidence of nausea, length of stay, or postoperative CSF leak. Multivariate analysis demonstrated that aprepitant decreased the incidence of postoperative vomiting with odds ratio of 0.107. CONCLUSION Aprepitant may serve as a useful preoperative treatment to reduce PONV in patients undergoing TSA. Further studies are needed to evaluate its impact in other arenas of endoscopic skull base surgery.
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Affiliation(s)
- Daniel J Lee
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer E Douglas
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeremy Chang
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jadyn Wilensky
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina Jackson
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Yoshor
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Kohanski
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua H Atkins
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Meyer TA, Hutson LR, Morris PM, McAllister RK. A Postoperative Nausea and Vomiting Update: Current information on New Drugs, Old Drugs, Rescue/Treatment, Combination Therapies and Nontraditional Modalities. Adv Anesth 2023; 41:17-38. [PMID: 38251617 DOI: 10.1016/j.aan.2023.05.002] [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] [Indexed: 01/23/2024]
Abstract
This article's objective is to present the latest evidence and information on the management of postoperative nausea and vomiting (PONV). PONV continues to affect 30% of the surgical population causing patient dissatisfaction, extending length of stay, and increasing overall costs. This review includes the introduction of 2 new intravenous formulations of antiemetics (amisulpride, aprepitant), updates on nontraditional therapies, suggestions for combination prophylaxis, emerging data on rescue treatment, and considerations for special populations and settings. Both of the new antiemetics provide promising options for pharmacologic interventions for PONV with favorable safety profiles.
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Affiliation(s)
- Tricia A Meyer
- Texas A&M University-School of Medicine, Temple, TX, USA.
| | - Larry R Hutson
- Texas A&M University-School of Medicine, Temple, TX, USA; Baylor College of Medicine - Temple, TX, USA; Department of Anesthesiology, Baylor Scott & White Medical Center-Temple, 2401 South 31st Street, Temple, TX 76508, USA
| | - Phillip M Morris
- Texas A&M University-School of Medicine, Temple, TX, USA; Department of Anesthesiology, Baylor Scott & White Medical Center-Temple, 2401 South 31st Street, Temple, TX 76508, USA
| | - Russell K McAllister
- Texas A&M University-School of Medicine, Temple, TX, USA; Baylor College of Medicine - Temple, TX, USA; Department of Anesthesiology, Baylor Scott & White Medical Center-Temple, 2401 South 31st Street, Temple, TX 76508, USA.
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Huang Q, Wang F, Liang C, Huang Y, Zhao Y, Liu C, Lin C, Zhang L, Zhou S, Wang Q, Li S, Gong R, Wu Q, Gu Y, Zhang J, Luo T, Wang W, Zhang S, Bizo Mailoga N, Wang K, Jin S, Zhao Y. Fosaprepitant for postoperative nausea and vomiting in patients undergoing laparoscopic gastrointestinal surgery: a randomised trial. Br J Anaesth 2023; 131:673-681. [PMID: 37423834 DOI: 10.1016/j.bja.2023.06.029] [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: 04/04/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a major problem after surgery. Even with double prophylactic therapy including dexamethasone and a 5-hydroxytryptamine-3 receptor antagonist, the incidence is still high in many at-risk patients. Fosaprepitant, a neurokinin-1 receptor antagonist, is an effective antiemetic, but its efficacy and safety in combination antiemetic therapy for preventing PONV remain unclear. METHODS In this randomised, controlled, double-blind trial, 1154 participants at high risk of PONV and undergoing laparoscopic gastrointestinal surgery were randomly assigned to either a fosaprepitant group (n=577) receiving fosaprepitant 150 mg i.v. dissolved in 0.9% saline 150 ml, or a placebo group (n=577) receiving 0.9% saline 150 ml before anaesthesia induction. Dexamethasone 5 mg i.v. and palonosetron 0.075 i.v. mg were each administered in both groups. The primary outcome was the incidence of PONV (defined as nausea, retching, or vomiting) during the first 24 postoperative hours. RESULTS The incidence of PONV during the first 24 postoperative hours was lower in the fosaprepitant group (32.4% vs 48.7%; adjusted risk difference -16.9% [95% confidence interval: -22.4 to -11.4%]; adjusted risk ratio 0.65 [95% CI: 0.57 to 0.76]; P<0.001). There were no differences in severe adverse events between groups, but the incidence of intraoperative hypotension was higher (38.0% vs 31.7%, P=0.026) and intraoperative hypertension (40.6% vs 49.2%, P=0.003) was lower in the fosaprepitant group. CONCLUSIONS Fosaprepitant added to dexamethasone and palonosetron reduced the incidence of PONV in patients at high risk of PONV undergoing laparoscopic gastrointestinal surgery. Notably, it increased the incidence of intraoperative hypotension. CLINICAL TRIAL REGISTRATION NCT04853147.
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Affiliation(s)
- Qingshan Huang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fan Wang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chujun Liang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yabin Huang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingyin Zhao
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuling Liu
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chunmeng Lin
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lizhen Zhang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoli Zhou
- Department of Anaesthesia, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiuling Wang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Department of Anaesthesia, Guizhou Daqin Cancer Hospital, Guiyang, China
| | - Shan Li
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruirui Gong
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Wu
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Center for Clinical Research, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuting Gu
- Department of Medical Statistics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinxin Zhang
- Medical Statistics and Epidemiology, Sun Yat-sen University, Guangzhou, China
| | - Tongfeng Luo
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Wang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Song Zhang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Nassirou Bizo Mailoga
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kai Wang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Sanqing Jin
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Yang Zhao
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Meyer TA, Habib AS, Wagner D, Gan TJ. Neurokinin-1 receptor antagonists for the prevention of postoperative nausea and vomiting. Pharmacotherapy 2023; 43:922-934. [PMID: 37166582 DOI: 10.1002/phar.2814] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/12/2023]
Abstract
Despite the availability of several classes of antiemetics, postoperative nausea and vomiting (PONV) remains a substantial burden for patients following surgery, resulting in patient dissatisfaction and prolonged stays in post-anesthesia care units and ultimately increasing the cost of care. Enhanced recovery protocols and PONV management guidelines are now centered on the assessment of the individual patient's risk for developing PONV, as well as multimodal prophylaxis using antiemetics targeting different mechanisms of action. Over the last two decades, the neurokinin-1 receptor (NK1R) has emerged as a therapeutic target for the management of PONV. This review of the literature explains the role of the NK1R and its ligand-substance P-in vomiting, describes the pharmacologic and pharmacokinetic properties of NK1R antagonists (NK1RAs) and summarizes the clinical evidence supporting NK1RAs for PONV prophylaxis in patients undergoing surgery. In particular, we discuss the therapeutic application of NK1RA in PONV prophylaxis protocols owing to their advantages over other antiemetic classes in efficacy, duration of efficacy, safety, pharmacology, and ease of administration. Future studies will be aimed at further investigating the efficacy and safety of NK1RA-based multimodal combinations, particularly among vulnerable populations (e.g., children and elderly).
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Affiliation(s)
- Tricia A Meyer
- Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Deborah Wagner
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Tong J Gan
- Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Liu Y, Chen X, Wang X, Zhong H, He H, Liu Y, Liao Y, Pan Z, Hu W, Liu W, Zheng F. The efficacy of aprepitant for the prevention of postoperative nausea and vomiting: A meta-analysis. Medicine (Baltimore) 2023; 102:e34385. [PMID: 37478247 PMCID: PMC10662847 DOI: 10.1097/md.0000000000034385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/27/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is one of the common adverse reactions after surgery. Recent randomized controlled trials (RCTs) investigating antiemetic drugs suggest that aprepitant has the strongest antiemetic effect of any single drug. This meta-analysis aimed to explore the efficacy of aprepitant for preventing PONV based on the existing literature. METHODS To identify RCTs investigating the use of aprepitant for PONV prevention, we searched PubMed, Embase, and Cochrane Library databases for articles published prior to March 20, 2022. Seventeen RCTs were identified, with 3299 patients, meeting the inclusion criteria. PONV incidence, complete response, 80 mg aprepitant combined with dexamethasone and ondansetron, vomiting, nausea, and analgesic dose-response were the main outcomes measured. RESULTS Compared with the control group, PONV incidence was significantly reduced among those receiving aprepitant (odds ratio [OR]: 0.34; 95% confidence interval [CI]: 0.26, 0.44; P < .0001), with a more complete response (OR: 1.35; 95% CI: 1.14, 1.59; P = .0004). Supplementation of 80 mg aprepitant in combination with dexamethasone and ondansetron substantially improved the effects of PONV (OR: 0.36; 95% CI: 0.16, 0.82; P = .01). Further, administration of 80 mg aprepitant was better at preventing vomiting than nausea (OR: 8.6; 95% CI: 3.84, 19. 29; P < .00001). No statistically significant difference between the dose-response of analgesics was identified (mean difference: -1.09; 95% CI: -6.48, 4.30; P = .69). The risk of bias was assessed independently by paired evaluators. CONCLUSION Aprepitant effectively reduces the incidence of PONV; however, the effects of postoperative analgesia require further exploration.
