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Singh K, Jain A, Panchal I, Madan H, Gupta A, Sharma A, Gupta S, Kostojchin A, Singh A, Sandhu IS, Mittal J, Bhogal L, Kolli ST, Bejugam VR, Chaturvedi S, Bhalla A, Piplani S. Ondansetron-induced QT prolongation among various age groups: a systematic review and meta-analysis. Egypt Heart J 2023; 75:56. [PMID: 37395900 DOI: 10.1186/s43044-023-00385-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/29/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Ondansetron is a selective 5-hydroxytryptamine type 3 serotonin-receptor antagonist with antiemetic properties used inadvertently in the emergency department for controlling nausea. However, ondansetron is linked with a number of adverse effects, including prolongation of the QT interval. Therefore, the purpose of this meta-analysis was to assess the occurrence of QT prolongation in pediatric, adult, and elderly patients receiving oral or intravenously administered ondansetron. METHODS A thorough electronic search was conducted on PubMed (Medline) and Cochrane Library from the databases' inception to August 10, 2022. Only those studies were considered in which ondansetron was administered orally or intravenously to participants for the treatment of nausea and vomiting. The prevalence of QT prolongation in multiple predefined age groups was the outcome variable. Analyses were conducted using Review manager 5.4 (Cochrane collaboration, 2020). RESULTS A total of 10 studies involving 687 ondansetron group participants were statistically analyzed. The administration of ondansetron was associated with a statistically significant prevalence of QT prolongation in all age groups. An age-wise subgroup analysis was conducted which revealed that the prevalence of QT prolongation among participants younger than 18 years was not statistically significant, whereas it was statistically significant among participants aged 18-50 years and among patients older than 50 years. CONCLUSIONS The present meta-analysis provides further evidence that oral or intravenous administration of Ondansetron may lead to QT prolongation, particularly among patients older than 18 years of age.
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Affiliation(s)
- Kamaldeep Singh
- Department of Medicine, KAHER's Jawaharlal Nehru Medical College, Belagavi, Karnataka, 590 010, India
| | - Arpit Jain
- Department of Medicine, KAHER's Jawaharlal Nehru Medical College, Belagavi, Karnataka, 590 010, India
| | - Ishita Panchal
- Department of Medicine, KAHER's Jawaharlal Nehru Medical College, Belagavi, Karnataka, 590 010, India
| | - Hritik Madan
- Department of Medicine, Adesh Medical College and Hospital, Ambala, 136 135, India
| | - Anubhav Gupta
- Department of Medicine, KAHER's Jawaharlal Nehru Medical College, Belagavi, Karnataka, 590 010, India
| | - Aakanksha Sharma
- Department of Internal Medicine, Icahn School of Medicine, Mount Sinai West Hospital, New York, NY, 10019, USA
| | - Surabhi Gupta
- Department of Internal Medicine, Christian Medical College, Ludhiana, Punjab, 141008, India
| | - Anastas Kostojchin
- Department of Medicine, Icahn School of Medicine at Mount Sinai/James J. Peters VA Medical Center, Bronx, NY, 10468, USA
| | - Anmol Singh
- Department of Cardiology, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | | | - Jayesh Mittal
- Department of Internal Medicine, St Mary Mercy Hospital Livonia, Trinity Health, Livonia, MI, 48154, USA
| | - Loveleen Bhogal
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC, 20010, USA
| | - Shiny Teja Kolli
- Department of Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, 10467, USA
| | - Vishal Reddy Bejugam
- Department of Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, 10467, USA
| | - Salil Chaturvedi
- Department of Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, 10467, USA
| | - Akhil Bhalla
- Department of Anesthesiology, Adesh Medical College and Hospital, Ambala, 136 135, India
| | - Shobhit Piplani
- Department of Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, 10467, USA.