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Affiliation(s)
- Yingchao Liu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xinli Chen
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiaohua Wang
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Huohu Zhong
- Department of Ultrasound, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hefan He
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yibin Liu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yuewen Liao
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zhigang Pan
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Weipeng Hu
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Weifeng Liu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Feng Zheng
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
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Padilla A, Habib AS. A pharmacological overview of aprepitant for the prevention of postoperative nausea and vomiting. Expert Rev Clin Pharmacol 2023:1-15. [PMID: 37128935 DOI: 10.1080/17512433.2023.2209722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Post-operative nausea and vomiting (PONV) affects 30% of all patients undergoing surgery and up to 80% of high-risk patients. Antiemetics for PONV prophylaxis target a variety of receptor systems, with varying degrees of efficacy and side effect profile. Neurokinin -1 receptor antagonists are the most recent class of compounds investigated for PONV prophylaxis, with aprepitant being the only one currently approved for this indication. AREAS COVERED This review covers the pathophysiology of PONV, current recommendations for PONV prophylaxis, pharmacokinetics, and pharmacodynamics of aprepitant, and the evidence for its efficacy in the management of PONV as a single agent and in combination therapy. EXPERT OPINION Aprepitant is effective for PONV prophylaxis. It has superior antivomiting efficacy, long half-life, and favorable side effect profile. Data on antiemetic combinations involving aprepitant are limited, and it not clear if the addition of other antiemetics to aprepitant result in improved PONV prophylaxis. The oral route of administration of aprepitant is a potential limitation in a busy clinical practice. However, the recent approval of an intravenous formulation could provide a more convenient route of administration. Aprepitant remains more expensive than other antiemetics, and there are no studies assessing the cost effectiveness of its use.
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Affiliation(s)
- Andrew Padilla
- Duke University School of Medicine, Duke University Medical Center
| | - Ashraf S Habib
- Division of Women's Anesthesia, Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center
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Gastroparesis: An Evidence-Based Review for the Bariatric and Foregut Surgeon. Surg Obes Relat Dis 2023; 19:403-420. [PMID: 37080885 DOI: 10.1016/j.soard.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.
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Braga ELC, Verçosa N, Cavalcanti IL. Comparative Study Between Fosaprepitant and Palonosetron in the Prophylaxis of Postoperative Nausea and Vomiting in Women Undergoing Laparoscopic Cholecystectomy: Prospective, Randomized and Double-Blind Study. Front Pharmacol 2022; 13:915347. [PMID: 35645797 PMCID: PMC9130472 DOI: 10.3389/fphar.2022.915347] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022] Open
Abstract
Objective: To test the hypothesis that the single use of fosaprepitant is not inferior to the use of palonosetron as antiemetic prophylaxis in the first 48 h after surgery in women undergoing laparoscopic cholecystectomy. Method: Eighty-eight nonsmoking women (American Society of Anesthesiologists physical status I or II) aged between 18 and 60 years who underwent laparoscopic cholecystectomy received 150 mg of fosaprepitant or 75 μg of palonosetron, administered intravenously after the induction of general anesthesia. Results: In the fosaprepitant group and in the palonosetron group, 13.6 and 18.2% of the patients, respectively, vomited in the first 48 h after surgery (p = 0.560). There were no differences between groups in the total frequency and intensity of nausea, number of complete responders, need for rescue medication, time required for the first rescue medication dose or number of adverse events. Conclusion: The administration of a single dose of fosaprepitant after the induction of anesthesia was as effective as the administration of a single dose of palonosetron for the prophylaxis of vomiting in the first 48 h after surgery in women undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Estêvão Luiz Carvalho Braga
- Department of General and Specialized Surgery, Medical Sciences Postgraduate Program, Fluminense Federal University, Niterói, Brazil
| | - Nubia Verçosa
- Department of Surgery/Anaesthesiology, Surgical Sciences Postgraduate Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ismar Lima Cavalcanti
- Department of General and Specialized Surgery, Medical Sciences Postgraduate Program, Fluminense Federal University, Niterói, Brazil
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A Randomized Controlled Trial for Prevention of Postoperative Nausea and Vomiting after Laparoscopic Sleeve Gastrectomy: Aprepitant/Dexamethasone vs. Mirtazapine/Dexamethasone. Anesthesiol Res Pract 2022; 2022:3541073. [PMID: 35535050 PMCID: PMC9078838 DOI: 10.1155/2022/3541073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/02/2022] [Accepted: 04/05/2022] [Indexed: 11/27/2022] Open
Abstract
Background Coadministration of different antiemetics proved to decrease postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG). This trial compared aprepitant/dexamethasone (A/D) combination vs mirtazapine/dexamethasone (M/D) combination vs dexamethasone (D) alone for prevention of PONV in morbidly obese patients undergoing LSG. Methods Ninety patients scheduled for LSG were randomly allocated to receive 8 mg dexamethasone intravenous infusion (IVI) only in the D group or in addition to 80 mg aprepitant capsule in the A/D group or in addition to 30 mg mirtazapine tablet in the M/D group. Assessment of PONV was carried out at 0–2 h (early) and 2–24 h (late). The primary outcome was the complete response 0‐24 h after surgery. Collective PONV, postoperative pain, side effects and patient satisfaction score were considered as secondary outcomes. Results The A/D and M/D groups were superior to the D group for a complete response within 0–24 h after surgery (79.3% for the A/D group, 78.6% for the M/D group, and 20.7% for the D group). The D group was inferior to the A/D and M/D groups regarding collective PONV and use of rescue antiemetic 0–24 h after surgery (P < 0.001, P < 0.001, respectively). The peak nausea scores (2–24 h) were significantly reduced in the M/D group in comparison to the D group (P=0.005). Patients in the M/D group showed high sedation scores, while those in the A/D group showed low pain scores (2–24 h) and less analgesic requirements (P < 0.001, P < 0.001, P < 0.001, respectively). The A/D and M/D groups were superior to the D group with regard to the patient satisfaction score (P < 0.001). Conclusion Aprepitant/dexamethasone combination and mirtazapine/dexamethasone combination were superior to dexamethasone alone in alleviating postoperative nausea and vomiting in morbidly obese patients scheduled to undergo laparoscopic sleeve gastrectomy. Trial Registration: ClinicalTrials.gov identifier: NCT04013386.
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12
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Prevention and Treatment of Gastrointestinal Morbidity. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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13
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Gurunathan U, Cavaye J, Dai B, Gurunathan K, Weir R, Yerkovich S. NK1 receptor antagonists versus other antiemetics in the prevention of postoperative nausea and vomiting following laparoscopic surgical procedures: a systematic review and meta-analysis. J Anaesthesiol Clin Pharmacol 2022; 38:35-47. [PMID: 35706647 PMCID: PMC9191784 DOI: 10.4103/joacp.joacp_464_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 11/04/2022] Open
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14
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Jin Z, Daksla N, Gan TJ. Neurokinin-1 Antagonists for Postoperative Nausea and Vomiting. Drugs 2021; 81:1171-1179. [PMID: 34106456 DOI: 10.1007/s40265-021-01532-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/20/2022]
Abstract
Postoperative nausea and vomiting (PONV) are the second most frequent adverse events after surgery second only to postoperative pain. Despite the advances in antiemetics and implementation of multimodal prophylactic interventions, the clinical management of PONV remains problematic. Neurokinin-1 (NK-1) receptor is a tachykinin receptor found throughout the central and peripheral nervous systems, with a particular affinity towards substance P. NK-1 receptors interact with several parts of the neuronal pathway for nausea and vomiting. This includes the chemoreceptor trigger zone, the gastrointestinal tract, and dorsal motor nucleus of the vagus. NK-1 antagonists are thought to prevent nausea and vomiting by downregulating the emetogenic signals at those points. As more head-to-head trials are conducted between the various anti-emetics, there is emerging evidence that NK-1 antagonists may be more effective in preventing PONV than several other antiemetics currently in use. In this review, we will discuss the pharmacology of NK-1 antagonists, their efficacy in clinical practice, and how they could fit into the framework of PONV management.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, 11794-8480, USA
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, 11794-8480, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, 11794-8480, USA.