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Vanneman MW, Madhok J, Weimer JM, Dalia AA. Perioperative Implications of the 2020 American Heart Association Scientific Statement on Drug-Induced Arrhythmias-A Focused Review. J Cardiothorac Vasc Anesth 2021; 36:952-961. [PMID: 34144871 DOI: 10.1053/j.jvca.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 11/11/2022]
Abstract
The recently released American Heart Association (AHA) scientific statement on drug-induced arrhythmias discussed medications commonly associated with bradycardia, supraventricular tachycardias, and ventricular arrhythmias. The foundational data for this statement were collected from general outpatient and inpatient populations. Patients undergoing surgical and minimally invasive treatments are a unique subgroup, because they may experience hemodynamic changes associated with anesthesia and their procedure, receive multiple drug combinations not given in either inpatient or outpatient settings, or experience postprocedural inflammatory syndromes. Accordingly, the generalizability of the AHA scientific statement to this perioperative population is unclear. This focused review highlights important aspects of the new AHA scientific statement and their application to the perioperative setting. The authors review medications frequently encountered and given by anesthesiologists and their risk of drug-induced arrhythmias and discuss common anesthetic and adjunctive medications and their associated risks of bradycardia, atrial fibrillation, torsades de pointes, and drug-induced Brugada syndrome. In many instances, the risk of arrhythmia reported by the AHA scientific statement in the general population appeared to be higher than found in perioperative arenas. Furthermore, the authors discuss the arrhythmia risk of additional medications commonly ordered or administered by anesthesiologists that are not included in the AHA scientific statement. As patient and procedural complexity increases and novel anesthetic combinations propagate, further research and observational studies will be required to delineate further perioperative risks for drug-induced arrhythmia.
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Affiliation(s)
- Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Jai Madhok
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jonathan M Weimer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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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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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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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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Singh PM, Borle A, Makkar JK, Trikha A, Fish D, Sinha A. Haloperidol Versus 5-HT 3 Receptor Antagonists for Postoperative Vomiting and QTc Prolongation: A Noninferiority Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. J Clin Pharmacol 2017; 58:131-143. [PMID: 28914976 DOI: 10.1002/jcph.999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/17/2017] [Indexed: 11/09/2022]
Abstract
Haloperidol is an antipsychotic with well-known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta-analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5-HT3 -receptor antagonists (5-HT3 -RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar in groups (fixed effects, P = 0.52, I2 = 0%). Trial-sequential analysis confirmed noninferiority of haloperidol over 5-HT3 -RAs (α = 5%, β = 20%, δ = 10%), with "information size" being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5-HT3 -RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, P = 0.23, I2 = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial-sequential analysis showed statistical equivalence (α = 5%, β = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X-intercept = 2.07, P = 0.10). We conclude that haloperidol is equivalent to the well-established 5-HT3 -RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5-HT3 -RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting.
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Affiliation(s)
- Preet Mohinder Singh
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Anuradha Borle
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Jeetinder Kaur Makkar
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anjan Trikha
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - David Fish
- Division Chief for Critical Care, Department of Anesthesiology, Temple University Health System, Philadelphia, PA, USA
| | - Ashish Sinha
- Anesthesiology and Perioperative, Medicine, Lewis Katz School of Medicine, Temple University Health System, Philadelphia, PA, USA
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Veiga-Gil L, Pueyo J, López-Olaondo L. Postoperative nausea and vomiting: physiopathology, risk factors, prophylaxis and treatment. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:223-232. [PMID: 28041609 DOI: 10.1016/j.redar.2016.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/09/2016] [Accepted: 10/10/2016] [Indexed: 06/06/2023]
Abstract
Recognising the importance of the prevention and early treatment of postoperative nausea and vomiting (PONV) is essential to avoid postoperative complications, improve patient satisfaction and enable the development of major outpatient surgery and fast-track surgery. The topic of PONV might seem to have become stagnant, but we are moving forward. New concepts and problems like post-discharge nausea and vomiting, new risk factors and new drugs are appearing. However, there continue to be mistaken notions about PONV, such as the association between PONV and post-anaesthesia care unit stays, or assuming that it is a risk factore characteristic of the patient, anaesthesia or surgery when it is not. Perhaps, now is the moment to tackle PONV in a different manner, implementing guidelines and going for more aggressive prophylaxis in some groups of patients. We present an extensive review of this topic.
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Affiliation(s)
- L Veiga-Gil
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Complejo Hospitalario de Navarra, Pamplona, Navarra, España.
| | - J Pueyo
- Departamento de Anestesiología y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - L López-Olaondo
- Departamento de Anestesiología y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, España
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Gender-Specific Differences in Low-Dose Haloperidol Response for Prevention of Postoperative Nausea and Vomiting: A Register-Based Cohort Study. PLoS One 2016; 11:e0146746. [PMID: 26751066 PMCID: PMC4713839 DOI: 10.1371/journal.pone.0146746] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 12/20/2015] [Indexed: 11/30/2022] Open
Abstract
Background Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after general anesthesia and surgery, with young non-smoking females receiving postoperative opioids being high-risk patients. This register-based study aims to evaluate the effect of low-dose haloperidol (0.5 mg intravenously) directly after induction of general anesthesia to reduce the incidence of PONV in the postoperative anesthesiological care unit (PACU). Methods Multivariable regression models were used to investigate the association between low-dose haloperidol and the occurrence of PONV using a patient registry containing 2,617 surgical procedures carried out at an university hospital. Results Haloperidol 0.5 mg is associated with a reduced risk of PONV in the total collective (adjusted odds ratio = 0.75, 95% confidence interval: [0.56, 0.99], p = 0.05). The results indicate that there is a reduced risk in male patients (adjusted odds ratio = 0.45, 95% confidence interval: [0.28, 0.73], p = 0.001) if a dose of 0.5 mg haloperidol was administered while there seems to be no effect in females (adjusted odds ratio = 1.02, 95% confidence interval: [0.71, 1.46], p = 0.93). Currently known risk factors for PONV such as female gender, duration of anesthesia and the use of opioids were confirmed in our analysis. Conclusion This study suggests that low-dose haloperidol has an antiemetic effect in male patients but has no effect in female patients. A confirmation of the gender-specific effects we have observed in this register-based cohort study might have major implications on clinical daily routine.
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Joo J, Park YG, Baek J, Moon YE. Haloperidol dose combined with dexamethasone for PONV prophylaxis in high-risk patients undergoing gynecological laparoscopic surgery: a prospective, randomized, double-blind, dose-response and placebo-controlled study. BMC Anesthesiol 2015; 15:99. [PMID: 26152218 PMCID: PMC4493951 DOI: 10.1186/s12871-015-0081-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 06/24/2015] [Indexed: 11/13/2022] Open
Abstract
Background Low-dose haloperidol is known to be effective for the prevention of postoperative nausea and vomiting (PONV). However, precise dose-response studies have not been completed, especially in patients at high risk for PONV who require combination therapy. This study sought to identify which dose of haloperidol 1mg or 2mg could be combined with dexamethasone without adverse effects in high-risk patients undergoing gynecological laparoscopic surgery. Methods Female adults (n = 150) with three established PONV risk factors based on Apfel’s score were randomized into one of three study groups. At the end of anesthesia, groups H0, H1, and H2 were given intravenous (IV) saline, haloperidol 1 mg, and haloperidol 2 mg, respectively. All patients were given dexamethasone 5 mg during the induction of anesthesia. The overall early (0–2 h) and late (2–24 h) incidences of nausea, vomiting, rescue anti-emetic administration, pain, and adverse effects (cardiac arrhythmias and extrapyramidal effects) were assessed postoperatively. The sedation score was recorded in the postanesthesia care unit (PACU). Results The total incidence of PONV over 24 h was significantly lower in groups H1 (29 %) and H2 (24 %) than in group H0 (54 %; P = 0.003), but there was no significant difference between groups H1 and H2. In the PACU, group H2 had a higher sedation score than groups H1 and H0 (P < 0.001). Conclusions For high-risk PONV patients undergoing gynecological laparoscopic surgery, when used with dexamethasone, 1-mg haloperidol was equally effective as 2 mg in terms of preventing PONV with the less sedative effect. Trial Registration ClinicalTrials.gov (NCT01639599).