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15
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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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16
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Majdaeen M, Dorri-Giv M, Olfat S, Ataei G, Abedi-Firouzjah R, Banaei A, Ranjbar S. Skin dose measurement and estimating the dosimetric effect of applicator misplacement in gynecological brachytherapy: A patient and phantom study. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2021; 29:917-929. [PMID: 34180462 DOI: 10.3233/xst-210911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To evaluate skin dose differences between TPS (treatment planning system) calculations and TLD (thermo-luminescent dosimeters) measurements along with the dosimetric effect of applicator misplacement for patients diagnosed with gynecological (GYN) cancers undergoing brachytherapy. METHODS The skin doses were measured using TLDs attached in different locations on patients' skin in pelvic regions (anterior, left, and right) for 20 patients, as well as on a phantom. In addition, the applicator surface dose was calculated with TLDs attached to the applicator. The measured doses were compared with TPS calculations to find TPS accuracy. For the phantom, different applicator shifts were applied to find the effect of applicator misplacement on the surface dose. RESULTS The mean absolute dose differences between the TPS and TLDs results for anterior, left, and right points were 3.14±1.03, 6.25±1.88, and 6.20±1.97 %, respectively. The mean difference on the applicator surface was obtained 1.92±0.46 %. Applicator misplacements of 0.5, 2, and 4 cm (average of three locations) resulted in 9, 36, and 61%, dose errors respectively. CONCLUSIONS The surface/skin differences between the calculations and measurements are higher in the left and right regions, which relate to the higher uncertainty of TPS dose calculation in these regions. Furthermore, applicator misplacements can result in high skin dose variations, therefore it can be an appropriate quality assurance method for future research.
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Affiliation(s)
- Mehrsa Majdaeen
- Department of Radiotherapy and Oncology, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Masoumeh Dorri-Giv
- Nuclear Medicine Research Center, Department of Nuclear Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shaghayegh Olfat
- Department of Medical Radiation, Engineering Faculty, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Gholamreza Ataei
- Department of Radiology Technology, Faculty of Paramedical Sciences, Babol University of Medical Science, Babol, Iran
| | | | - Amin Banaei
- Department of Medical Physics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Sahar Ranjbar
- Department of Medical Physics and Engineering, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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17
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Jin Z, Gan TJ, Bergese SD. Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies. Ther Clin Risk Manag 2020; 16:1305-1317. [PMID: 33408475 PMCID: PMC7780848 DOI: 10.2147/tcrm.s256234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA.,Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
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18
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The next generation of antiemetics for the management of postoperative nausea and vomiting. Best Pract Res Clin Anaesthesiol 2020; 34:759-769. [PMID: 33288125 DOI: 10.1016/j.bpa.2020.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022]
Abstract
Postoperative nausea and vomiting (PONV) afflict approximately 30% of patients overall and up to 80% of high-risk patients after surgery. Optimal pharmacological prophylaxis of PONV is challenging as it necessitates the consideration of PONV risk, drug efficacy, and potential adverse effects. Despite significant advances in our understanding of the pathophysiology and risk factors of PONV, its incidence has remained largely unchanged. Newer antiemetics have been introduced that may have improved safety profiles, longer duration of action, and better efficacy. This review aims to summarize the recent developments pertaining to these new agents and their potential application toward the management of PONV.
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Weibel S, Rücker G, Eberhart LH, Pace NL, Hartl HM, Jordan OL, Mayer D, Riemer M, Schaefer MS, Raj D, Backhaus I, Helf A, Schlesinger T, Kienbaum P, Kranke P. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev 2020; 10:CD012859. [PMID: 33075160 PMCID: PMC8094506 DOI: 10.1002/14651858.cd012859.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects. OBJECTIVES • To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification). SELECTION CRITERIA Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded. DATA COLLECTION AND ANALYSIS A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo. MAIN RESULTS We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353. AUTHORS' CONCLUSIONS We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).
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Affiliation(s)
- Stephanie Weibel
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Leopold Hj Eberhart
- Department of Anaesthesiology & Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Hannah M Hartl
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Olivia L Jordan
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Debora Mayer
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Manuel Riemer
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maximilian S Schaefer
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Diana Raj
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Insa Backhaus
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antonia Helf
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Tobias Schlesinger
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Peter Kranke
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
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Elvir-Lazo OL, White PF, Yumul R, Cruz Eng H. Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review. F1000Res 2020; 9. [PMID: 32913634 PMCID: PMC7429924 DOI: 10.12688/f1000research.21832.1] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/10/2023] Open
Abstract
Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.
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Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,The White Mountain Institute, The Sea Ranch, Sonoma, CA, 95497, USA.,Instituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,David Geffen School of Medicine-UCLA, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90095, USA
| | - Hillenn Cruz Eng
- Department of Anesthesiology, PennState Hershey Medical Center, Hershey, PA, 17033, USA
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Murakami C, Kakuta N, Satomi S, Nakamura R, Miyoshi H, Morio A, Saeki N, Kato T, Ohshita N, Tanaka K, Tsutsumi YM. [Neurokinin-1 receptor antagonists for postoperative nausea and vomiting: a systematic review and meta-analysis]. Rev Bras Anestesiol 2020; 70:508-519. [PMID: 32753114 DOI: 10.1016/j.bjan.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/23/2020] [Accepted: 04/12/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Postoperative Nausea and Vomiting (PONV) is a common complication of general anesthesia. Several kinds of antiemetics, including 5-Hydroxytryptamine3 (5-HT3) receptor antagonists and Neurokinin-1 (NK-1) receptor antagonists, have been used to treat PONV. OBJECTIVES To compare the antiemetic effect of NK-1 receptor antagonists, including fosaprepitant. DATA SOURCES Online databases (PubMed, MEDLINE, Scopus, The Cochrane Library databases) were used. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS Randomized Controlled Trials (RCTs) performed in patients over 18 years with ASA-PS of I-III, aimed to assess the efficacy of antiemetics including NK-1 receptor antagonists and 5-HT3 receptor antagonists, and compared the incidence of PONV were included. STUDY APPRAISAL AND SYNTHESIS METHODS All statistical assessments were conducted by a random effect approach and odds ratios and 95% Confidence Intervals were calculated. RESULTS Aprepitant 40mg and 80mg significantly reduced the incidence of vomiting 0-24hours postoperatively (Odds Ratio [OR = 0.40]; 95% Confidence Interval [95% CI 0.30-0.54]; p < 0.001, and OR = 0.32; 95% CI 0.19-0.56; p < 0.001). Fosaprepitant could also reduce the incidence of vomiting significantly both 0-24h and 0-48hours postoperatively (OR = 0.07; 95% CI 0.02-0.24; p < 0.001 and OR = 0.07; 95% CI 0.02-0.23; p < 0.001). LIMITATIONS Risk factors for PONV are not considered, RCTs using multiple antiemetics are included, RCTs for fosaprepitant is small, and some bias may be present. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Aprepitant and fosaprepitant can be effective prophylactic antiemetics for postoperative vomiting. However, more studies are required for higher-quality meta-analyses. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42019120188.
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Affiliation(s)
- Chiaki Murakami
- Tokushima University, Department of Anesthesiology, Kumamoto, Japão
| | - Nami Kakuta
- Tokushima University, Department of Anesthesiology, Kumamoto, Japão
| | - Shiho Satomi
- University of California, Department of Anesthesiology, San Diego, EUA
| | - Ryuji Nakamura
- Hiroshima University, Department of Anesthesiology and Critical Care, Minami, Japão
| | - Hirotsugu Miyoshi
- Hiroshima University, Department of Anesthesiology and Critical Care, Minami, Japão
| | - Atsushi Morio
- Hiroshima University, Department of Anesthesiology and Critical Care, Minami, Japão
| | - Noboru Saeki
- Hiroshima University, Department of Anesthesiology and Critical Care, Minami, Japão
| | - Takahiro Kato
- Hiroshima University, Department of Anesthesiology and Critical Care, Minami, Japão
| | - Naohiro Ohshita
- Osaka Dental University, Department of Anesthesiology, Chuo, Japão
| | - Katsuya Tanaka
- Tokushima University, Department of Anesthesiology, Kumamoto, Japão
| | - Yasuo M Tsutsumi
- Hiroshima University, Department of Anesthesiology and Critical Care, Minami, Japão.
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Fox G, Kranke P. A pharmacological profile of intravenous amisulpride for the treatment of postoperative nausea and vomiting. Expert Rev Clin Pharmacol 2020; 13:331-340. [PMID: 32245336 DOI: 10.1080/17512433.2020.1750366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The issue of postoperative nausea and vomiting (PONV) remains important in surgical practice, contributing to patient distress, slower recovery, and increased use of healthcare resources. Many surgical patients report it to be a worse problem than the pain. New antiemetics of different classes are still needed to help manage PONV effectively, especially the treatment of established PONV after the failure of common prophylactic antiemetics such as 5-HT3-antagonists and corticosteroids. Intravenous amisulpride, a drug with a long history of safe use in oral form as an antipsychotic, has recently been approved in the US (trade name: Barhemsys) as an intravenous antiemetic for the prevention and treatment of PONV. AREAS COVERED This review article summarizes the published data on the clinical pharmacology, safety, and efficacy of intravenous amisulpride as an antiemetic, supplemented by published data on oral amisulpride, where relevant to the intravenous form. Literature was obtained via the PubMed search terms 'intravenous amisulpride' and 'amisulpride AND safety.' Both primary and secondary pharmacology are covered, along with clinical pharmacokinetics (distribution, metabolism, and excretion). The review of clinical safety and efficacy includes data from four studies in the prevention of PONV, two in the treatment of PONV and two investigating effects on the QT interval of the electrocardiogram in healthy volunteers. EXPERT OPINION Given the importance of sufficient PONV prevention for patients and the healthcare system, the availability of intravenous amisulpride is helpful, restoring the dopamine-antagonist class as a potential mainstay in both combination prophylaxis and treatment.