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Affiliation(s)
- Jin Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
| | - Yong Gyu Park
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jungwon Baek
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
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Tricco AC, Soobiah C, Blondal E, Veroniki AA, Khan PA, Vafaei A, Ivory J, Strifler L, Ashoor H, MacDonald H, Reynen E, Robson R, Ho J, Ng C, Antony J, Mrklas K, Hutton B, Hemmelgarn BR, Moher D, Straus SE. Comparative safety of serotonin (5-HT3) receptor antagonists in patients undergoing surgery: a systematic review and network meta-analysis. BMC Med 2015; 13:142. [PMID: 26084332 PMCID: PMC4472408 DOI: 10.1186/s12916-015-0379-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 05/19/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Serotonin (5-HT3) receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients, but these agents may be harmful. We conducted a systematic review on the comparative safety of 5-HT3 receptor antagonists. METHODS Searches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or other antiemetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by two reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. PROSPERO registry number: CRD42013003564. RESULTS Overall, 120 studies and 27,787 patients were included after screening of 7,608 citations and 1,014 full-text articles. Significantly more patients receiving granisetron plus dexamethasone experienced an arrhythmia relative to placebo (odds ratio (OR) 2.96, 95 % confidence interval (CI) 1.11-7.94), ondansetron (OR 3.23, 95 % CI 1.17-8.95), dolasetron (OR 4.37, 95 % CI 1.51-12.62), tropisetron (OR 3.27, 95 % CI 1.02-10.43), and ondansetron plus dexamethasone (OR 5.75, 95 % CI 1.71-19.34) in a NMA including 31 randomized clinical trials (RCTs) and 6,623 patients of all ages. No statistically significant differences in delirium frequency were observed across all treatment comparisons in a NMA including 18 RCTs and 3,652 patients. CONCLUSION Granisetron plus dexamethasone increases the risk of arrhythmia.
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 6th floor, 155 College St, Toronto, ON, M5T 3M7, Canada.
| | - Charlene Soobiah
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Institute for Health Policy Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON, M5T 3M6, Canada.
| | - Erik Blondal
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Areti A Veroniki
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Paul A Khan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Afshin Vafaei
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - John Ivory
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Lisa Strifler
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Huda Ashoor
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Heather MacDonald
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Emily Reynen
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Reid Robson
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Joanne Ho
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Carmen Ng
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
| | - Kelly Mrklas
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Departments of Community Health Sciences, Faculty of Medicine, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive, Calgary, AB, T2N 4Z6, Canada.
| | - Brian Hutton
- Clinical Epidemiology Program, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Brenda R Hemmelgarn
- Departments of Community Health Sciences, Faculty of Medicine, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive, Calgary, AB, T2N 4Z6, Canada.
| | - David Moher
- Clinical Epidemiology Program, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada. .,Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada.
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Dosis bajas de haloperidol en combinación con ondansetrón no son eficaces para la profilaxis de náuseas y vómitos postoperatorios en pacientes propicios a esta complicación. Cir Esp 2015; 93:110-6. [DOI: 10.1016/j.ciresp.2014.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 11/18/2022]
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12
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Low Doses of Haloperidol Combined With Ondansetron Are not Effective for Prophylaxis of Postoperative Nausea and Vomiting in Susceptible Patients. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.cireng.2014.01.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Postoperative and Postdischarge Nausea and Vomiting After Ambulatory Surgery: An Update. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0076-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.
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Benevides ML, Oliveira SDS, Aguilar-Nascimento JE. Combination of Haloperidol, Dexamethasone, and Ondansetron Reduces Nausea and Pain Intensity and Morphine Consumption after Laparoscopic Sleeve Gastrectomy. Braz J Anesthesiol 2013. [DOI: 10.1016/j.bjane.2012.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Benevides ML, Oliveira SDS, Aguilar-Nascimento JE. A Associação de Haloperidol, Dexametasona e Ondansetrona Reduz a Intensidade de Náusea, Dor e Consumo de Morfina após Gastrectomia Vertical Laparoscópica. Rev Bras Anestesiol 2013; 63:404-9. [DOI: 10.1016/j.bjan.2012.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 07/30/2012] [Indexed: 11/29/2022] Open
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McLean SL, Blenkinsopp A, Bennett MI. Using haloperidol as an antiemetic in palliative care: informing practice through evidence from cancer treatment and postoperative contexts. J Pain Palliat Care Pharmacother 2013; 27:132-5. [PMID: 23627663 DOI: 10.3109/15360288.2013.782937] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Nausea and vomiting are common symptoms in palliative care. Haloperidol is often used as an antiemetic in this context, although direct evidence supporting this practice is limited. To evaluate the efficacy and clinical use of haloperidol as an antiemetic in nonpalliative care contexts to inform practice, the authors conducted a rapid review of (i) published evidence to supplement existing systematic reviews, and (ii) practical aspects affecting the use of haloperidol including formulations and doses that are commonly available internationally. In nausea and vomiting related to cancer treatment, haloperidol was superior to control in two small studies. In postoperative nausea and vomiting (PONV), two randomized controlled trials found treatment with haloperidol comparable to ondansetron. In palliative care, an observational study found a complete response rate of 24% with haloperidol (one in four patients) which would be consistent with a number needed to treat (NNT) of 3 to 5 derived from PONV. There remains insufficient direct evidence to definitively support the use of haloperidol for the management of nausea and vomiting in palliative care. However, generalizing evidence from other clinical contexts may have some validity.
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Affiliation(s)
- Samantha L McLean
- School of Pharmacy, University of Bradford, Richmond Road, Bradford, UK.
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Lu KZ, Shen H, Chen Y, Li MG, Tian GP, Chen J. Ondansetron does not attenuate the analgesic efficacy of nefopam. Int J Med Sci 2013; 10:1790-4. [PMID: 24273453 PMCID: PMC3837238 DOI: 10.7150/ijms.5386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 10/17/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate if there is any interaction between ondansetron and nefopam when they are continuously co-administrated during patient-controlled intravenous analgesia (PCIA). METHODS The study was a prospective, randomized, controlled, non-inferiority clinical trial comparing nefopam-plus-ondansetron to nefopam alone. A total of 230 postoperative patients using nefopam for PCIA, were randomly assigned either to a group receiving continuous infusion of ondansetron (Group O) or to the other group receiving the same volume of normal saline continuously (Group N). Postoperative pain intensity scores, the sum of pain intensity difference over 24 hours postoperatively (SPID24hr), the incidence of adverse events, and the total consumption of nefopam were evaluated respectively. RESULTS Postoperative pain was treated successfully in both groups. The mean SPID24hr scores were 95.6 mm in Group N and 109.3mm in Group O [95% confidence interval (CI) -14.28, 24.32]. The lower margin of the 95% CI was above the pre-determined non-inferiority margin (-30mm) for SPID24hr, which indicated that nefopam-plus-ondansetron was not worse than the nefopam alone in term of analgesic efficacy. In addition, there was no statistical difference between the two groups in term of cumulative consumption of nefopam. Compared with Group N, postoperative vomiting was significantly reduced in Group O during the postoperative 24 hours (P < 0.05). Less rescue antiemetics were given to patients in Group O than those receiving nefopam alone (P < 0.05). There were no differences in postoperative nausea between the two groups. CONCLUSION Nefopam-plus-ondansetron is not inferior to nefopam alone in relieving the pain in PCIA after minimally invasive surgery. In addition, adverse events are reduced without compromising analgesic efficacy.
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Affiliation(s)
- Kai-zhi Lu
- 1. Department of Anaesthesiology, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
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Chaparro C, Moreno D, Ramírez V, Fajardo A, González D, Sanín A, Grueso R. Haloperidol como profilaxis para náuseas y vómito postoperatorios: revisión sistemática. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.rca.2012.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Chaparro C, Moreno D, Ramírez V, Fajardo A, González D, Sanín A, Grueso R. Haloperidol as prophylactic treatment for postoperative nausea and vomiting: Systematic literature review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2012.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Chaparro C, Moreno D, Ramírez V, Fajardo A, González D, Sanín A, Grueso R. Haloperidol as prophylactic treatment for postoperative nausea and vomiting: Systematic literature review☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341010-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Le TP, Gan TJ. Postoperative Nausea and Vomiting. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Mazo V, Vila P, Sabaté S, Orrego C, Canet J. [Evaluation of the efficiency of pharmacological antiemetic prophylaxis in different risk groups after general anaesthesia in the surgical population of Catalonia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:244-253. [PMID: 22652333 DOI: 10.1016/j.redar.2012.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 03/27/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To assess the efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthetic in different postoperative nausea and vomiting (NVPO) risk groups. MATERIAL AND METHODS A randomised, observational, prospective and multicentre cohort study was conducted. The study included 1239 patients from 26 hospitals who were subjected to elective surgery under general anaesthesia. The data collected included, demographic characteristics, the NVPO risk factors, anaesthetic technique, type of surgery, the duration, fluid therapy, antiemetic prophylaxis administered, and the incidence of NVPO in the first 24h after surgery. A stratified analysis (low, moderate and high risk) was performed with the intention of evaluating the relationship between prophylaxis and NVPO using a logistic regression model adjusted for propensity score. The number of patients needed to treat (NNT) to prevent an NVPO episode was then calculated for each of the strata. RESULTS The incidence of NVPO in the low risk stratum was 21.6% without prophylaxis and 8.6% with prophylaxis, 31.3% compared to 17.7% in the moderate risk, and 46.5% compared to 32.7% in the high risk group. There was a significant protective effect in the three strata (odds ratio between treated and untreated patients) and in the NNT (95% CI) was 7 (5-11) in the low risk stratum, 7 (5-13) in that of the moderate risk, and 6 (4-16) in the high risk. CONCLUSIONS The efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthesia was similar in all risk groups. Not providing antiemetic prophylaxis in low risk patients may not be justified due to the cost-effectiveness criteria. Future clinical guidelines to improve the quality of health care of patients operated on under general anaesthesia should consider the advantages of a universal NVPO prophylaxis.