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Affiliation(s)
- Gabriel Fox
- The Officers' Mess, Acacia Pharma Ltd , Cambridge, UK
| | - Peter Kranke
- Department of Anaesthesia and Critical Care, University Hospitals of Würzburg , Würzburg, Germany
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Klyukin MI, Kulikov AS, Lubnin AY. [Postoperative nausea and vomiting in neurosurgery: the approaches are varied but the problem remains unsolved]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:93-100. [PMID: 31166323 DOI: 10.17116/neiro20198302193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postoperative nausea and vomiting (PONV) can induce brain displacement and herniation, especially in patients with cerebral edema. OBJECTIVE To evaluate the urgency of the problem associated with postoperative nausea and vomiting in current clinical practice (with modern approaches being used for its prevention) and to reveal the risk factors of PONV that are typically encountered in neurosurgical patients. MATERIAL AND METHODS A prospective observational study involved 240 patients who had undergone elective surgeries at the N.N. Burdenko National Scientific and Practical Center for Neurosurgery between July and November 2017. The data were collected from the questionnaires filled out by the patients during the first 48 h after the surgery and from patients' medical records. RESULTS The overall rate of PONV was 39.6%. Thirty-six out of 53 (68%) patients developed PONV after the posterior fossa surgeries. The risk of PONV in this group was significantly higher (p<0.05) compared to the rate of PONV after interventions at a different location. The rate of PONV after treatment of extracranial pathology was ~10.5%; for a different location, it was as high as 32-37%. Intraoperative dexamethasone was used in 156 (65%) patients; in this group, the rate of PONV was 39.9%. Patients received ondansetron at a dose of 8 mg for a preventive purpose at the end of the surgery. A total of 162 patients were given the drug; 59 (36.4%) of them developed POTV during 48 h post-administration. Seventy-eight patients did not receive ondansetron. Thirty-six of them (46.2%) (p>0.05) developed POTV. The rate of POTV assessed during the first 8 h after surgery was 22.8% in patients who had received ondansetron and 37.2% in those who had not received it (p<0.05). Patients who had not intraoperatively received a combination of these drugs developed POTV in 55 (45%) cases (p>0.05). CONCLUSION The problem associated in POTV remains topical in neurosurgery. The current approaches are not absolutely effective for prevention of POTV, whose rate ranges between 10.5 and 68% depending on surgery location. Further studies focused on administration of NK-1 receptor antagonists and electrical stimulation of the median nerve are needed to enhance the effectiveness of POTV prevention.
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Affiliation(s)
- M I Klyukin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A S Kulikov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A Yu Lubnin
- Burdenko Neurosurgical Institute, Moscow, Russia
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Salman FT, DiCristina C, Chain A, Afzal AS. Pharmacokinetics and pharmacodynamics of aprepitant for the prevention of postoperative nausea and vomiting in pediatric subjects. J Pediatr Surg 2019; 54:1384-1390. [PMID: 30381138 DOI: 10.1016/j.jpedsurg.2018.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/06/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND/PURPOSE This multicenter, randomized, partially-blinded phase IIb study evaluated the pharmacokinetics (PK)/pharmacodynamics, safety, and tolerability of aprepitant in pediatric subjects for the prevention of postoperative nausea and vomiting (PONV). METHODS Subjects aged birth to 17 years scheduled to undergo surgery and receive general anesthesia with ≥1 risk factor for PONV were randomly assigned to 1 of 3 aprepitant dose regimens (a single oral dose of aprepitant equivalent to adult doses of 10 mg, 40 mg, or 125 mg), or a control regimen of ondansetron before anesthesia. Assessments included PK, safety, and exploratory efficacy (complete response [CR; no emesis, retching, or dry heaves and no rescue therapy within 0-24 h following surgery] and no vomiting [NV; no emesis, retching, or dry heaves within 0-24 h following surgery]). RESULTS Of 220 randomized and treated subjects, 119 receiving a single aprepitant dose were sampled for PK analysis and had evaluable aprepitant plasma concentrations. A dose-dependent relationship in exposure (AUC0-8 h and Cmax) was observed. Aprepitant was generally well tolerated, and the CR and NV rates were high (>80%) across treatment groups. CONCLUSIONS PK, safety, and preliminary efficacy analyses support further clinical evaluation of aprepitant for PONV prophylaxis in pediatric patients. CLINICALTRIALS. GOV ID NCT01732458 LEVEL OF EVIDENCE: Therapeutic, Level I.
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Affiliation(s)
- F Tansu Salman
- Department of Pediatric Surgery, Istanbul Medical Faculty, Istanbul University, Capa, 34452 Fatih/Istanbul, Turkey
| | - Cara DiCristina
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA
| | - Anne Chain
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA
| | - Amna Sadaf Afzal
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA.
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Holder-Murray J, Esper SA, Boisen ML, Gealey J, Meister K, Medich DS, Subramaniam K. Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens. Korean J Anesthesiol 2019; 72:344-350. [PMID: 31096730 PMCID: PMC6676025 DOI: 10.4097/kja.d.18.00355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 05/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enhanced recovery protocols (ERP) provide optimal perioperative care for surgical patients. Postoperative nausea and vomiting (PONV) is common after colorectal surgery (CRS). We aim to compare the efficacy of aprepitant to a cost-effective alternative, perphenazine, as components of triple antiemetic prophylaxis in ERP patients. METHODS Patients who underwent ERP CRS at a single institution from July 2015 to July 2017 were evaluated retrospectively. Only subjects who received aprepitant (Group 1) or perphenazine (Group 2) preoperatively for PONV prophylaxis were included. Patient characteristics, simplified Apfel PONV scores, perioperative medications, and PONV incidence were compared between the groups. PONV was defined as the need for rescue antiemetics on postoperative days (POD) 0-5. RESULTS Five hundred ninety-seven patients underwent CRS of which 498 met the inclusion criteria. Two hundred thirty-one (46.4%) received aprepitant and 267 (53.6%) received perphenazine. The incidence of early PONV (POD 0-1) was comparable between the two groups: 44.2% in Group 1 and 44.6% in Group 2 (P = 0.926). Late PONV (POD 2-5) occurred less often in Group 1 than Group 2, respectively (35.9% vs. 45.7%, P = 0.027). After matching the groups for preoperative, procedural, and anesthesia characteristics (164 pairs), no difference in early or late PONV could be demonstrated between the groups. CONCLUSIONS The incidence of PONV remains high despite most patients receiving three prophylactic antiemetic medications. Perphenazine can be considered a cost-effective alternative to oral aprepitant for prophylaxis of PONV in patients undergoing CRS within an ERP.
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Affiliation(s)
| | - Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie Gealey
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katie Meister
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David S Medich
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ma K, Wu X, Chen Y, Yuan H. Effect of multimodal intervention on postoperative nausea and vomiting in patients undergoing gynecological laparoscopy. J Int Med Res 2019; 47:2026-2033. [PMID: 30885027 PMCID: PMC6567741 DOI: 10.1177/0300060519835700] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Postoperative nausea and vomiting (PONV) is a common complication in patients undergoing gynecological laparoscopic surgery, and achieving good results is difficult with a single antiemetic method. This study investigated whether multimodal intervention can reduce PONV in patients undergoing gynecological laparoscopic surgery. METHODS A total of 153 patients who underwent gynecological laparoscopic surgery were randomized into the control group and multimodal group. Patients in the multimodal group received dexmedetomidine 1 µg/kg intravenously 15 minutes before induction of anesthesia. A bilateral transversus abdominis plane block was performed with 0.375% ropivacaine 30 mL after induction of anesthesia. Scores of postoperative nausea and vomiting, the visual analog scale, and the Bruggemann comfort scale (BCS) were assessed 24 hours postoperatively. RESULTS Nausea and vomiting scores were significantly lower at 2, 6, and 24 hours in the multimodal group compared with the control group. BCS scores were significantly higher at 0 to 24 hours in the multimodal group compared with the control group. CONCLUSIONS Multimodal intervention improves PONV and increases patients' comfort. The multimodal approach can also enhance recovery after gynecological laparoscopic surgery.
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Affiliation(s)
- Kai Ma
- 1 Department of Anesthesiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Xiuxiu Wu
- 2 Department of Anesthesiology, Ningbo No. 2 Hospital, Ningbo, China
| | - Yongquan Chen
- 1 Department of Anesthesiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Hui Yuan
- 2 Department of Anesthesiology, Ningbo No. 2 Hospital, Ningbo, China
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Jeyabalan S, Thampi SM, Karuppusami R, Samuel K. Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries. Indian J Anaesth 2019; 63:289-294. [PMID: 31000893 PMCID: PMC6460978 DOI: 10.4103/ija.ija_724_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Aims: Aprepitant, a Neurokinin-1 receptor antagonist, has been evaluated in abdominal and neurosurgeries, but its effect is less clear in breast and thyroid surgeries, which are also known to be high risk for post-operative nausea and vomiting (PONV). This study was done to compare the antiemetic efficacy of ondansetron and aprepitant in women undergoing mastectomy and thyroidectomy. Methods: One hundred and twenty-five ASA I and II, female patients, aged between 18 and 65 years were randomly assigned into Group I (ondansetron group, n = 62) or Group II (aprepitant group, n = 63), by computer-generated random sequencing. Per protocol analysis was done to assess the incidence and severity of PONV, use of rescue antiemetics, and patient satisfaction with PONV control between the two groups, till 24 h post-surgery. Results: In the immediate postoperative period, 79.7% of patients in Group I and 85.2% in Group II were free of emesis (P value: 0.49). In Group I, the first episode of vomiting occurred within a median duration 90 min (IQR 2575: 45-147) postoperatively, whereas the median duration in Group II was 160 min (IQR 25-75: 26-490), with request for rescue antiemetic at 60 min in Group I (IQR 25-75: 27-360) and 147 min in Group II (IQR 25-75: 11-457). Conclusion: A single dose of oral aprepitant has comparable effects to injection ondansetron administered eighth hourly in preventing PONV, the severity of nausea, number of rescue antiemetics, and the time to first emetic episode in the 24-h postoperative period. CTRI Reg No: REF/2017/06/014637.
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Affiliation(s)
- Salome Jeyabalan
- Department of Anesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Suma Mary Thampi
- Department of Anesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Kunder Samuel
- Department of Anesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Bilgen S, Kızılcık N, Haliloğlu M, Yıldırım G, Kaspar EÇ, Köner Ö. Effect of the Dexamethasone-Ondansetron Combination Versus Dexamethasone-Aprepitant Combination to Prevent Postoperative Nausea and Vomiting. Turk J Anaesthesiol Reanim 2018; 46:373-380. [PMID: 30263861 DOI: 10.10.5152/tjar.2018.53179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/30/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Postoperative nausea and vomiting (PONV) is a common problem associated with general anaesthesia. The incidence can be as high as 80% in high-risk patients. Our primary objective was to compare the efficacy of the combination of dexamethasone-ondansetron and dexamethasone-aprepitant in patients undergoing laparoscopic surgery. Methods Seventy 18 to 60 years old patients scheduled for laparoscopic surgery were included in the study. Sixty-seven patients completed the study. Patients in the dexamethasone-aprepitant group (group DA, n=35) received 40 mg of aprepitant orally 1-2 hours before the induction of anaesthesia and 2 mL saline intravenously (iv) within the last 30 minutes of surgery; patients in the dexamethasone-ondansetron group (group DO, n=35) received oral placebo identical to aprepitant 1-2 hours before the induction of anaesthesia and 4 mg ondansetron iv within the last 30 minutes of surgery. All patients received 8 mg dexamethasone iv after the induction of anaesthesia. The primary outcome was a complete response (no postoperative nausea, retching and vomiting and no need for rescue antiemetic); the secondary outcomes were the incidence of nausea, retching, vomiting, the need of rescue antiemetic and opioid consumption within 24 hours after surgery. Results A complete response was not significantly different between the groups (group DO: 67%, DA: 69%) at 24 hours (p=0.93). The incidence of PONV and postoperative opioid consumption was similar between the groups. Conclusion The study was designed to evaluate whether the combination of dexamethasone-aprepitant is better than the combination of dexamethasone-ondansetron regarding the complete response for PONV in patients undergoing laparoscopic surgery. The results however showed that dexamethasone-aprepitant has not improved the complete response for PONV compared to dexamethasone-ondansetron.
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Affiliation(s)
- Sevgi Bilgen
- Department of Anaesthesiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Nurcan Kızılcık
- Department of Anaesthesiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Murat Haliloğlu
- Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Gazi Yıldırım
- Department of Obstetric and Gynecology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Elif Çiğdem Kaspar
- Department of Biostatistics, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Özge Köner
- Department of Anaesthesiology, Yeditepe University School of Medicine, İstanbul, Turkey
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Iadarola MJ, Sapio MR, Wang X, Carrero H, Virata-Theimer ML, Sarnovsky R, Mannes AJ, FitzGerald DJ. Analgesia by Deletion of Spinal Neurokinin 1 Receptor Expressing Neurons Using a Bioengineered Substance P-Pseudomonas Exotoxin Conjugate. Mol Pain 2018; 13:1744806917727657. [PMID: 28814145 PMCID: PMC5574484 DOI: 10.1177/1744806917727657] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Cell deletion approaches to pain directed at either the primary nociceptive afferents or
second-order neurons are highly effective analgesic manipulations. Second-order spinal
neurons expressing the neurokinin 1 (NK1) receptor are required for the perception of many
types of pain. To delete NK1+ neurons for the purpose of pain control, we generated a
toxin–peptide conjugate using DTNB-derivatized (Cys0) substance P (SP) and a
N-terminally truncated Pseudomonas exotoxin (PE35) that retains the endosome-release and
ADP-ribosylation enzymatic domains but with only one free sulfhydryl side chain for
conjugation. This allowed generation of a one-to-one product linked by a disulfide bond
(SP-PE35). In vitro, Chinese hamster ovary cells stably transfected with the NK1 receptor
exhibited specific cytotoxicity when exposed to SP-PE35
(IC50 = 5 × 10−11 M), whereas the conjugate was nontoxic to NK2
and NK3 receptor-bearing cell lines. In vivo studies showed that, after infusion into the
spinal subarachnoid space, the toxin was extremely effective in deleting NK1
receptor-expressing cells from the dorsal horn of the spinal cord. The specific cell
deletion robustly attenuated thermal and mechanical pain sensations and inflammatory
hyperalgesia but did not affect motoric capabilities. NK1 receptor cell deletion and
antinociception occurred without obvious lesion of non–receptor-expressing cells or
apparent reorganization of primary afferent innervation. These data demonstrate the
extraordinary selectivity and broad-spectrum antinociceptive efficacy of this
ligand-directed protein therapeutic acting via receptor-mediated endocytosis. The loss of
multiple pain modalities including heat and mechanical pinch, transduced by different
populations of primary afferents, shows that spinal NK1 receptor-expressing neurons are
critical points of convergence in the nociceptive transmission circuit. We further suggest
that therapeutic end points can be effectively and safely achieved when SP-PE35 is locally
infused, thereby producing a regionally defined analgesia.
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Affiliation(s)
- Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892
| | | | - Xunde Wang
- Biotherapy Section, Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, Bethesda, MD 20892
| | - Hector Carrero
- Pain and Neurosensory Mechanisms Branch, National Institutes of Dental and Craniofacial
| | - Maria Luisa Virata-Theimer
- Biotherapy Section, Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, Bethesda, MD 20892
| | - Robert Sarnovsky
- Biotherapy Section, Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, Bethesda, MD 20892
| | - Andrew J Mannes
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892
| | - David J FitzGerald
- Biotherapy Section, Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, Bethesda, MD 20892
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Bilgen S, Kızılcık N, Haliloğlu M, Yıldırım G, Kaspar EÇ, Köner Ö. Effect of the Dexamethasone-Ondansetron Combination Versus Dexamethasone-Aprepitant Combination to Prevent Postoperative Nausea and Vomiting. Turk J Anaesthesiol Reanim 2018. [PMID: 30263861 DOI: 10.5152/tjar.2018.53179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Postoperative nausea and vomiting (PONV) is a common problem associated with general anaesthesia. The incidence can be as high as 80% in high-risk patients. Our primary objective was to compare the efficacy of the combination of dexamethasone-ondansetron and dexamethasone-aprepitant in patients undergoing laparoscopic surgery. Methods Seventy 18 to 60 years old patients scheduled for laparoscopic surgery were included in the study. Sixty-seven patients completed the study. Patients in the dexamethasone-aprepitant group (group DA, n=35) received 40 mg of aprepitant orally 1-2 hours before the induction of anaesthesia and 2 mL saline intravenously (iv) within the last 30 minutes of surgery; patients in the dexamethasone-ondansetron group (group DO, n=35) received oral placebo identical to aprepitant 1-2 hours before the induction of anaesthesia and 4 mg ondansetron iv within the last 30 minutes of surgery. All patients received 8 mg dexamethasone iv after the induction of anaesthesia. The primary outcome was a complete response (no postoperative nausea, retching and vomiting and no need for rescue antiemetic); the secondary outcomes were the incidence of nausea, retching, vomiting, the need of rescue antiemetic and opioid consumption within 24 hours after surgery. Results A complete response was not significantly different between the groups (group DO: 67%, DA: 69%) at 24 hours (p=0.93). The incidence of PONV and postoperative opioid consumption was similar between the groups. Conclusion The study was designed to evaluate whether the combination of dexamethasone-aprepitant is better than the combination of dexamethasone-ondansetron regarding the complete response for PONV in patients undergoing laparoscopic surgery. The results however showed that dexamethasone-aprepitant has not improved the complete response for PONV compared to dexamethasone-ondansetron.