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Affiliation(s)
- V Mazo
- Servicio de Anestesiología y Reanimación, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
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Chandrakantan A, Glass PSA. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth 2012; 107 Suppl 1:i27-40. [PMID: 22156268 DOI: 10.1093/bja/aer358] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.
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Affiliation(s)
- A Chandrakantan
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA.
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Affiliation(s)
- Hyun Chul Lim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Minville V, Fourcade O, Mazoit J, Girolami J, Tack I. Ondansetron does not block paracetamol-induced analgesia in a mouse model of fracture pain. Br J Anaesth 2011; 106:112-8. [DOI: 10.1093/bja/aeq277] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Rüsch D, Eberhart LHJ, Wallenborn J, Kranke P. Nausea and vomiting after surgery under general anesthesia: an evidence-based review concerning risk assessment, prevention, and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:733-41. [PMID: 21079721 DOI: 10.3238/arztebl.2010.0733] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 04/13/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The German-language recommendations for the management of postoperative nausea and vomiting (PONV) have been revised by an expert committee. Major aspects of this revision are presented here in the form of an evidence-based review article. METHODS The literature was systematically reviewed with the goal of revising the existing recommendations. New evidence-based recommendations for the management of PONV were developed, approved by consensus, and graded according to the scheme of the Scottish Intercollegiate Guidelines Network (SIGN). RESULTS The relevant risk factors for PONV include female sex, nonsmoker status, prior history of PONV, motion sickness, use of opioids during and after surgery, use of inhalational anesthetics and nitrous oxide, and the duration of anesthesia. PONV scoring systems provide a rough assessment of risk that can serve as the basis for a risk-adapted approach. Risk-adapted prophylaxis, however, has not been shown to provide any greater benefit than fixed (combination) prophylaxis, and PONV risk scores have inherent limitations; thus, fixed prophylaxis may be advantageous. Whichever of these two approaches to manage PONV is chosen, high-risk patients must be given multimodal prophylaxis, involving both the avoidance of known risk factors and the application of multiple validated and effective antiemetic interventions. PONV should be treated as soon as it arises, to minimize patient discomfort, the risk of medical complications, and the costs involved. CONCLUSION PONV lowers patient satisfaction but is treatable. The effective, evidence-based measures of preventing and treating it should be implemented in routine practice.
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Affiliation(s)
- Dirk Rüsch
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Gießen und Marburg GmbH
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Le TP, Gan TJ. Update on the management of postoperative nausea and vomiting and postdischarge nausea and vomiting in ambulatory surgery. Anesthesiol Clin 2010; 28:225-249. [PMID: 20488392 DOI: 10.1016/j.anclin.2010.02.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Postoperative nausea and vomiting (PONV) continues to be one of the most common complaints following surgery, occurring in more than 30% of surgeries, or as high as 70% to 80% in certain high-risk populations without prophylaxis. The 5-hydroxytryptamine type 3 (5-HT(3)) receptor antagonists continue to be the mainstay of antiemetic therapy, but newer approaches, such as neurokinin-1 antagonists, a longer-acting serotonin receptor antagonist, multimodal management, and novel techniques for managing high-risk patients are gaining prominence. The related problem of postdischarge nausea and vomiting (PDNV) has received increasing attention from health care providers. The issues of PONV and PDNV are especially significant in the context of ambulatory surgeries, which comprise more than 60% of the combined 56.4 million ambulatory and inpatient surgery visits in the United States. Because of the relatively brief period that ambulatory patients spend in health care facilities, it is particularly important to prevent and treat PONV and PDNV swiftly and effectively.
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Affiliation(s)
- Tina P Le
- Department of Anesthesiology, Duke University Medical Center, Duke University School of Medicine, Durham, NC 27710, USA
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