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Affiliation(s)
- Sevgi Bilgen
- Department of Anaesthesiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Nurcan Kızılcık
- Department of Anaesthesiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Murat Haliloğlu
- Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Gazi Yıldırım
- Department of Obstetric and Gynecology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Elif Çiğdem Kaspar
- Department of Biostatistics, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Özge Köner
- Department of Anaesthesiology, Yeditepe University School of Medicine, İstanbul, Turkey
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Tateosian VS, Champagne K, Gan TJ. What is new in the battle against postoperative nausea and vomiting? Best Pract Res Clin Anaesthesiol 2018; 32:137-148. [PMID: 30322455 DOI: 10.1016/j.bpa.2018.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 12/21/2022]
Abstract
The issue of postoperative nausea and vomiting (PONV) still poses a significant burden on our patients. Although rarely associated with a life-threatening condition, it is consistently considered as one of the most undesirable side effects of surgery and anesthesia. There are well-established risk factors for the development of PONV that include patient-related factors, anesthetic technique, use of volatile anesthetics, use of nitrous oxide, duration of anesthesia, opioid administration, and type of surgery. Because pharmacologic interventions for PONV are not without risks, practitioners must assess patient's risk status from low to high and consider the benefits of treatment. This review summarizes the current state of knowledge related to PONV and provides a practical approach toward risk assessment, prevention, and numerous treatment strategies.
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Affiliation(s)
- Vahé S Tateosian
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, 11794, USA.
| | - Katelynn Champagne
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, 11794, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, 11794, USA
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Yoo JH, Kim SI, Chung JW, Jun MR, Han YM, Kim YJ. Aprepitant in combination with palonosetron for the prevention of postoperative nausea and vomiting in female patients using intravenous patient-controlled analgesia. Korean J Anesthesiol 2018; 71:440-446. [PMID: 29843509 PMCID: PMC6283706 DOI: 10.4097/kja.d.18.00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/28/2018] [Indexed: 12/04/2022] Open
Abstract
Background The aim of this study was to evaluate aprepitant in combination with palonosetron as compared to palonosetron alone for the prevention of postoperative nausea and vomiting (PONV) in female patients receiving fentanyl- based intravenous patient-controlled analgesia (IV-PCA). Methods In this randomized single-blinded study, 100 female patients scheduled for elective surgery under general anesthesia were randomized to two groups: Group AP (80 mg aprepitant plus 0.075 mg palonosetron, n = 50) and Group P (0.075 mg palonosetron, n = 50). The patients in group AP received 80 mg aprepitant per oral 1–3 h before surgery, while all patients received 0.075 mg palonosetron after induction of standardized anesthesia. All patients had postoperative access to fentanyl-based IV-PCA. The incidence of nausea and vomiting, use of rescue medication, and severity of nausea were evaluated at 6 and 24 h after surgery. Results The incidence of nausea (54%) and vomiting (2%) in group AP did not differ significantly from that in group P (48% and 14%, respectively) during the first 24 h after surgery (P > 0.05). Patient requirements for rescue medication in group AP (29%) were similar to those in group P (32%) at 24 h after surgery (P > 0.05). There was no difference between the groups in severity of nausea during the first 24 h after surgery (P > 0.05). Conclusions Aprepitant combined with palonosetron did not reduce the incidence of PONV as compared to palonosetron alone within 24 h of surgery in women receiving fentanyl-based IV-PCA.
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Affiliation(s)
- Jae Hwa Yoo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Soon Im Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Ji Won Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Mi Roung Jun
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Yoo Mi Han
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Yong Jik Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Pasricha PJ, Yates KP, Sarosiek I, McCallum RW, Abell TL, Koch KL, Nguyen LAB, Snape WJ, Hasler WL, Clarke JO, Dhalla S, Stein EM, Lee LA, Miriel LA, Van Natta ML, Grover M, Farrugia G, Tonascia J, Hamilton FA, Parkman HP. Aprepitant Has Mixed Effects on Nausea and Reduces Other Symptoms in Patients With Gastroparesis and Related Disorders. Gastroenterology 2018; 154:65-76.e11. [PMID: 29111115 PMCID: PMC5742047 DOI: 10.1053/j.gastro.2017.08.033] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/15/2017] [Accepted: 08/18/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS There are few effective treatments for nausea and other symptoms in patients with gastroparesis and related syndromes. We performed a randomized trial of the ability of the neurokinin-1 receptor antagonist aprepitant to reduce symptoms in patients with chronic nausea and vomiting caused by gastroparesis or gastroparesis-like syndrome. METHODS We conducted a 4-week multicenter, double-masked trial of 126 patients with at least moderate symptoms of chronic nausea and vomiting of presumed gastric origin for a minimum of 6 months. Patients were randomly assigned to groups given oral aprepitant (125 mg/day, n = 63) or placebo (n = 63). The primary outcome from the intention-to-treat analysis was reduction in nausea, defined as a decrease of 25 mm or more, or absolute level below 25 mm, on a daily patient-reported 0-to-100 visual analog scale (VAS) of nausea severity. We calculated relative risks of nausea improvement using stratified Cochran-Mental-Haenszel analysis. RESULTS Aprepitant did not reduce symptoms of nausea, based on the primary outcome measure (46% reduction in the VAS score in the aprepitant group vs 40% reduction in the placebo group; relative risk, 1.2; 95% CI, 0.8-1.7) (P = .43). However, patients in the aprepitant group had significant changes in secondary outcomes such as reduction in symptom severity (measured by the 0-5 Gastroparesis Clinical Symptom Index) for nausea (1.8 vs 1.0; P = .005), vomiting (1.6 vs 0.5; P = .001), and overall symptoms (1.3 vs 0.7; P = .001). Adverse events, predominantly mild or moderate in severity grade, were more common in aprepitant (22 of 63 patients, 35% vs 11 of 63, 17% in the placebo group) (P = .04). CONCLUSIONS In a randomized trial of patients with chronic nausea and vomiting caused by gastroparesis or gastroparesis-like syndrome, aprepitant did not reduce the severity of nausea when reduction in VAS score was used as the primary outcome. However, aprepitant had varying effects on secondary outcomes of symptom improvement. These findings support the need to identify appropriate patient outcomes for trials of therapies for gastroparesis, including potential additional trials for aprepitant. ClinicalTrials.gov no: NCT01149369.
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Affiliation(s)
| | - Katherine P Yates
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | | | | | | | | | | | - William L Hasler
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI
| | - John O Clarke
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sameer Dhalla
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ellen M Stein
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Linda A Lee
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura A Miriel
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Mark L Van Natta
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | | | - James Tonascia
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Frank A Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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A Comparison of Fosaprepitant and Ondansetron for Preventing Postoperative Nausea and Vomiting in Moderate to High Risk Patients: A Retrospective Database Analysis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5703528. [PMID: 29410964 PMCID: PMC5749222 DOI: 10.1155/2017/5703528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/28/2017] [Indexed: 11/17/2022]
Abstract
Postoperative nausea and vomiting (PONV) occur in 30–50% of patients undergoing general anesthesia and in 70–80% of high PONV risk patients. In this study, we investigated the efficacy of fosaprepitant, a neurokinin-1 (NK1) receptor antagonist, compared to ondansetron, a selective 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, in moderate to high PONV risk patients from our previous randomized controlled trials. Patients (171 patients from 4 pooled studies) with the Apfel simplified score ≥ 2 and undergoing general anesthesia were randomly allocated to receive intravenous fosaprepitant 150 mg (NK1 group, n = 82) and intravenous ondansetron 4 mg (ONS group, n = 89) before induction of anesthesia. Incidence of vomiting was significantly lower in the NK1 group compared to the ONS group 0–2, 0–24, and 0–48 hours after surgery (2 versus 17%, 2 versus 28%, and 2 versus 29%, resp.). However, no significant differences in PONV, complete response, rescue antiemetic use, and nausea score were observed between groups 0–48 hours after surgery. In moderate to high PONV risk patients, fosaprepitant decreased the incidence of vomiting and was superior to ondansetron in preventing postoperative vomiting 0–48 hours after surgery.
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Therneau IW, Martin EE, Sprung J, Kellogg TA, Schroeder DR, Weingarten TN. The Role of Aprepitant in Prevention of Postoperative Nausea and Vomiting After Bariatric Surgery. Obes Surg 2017; 28:37-43. [DOI: 10.1007/s11695-017-2797-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Halliday TA, Sundqvist J, Hultin M, Walldén J. Post-operative nausea and vomiting in bariatric surgery patients: an observational study. Acta Anaesthesiol Scand 2017; 61:471-479. [PMID: 28374473 DOI: 10.1111/aas.12884] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The risk of post-operative nausea and vomiting (PONV) in patients undergoing bariatric surgery is unclear. The aim of the study was to investigate the risk of PONV and the use and effectiveness of PONV prophylaxis. METHODS This prospective observational study included 74 patients undergoing bariatric surgery with total intravenous anaesthesia. Patients were given PONV prophylaxis based on published guidelines and a simplified PONV risk score. Perioperative data were collected and a questionnaire was used at 2, 4, 6, 24, 48 and 72 h after the operation to evaluate PONV. Data are presented as risk (%) with the 95% confidence interval. RESULTS Sixty five per cent (54-75) of the patients experienced PONV in the first 24 post-operative hours and the risk increased with the number of risk factors for PONV. PONV occurred in 78% (66-87) of women and 26% (12-49) of men during the first 24 h. In relation to the guidelines, one patient received suboptimal PONV prophylaxis, 23% received optimal prophylaxis and 76% supra-optimal prophylaxis. The risk of PONV was 82% (59-94) with optimal prophylaxis and 59% (46-71) with supra-optimal prophylaxis. Of all patients, 34% (24-45) experienced severe PONV in the first 24 h that limited their activity. CONCLUSIONS The incidence of PONV in bariatric surgery patients was high despite a PONV prophylaxis regime following current guidelines. These results cast doubt as to the effectiveness of the usual PONV prophylaxis in this patient group and point to the need for further investigation of PONV prophylaxis and treatment in bariatric surgery patients.
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Affiliation(s)
- T. A. Halliday
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sundsvall Umeå University Sundsvall Sweden
| | - J. Sundqvist
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sundsvall Umeå University Sundsvall Sweden
| | - M. Hultin
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sunderbyn Umeå University Luleå Sweden
| | - J. Walldén
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sundsvall Umeå University Sundsvall Sweden
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An update on the management of postoperative nausea and vomiting. J Anesth 2017; 31:617-626. [PMID: 28455599 DOI: 10.1007/s00540-017-2363-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/20/2017] [Indexed: 01/22/2023]
Abstract
Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.
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Aprepitant: A New Modality for the Prevention of Postoperative Nausea and Vomiting: An Evidence-Based Review. J Perianesth Nurs 2017; 30:406-17. [PMID: 26408515 DOI: 10.1016/j.jopan.2014.11.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 10/06/2014] [Accepted: 11/10/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE Postoperative nausea and vomiting (PONV) affects as many as 30% of surgical patients. Aprepitant, an antagonist of the neurokinin-1 receptor with a 40% half-life, may be effective for prophylaxis for PONV. This review describes the evidence of adding aprepitant to antiemetic therapy for PONV prophylaxis. METHODS A literature search was conducted to answer the population-intervention-comparison-outcome-time (PICOT) question: In adult patients undergoing general anesthesia (P), does aprepitant (I) decrease PONV (O) postoperatively (T) as compared to patients receiving other antiemetic therapy or a placebo (C)? RESULTS Eight randomized controlled trials, one prognostic study, and one post hoc analysis were appraised. Perioperatively, aprepitant decreased the severity and number of episodes of PONV. DISCUSSION Aprepitant appears to be more effective in decreasing the incidence of PONV postoperatively as compared with ondansetron. It is recommended that aprepitant is used to treat patients at risk for PONV and for whom PONV could lead to catastrophic adverse outcomes.
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Atsuta J, Inoue S, Tanaka Y, Abe K, Nakase H, Kawaguchi M. Fosaprepitant versus droperidol for prevention of PONV in craniotomy: a randomized double-blind study. J Anesth 2016; 31:82-88. [PMID: 27757553 DOI: 10.1007/s00540-016-2267-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/03/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Postoperative nausea and vomiting (PONV) is a common complication after craniotomy. Vomiting may be a potentially hazardous complication in neurosurgical patients. We compared the efficacy of fosaprepitant and droperidol for the prevention of PONV, vomiting in particular, after craniotomy. METHODS Patients scheduled to undergo elective craniotomy were enrolled in the study and randomly divided in a double-blind manner into two groups to receive either 150 mg of fosaprepitant (group F) or 1.25 mg of droperidol (group D). Dexamethasone (9.9 mg) was given to all patients, except those with diabetes mellitus. The incidence of PONV, frequency of vomiting, nausea score, and use of rescue antiemetic during the first 72 h after surgery were assessed at five time intervals (0-2, 2-6, 6-24, 24-48, and 48-72 h). RESULTS Of the 200 randomized patients eligible for entry into the study, 186 were ultimately included for analysis. There were no significant differences in demographics or intraoperative variables between the two treatment groups. Over the entire 72-h post-craniotomy observation period the overall and cumulative incidence of vomiting was significantly lower in group F patients than in group D patients, while there were no between-group differences in the overall and cumulative incidence of PONV or in complete response (no PONV and no rescue antiemetic). The incidence and frequency of vomiting during each of the five observational periods were significantly lower in group F patients than group D patients, although there were no differences in the nausea score and antiemetic use between the groups. CONCLUSION Based on the results, fosaprepitant was more effective than droperidol in the prevention of vomiting after craniotomy over the entire 72-h study period. However, there was no difference in the incidence of nausea and antiemetic use.
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Affiliation(s)
- Jun Atsuta
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8521, Japan.
| | - Satoki Inoue
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8521, Japan
| | - Yuu Tanaka
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8521, Japan
| | - Keiko Abe
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8521, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8521, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8521, Japan
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Pritchett W, Kinsley K. Benefits and Risks of Fosaprepitant in Patients Receiving Emetogenic Regimens. Clin J Oncol Nurs 2016; 20:555-6. [PMID: 27668376 DOI: 10.1188/16.cjon.555-556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fosaprepitant dimeglumine (Emend IV®) is an IV antiemetic that may be beneficial to patients receiving highly emetogenic regimens. Aprepitant (Emend®) is an oral medication that is administered for three consecutive days, whereas fosaprepitant is a single-dose IV medication that is administered on the day of chemotherapy for 20-30 minutes (depending on the IV access type). Fosaprepitant may be useful, yet it can also present a risk for hypersensitivity reactions and phlebitis. Oncology nurses must be aware of the signs and symptoms of these potential adverse events to properly care for their patients.
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Comparison of the Prophylactic Antiemetic Efficacy of Aprepitant Plus Palonosetron Versus Aprepitant Plus Ramosetron in Patients at High Risk for Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy: A Prospective Randomized-controlled Trial. Surg Laparosc Endosc Percutan Tech 2016; 26:354-357. [DOI: 10.1097/sle.0000000000000316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aprepitant for antiemesis after laparoscopic gynaecological surgery: A randomised controlled trial. Eur J Anaesthesiol 2016; 33:90-5. [PMID: 26694939 DOI: 10.1097/eja.0000000000000242] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ondansetron, a 5-HT3 receptor antagonist, and aprepitant, a neurokinin-1 receptor antagonist, block the emetic effect of serotonin and neurokinin, respectively. Aprepitant combined with ondansetron can be more effective for preventing emesis in patients at high risk of postoperative nausea and vomiting (PONV). OBJECTIVE To investigate the prophylactic effect of combining aprepitant with ondansetron compared with ondansetron alone on PONV in patients with fentanyl-based patient-controlled analgesia (PCA) after laparoscopic gynaecological surgery. DESIGN Single-centre, double-blinded randomised controlled trial. SETTING A major university hospital in Seoul, Korea, between July 2012 and April 2013. PATIENTS One hundred and twenty-five female patients (American Society of Anesthesiologists' physical status 1 or 2) with fentanyl-based intravenous PCA after gynaecological laparoscopy were recruited to the study, and 110 completed the protocol. INTERVENTIONS Oral aprepitant 80 mg or placebo was given 1 h before anaesthesia. In all patients, ondansetron 4 mg was administered intravenously at the end of surgery and 12 mg was added to the PCA solution. MAIN OUTCOME MEASURES The primary outcome measure was complete response (no PONV and no rescue antiemetics) up to 48 h postoperatively. RESULTS There was no difference in the proportion of complete responses to 48 h between the groups (P = 0.05), but in the post-anaesthesia care unit and up to 24 h postoperatively, the proportion was significantly higher in the aprepitant and ondansetron group than in the ondansetron only group (76 vs. 50%, P = 0.004 and 38 vs. 16%, P = 0.011, respectively). In the aprepitant and ondansetron group, the time to first PONV was delayed (P = 0.014) and the incidence of nausea up to 24 h postoperatively was lower (P = 0.014). However, there were no differences in the incidences of retching or vomiting, the severity of nausea, use of rescue antiemetics or the incidence of side-effects. CONCLUSION Aprepitant 80 mg orally with ondansetron is effective in suppressing early PONV up to 24 h postoperatively and delays the time to first PONV in patients with fentanyl-based intravenous PCA after gynaecological laparoscopy. However, the combination prophylaxis with aprepitant and ondansetron failed to reach the predefined primary study outcome when compared with ondansetron alone. TRIAL REGISTRATION Clinicaltrial.gov identifier: NCT01897337.
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Bergese SD, Puente EG, Antor MA, Viloria AL, Yildiz V, Kumar NA, Uribe AA. A Prospective, Randomized, Double-Blinded, Double-Dummy Pilot Study to Assess the Preemptive Effect of Triple Therapy with Aprepitant, Dexamethasone, and Promethazine versus Ondansetron, Dexamethasone and Promethazine on Reducing the Incidence of Postoperative Nausea and Vomiting Experienced by Patients Undergoing Craniotomy Under General Anesthesia. Front Med (Lausanne) 2016; 3:29. [PMID: 27458584 PMCID: PMC4932110 DOI: 10.3389/fmed.2016.00029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/23/2016] [Indexed: 11/24/2022] Open
Abstract
Introduction Postoperative nausea and vomiting (PONV) is among the most common distressing complications of surgery under anesthesia. Previous studies have demonstrated that patients who undergo craniotomy have incidences of nausea and vomiting as high as 50–70%. The main purpose of this pilot study is to assess the incidence of PONV by using two different prophylactic regimens in subjects undergoing a craniotomy. Thus, we designed this study to assess the efficacy and safety of triple therapy with the combination of dexamethasone, promethazine, and aprepitant versus ondansetron to reduce the incidence of PONV in patients undergoing craniotomy. Materials and methods This is a prospective, single center, two-armed, randomized, double-dummy, double-blind, pilot study. Subjects were randomly assigned to one of the two treatment groups. Subjects received 40 mg of aprepitant pill (or matching placebo pill) 30–60 min before induction of anesthesia and 4 mg of ondansetron IV (or 2 ml of placebo saline solution) at induction of anesthesia. In addition, all subjects received 25 mg of promethazine IV and 10 mg of dexamethasone IV at induction of anesthesia. Assessments of PONV commenced for the first 24 h after surgery and were subsequently assessed for up to 5 days. Results The overall incidence of PONV during the first 24 h after surgery was 31.0% (n = 15) in the aprepitant group and 36.2% (n = 17) for the ondansetron group. The median times to first emetic and significant nausea episodes were 7.6 (2.9, 48.7) and 14.3 (4.4, 30.7) hours, respectively, for the aprepitant group and 6.0 (2.2, 29.5) and 9.6 (0.7, 35.2) hours, respectively, for the ondansetron group. There were no statistically significant differences between these groups. No adverse events directly related to study medications were found. Conclusion This pilot study showed similar effectiveness when comparing the two PONV prophylaxis regimens. Our data showed that both treatments could be effective regimens to prevent PONV in patients undergoing craniotomy under general anesthesia. Future trials testing new PONV prophylaxis regimens in this surgical population should be performed to gain a better understanding of how to best provide prophylactic treatment.
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Affiliation(s)
- Sergio Daniel Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University Medical Center, Columbus, OH, USA
| | - Erika G Puente
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Maria A Antor
- Department of Anesthesiology, Jackson Memorial Hospital, University of Miami , Miami, FL , USA
| | - Adolfo L Viloria
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Vedat Yildiz
- Center for Biostatistics, The Ohio State University , Columbus, OH , USA
| | - Nicolas Alexander Kumar
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Alberto A Uribe
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 372] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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Perioperative use of centrally acting angiotensin-converting enzyme inhibitor may increase patients’ risk for postoperative nausea and vomiting. Med Hypotheses 2016; 86:1-2. [DOI: 10.1016/j.mehy.2015.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/25/2015] [Indexed: 11/17/2022]
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Shaikh SI, Nagarekha D, Hegade G, Marutheesh M. Postoperative nausea and vomiting: A simple yet complex problem. Anesth Essays Res 2016; 10:388-396. [PMID: 27746521 PMCID: PMC5062207 DOI: 10.4103/0259-1162.179310] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) is one of the complex and significant problems in anesthesia practice, with growing trend toward ambulatory and day care surgeries. This review focuses on pathophysiology, pharmacological prophylaxis, and rescue therapy for PONV. We searched the Medline and PubMed database for articles published in English from 1991 to 2014 while writing this review using “postoperative nausea and vomiting, PONV, nausea-vomiting, PONV prophylaxis, and rescue” as keywords. PONV is influenced by multiple factors which are related to the patient, surgery, and pre-, intra-, and post-operative anesthesia factors. The risk of PONV can be assessed using a scoring system such as Apfel simplified scoring system which is based on four independent risk predictors. PONV prophylaxis is administered to patients with medium and high risks based on this scoring system. Newer drugs such as neurokinin-1 receptor antagonist (aprepitant) are used along with serotonin (5-hydroxytryptamine subtype 3) receptor antagonist, corticosteroids, anticholinergics, antihistaminics, and butyrophenones for PONV prophylaxis. Combination of drugs from different classes with different mechanism of action are administered for optimized efficacy in adults with moderate risk for PONV. Multimodal approach with combination of pharmacological and nonpharmacological prophylaxis along with interventions that reduce baseline risk is employed in patients with high PONV risk.
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Affiliation(s)
- Safiya Imtiaz Shaikh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - D Nagarekha
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - Ganapati Hegade
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - M Marutheesh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
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48
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Singh PM, Borle A, Rewari V, Makkar JK, Trikha A, Sinha AC, Goudra B. Aprepitant for postoperative nausea and vomiting: a systematic review and meta-analysis. Postgrad Med J 2015; 92:87-98. [PMID: 26627976 DOI: 10.1136/postgradmedj-2015-133515] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 11/09/2015] [Indexed: 01/08/2023]
Abstract
Postoperative nausea and vomiting (PONV) is an important clinical problem. Aprepitant is a relatively new agent for this condition which may be superior to other treatment. A systematic review was performed after searching a number of medical databases for controlled trials comparing aprepitant with conventional antiemetics published up to 25 April 2015 using the following keywords: 'Aprepitant for PONV', 'Aprepitant versus 5-HT3 antagonists' and 'NK-1 versus 5-HT3 for PONV'. The primary outcome for the pooled analysis was efficacy of aprepitant in preventing vomiting on postoperative day (POD) 1 and 2. 172 potentially relevant papers were identified of which 23 had suitable data. For the primary outcome, 14 papers had relevant data. On POD1, 227/2341 patients (9.7%) patients randomised to aprepitant had a vomiting episode compared with 496/2267 (21.9%) controls. On POD2, the rate of vomiting among patients receiving aprepitant was 6.8% compared with 12.8% for controls. The OR for vomiting compared with controls was 0.48 (95% CI 0.34 to 0.67) on POD1 and 0.54 (95% CI 0.40 to 0.72) on POD2. Aprepitant also demonstrated a better profile with a lower need for rescue antiemetic and a higher complete response. Efficacy for vomiting prevention was demonstrated for 40 mg, 80 mg and 125 mg without major adverse effects. For vomiting comparison there was significant unexplainable heterogeneity (67.9% and 71.5% for POD1 and POD2, respectively). We conclude that (1) aprepitant reduces the incidence of vomiting on both POD1 and POD2, but there is an unexplained heterogeneity which lowers the strength of the evidence; (2) complete freedom from PONV on POD1 is highest for aprepitant with minimum need for rescue; and (3) oral aprepitant (80 mg) provides an effective and safe sustained antivomiting effect.
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Affiliation(s)
- Preet Mohinder Singh
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Anuradha Borle
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Vimi Rewari
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Jeetinder Kaur Makkar
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anjan Trikha
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ashish C Sinha
- Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Basavana Goudra
- Department of Anesthesia, Hospital of the University of Pennsylvania and Perleman School of Medicine, Philadelphia, Pennsylvania, USA
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Kakuta N, Kume K, Hamaguchi E, Tsutsumi R, Mita N, Tanaka K, Tsutsumi YM. The effects of intravenous fosaprepitant and ondansetron in the prevention of postoperative nausea and vomiting in patients who underwent lower limb surgery: a prospective, randomized, double-blind study. J Anesth 2015. [DOI: 10.1007/s00540-015-2054-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW Postoperative nausea and vomiting (PONV) continues to be one of the most common postsurgical medical problems. An understanding of the pathophysiology of PONV and the pharmacological profiles of agents affecting receptors involved in emesis is necessary to effectively treat PONV. RECENT FINDINGS Although serotonin receptor antagonists remain key in the multimodal approach to PONV management, new research developments involving antiemetics, such as neurokinin-1 antagonists, corticosteroids, dopamine antagonists, and cholinergic antagonists, have yielded valuable efficacy and safety information. SUMMARY Proper management of PONV includes an evaluation of risk factors, a strategy for prophylaxis, and rescue antiemetic treatment if necessary. In high-risk patients, combination therapy is recommended in preventing PONV. Knowledge of antiemetic efficacy and safety may facilitate an increase in patient satisfaction, decreased negative health consequences, and reduced medical costs.
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