Pharmacotherapy of postoperative nausea and vomiting

Total intravenous anesthesia versus inhalation anesthesia: how do outcomes compare?

RECENT FINDINGS

Surgical procedures that involve general anesthesia are performed with either volatile anesthetics or propofol-based total intravenous anesthesia. Both techniques are safe and provide appropriate conditions for surgery. Despite being a well established anesthetic, the use of propofol-based total intravenous anesthesia (TIVA) remains low. Possible explanations include the perceived increase risk of awareness, lack of target controlled infusion devices, increased turnover time for device set up and individual preference.

SUMMARY

There are some scenarios where patients could potentially benefit from propofol-based TIVA rather than a volatile anesthetic (e.g. postoperative nausea and vomiting) and some other clinical scenarios where the use of propofol-based anesthesia remains controversial since the strength of the evidence remains low.

PURPOSE

In this review we will summarize the clinical evidence comparing the effect of propofol-based TIVA and volatile anesthetic on postoperative outcomes such as postoperative nausea and vomiting, postoperative pain, quality of recovery, postoperative cognitive dysfunction and cancer outcomes.

Metoclopramide and Propofol to Prevent Nausea and Vomiting during Cesarean Section under Spinal Anesthesia: A Randomized, Placebo-Controlled, Double-Blind Trial

BACKGROUND

Intra-operative nausea, vomiting and retching (NVR) are frequently associated with subarachnoid anesthesia (SA) in women undergoing cesarean section (CS). In this study performed in women undergoing CS under SA with a risk factor control strategy, we compared saline (placebo), propofol, metoclopramide and both drugs to prevent NVR.

METHODS

We recorded NVR events in 110 women undergoing CS who were randomized after umbilical cord clamping to receive saline (S; n = 27), metoclopramide 10 mg (M; n = 28), propofol 1 mg/kg/h (P; n = 27) or both drugs (PM; n = 28).

RESULTS

The proportion of women with intra-operative nausea was: S: 17/27 (63%); P: 15/27 (56%); M: 13/28 (46%); PM: 6/28 (21%) (p = 0.012, Cramér's V = 0.31 (large effect). The proportion of women with intra-operative vomiting/retching was: S: 9/27 (33%); M: 7/27 (25%); P: 3/28 (11%); PM 2/28 (7%) (p = 0.049, Cramér's V = 0.26 (medium effect). Post-hoc multiple comparisons revealed a significant reduction in NVR episodes and NRS scores between the PM group and control. Sedation scores did not differ among groups.

CONCLUSION

In women undergoing CS under SA with a risk factor control strategy, combined propofol and metoclopramide reduce nausea and vomiting.

The effectiveness of ramosetron and ondansetron for preventing postoperative nausea and vomiting after arthroscopic rotator cuff repair: a randomized controlled trial

Background

Arthroscopic rotator cuff repair is a painful procedure, and treatment of emetic events associated with drugs used in the current multimodal pain management remains challenging. This study aimed to evaluate the effectiveness of ramosetron or ondansetron to relieve postoperative nausea and vomiting (PONV) and pain after arthroscopic rotator cuff repair.

Methods

In total, 122 consecutive patients undergoing arthroscopic rotator cuff repair were randomly allocated into three groups: ramosetron group (n = 39), ondansetron group (n = 43), and control group (n = 40). Then, 0.3 mg of ramosetron or 8 mg of ondansetron was administered intravenously at the end of surgery according to group. All patients received general anesthesia and multimodal pain management protocol including preemptive analgesic medication, fentanyl-based intravenous patient-controlled analgesia, and postoperative analgesic medication. Incidence of emetic events, rescue antiemetic requirements (10 mg of metoclopramide, IV), complete response, pain level, and side effects were recorded in three periods: 0–6, 6–24, and 24–48 h postoperatively. The severity of nausea and pain was evaluated using a visual analog scale.

Results

The ramosetron group tended to have a lower incidence and severity of nausea during the 6- to 24-h postoperative period and fewer rescue antiemetic drug requirements during the 0- to 48-h period than the control group, showing statistical significance. Additionally, the frequency of complete response of the ramosetron and ondansetron groups was significantly higher than that of the control group. No difference was found among the groups in the pain level except during the 0- to 6-h period. The two groups have a higher complete response during the 6- to 24-h period than the control group.

Conclusions

Ramosetron use led to a lower incidence, mild severity of nausea, and reduced use of rescue antiemetic drug after arthroscopic rotator cuff repair during the 6- to 24-h postoperative period than the control.

Level of evidence

Level I, randomized controlled trials, treatment study

Improved prophylaxis of postoperative nausea vomiting: Palonosetron a novel antiemetic

Many anti-emetics are used in clinical practice. Palonosetron hydrochloride is one of them. It is a novel, centrally acting antiemetic, and anti-nausea agent. This drug is an antagonist of serotonin receptor subtype 3 (5-HT3). This drug has longer duration of action which makes it useful in the prevention and treatment of acute and delayed onset of nausea and vomiting. This drug was initially used for chemotherapy induced nausea and vomiting. Federal drug agency (FDA) has approved it for prevention and treatment of post-operative nausea and vomiting. The literature search for this article was done using Google scholar and Pubmed using the terms "Palonosetron," "longer duration of action," "nausea," "vomiting," and "postoperative".

Efficacy of palonosetron and ramosetron on postoperative nausea and vomiting related to intravenous patient-controlled analgesia with opioids after gynecological laparoscopic surgery (double-blinded prospective randomized controlled trial)

PURPOSE

The study was designed to assess the efficacy of palonosetron and ramosetron in preventing postoperative nausea and vomiting (PONV) related to intravenous (IV) patient-controlled analgesia (PCA) with opioids after gynecological laparoscopic surgery.

METHODS

Patients were randomly allocated to 4 groups-C, P, R0.3 and RPCA. At the end of surgery, group C received an infusion of 50 ml normal saline, group P received palonosetron 75 μg mixed in 50 ml normal saline, and groups R0.3 and RPCA received ramosetron 0.3 mg mixed in 50 ml normal saline. A PCA pump containing fentanyl was connected for all groups; however, ramosetron 0.6 mg was mixed with the PCA regimen for the RPCA group. PONV and postoperative pain were assessed.

RESULTS

PONV incidence and scale, and Rhodes index in RPCA group between 24 and 72 h after discharge from the post-anesthetic care unit (PACU) showed significantly lower values, compared with the other groups. PONV incidence and scale, and Rhodes index in P group and R0.3 group were lower than the corresponding values in C group at all times, without statistical significance.

CONCLUSION

A single dose of palonosetron 75 μg or ramosetron 0.3 mg was unable to prevent PONV related to IV PCA with opioids in patients undergoing gynecological laparoscopic surgery. The combination of a single dose of ramosetron 0.3 mg, followed by ramosetron 0.6 mg mixed with PCA, significantly decreased PONV compared with a single dose of palonosetron 75 μg or ramosetron 0.3 mg.

Comparison of vestipitant with ondansetron for the treatment of breakthrough postoperative nausea and vomiting after failed prophylaxis with ondansetron

BACKGROUND

Postoperative nausea and vomiting (PONV) is common; ondansetron is often used as prophylaxis or for breakthrough episodes. Vestipitant is a neurokinin 1 (NK-1) receptor antagonist that is effective for prophylaxis, but its efficacy for treating established PONV is unknown. This study was performed to evaluate the efficacy and safety of vestipitant, compared with ondansetron for the treatment of breakthrough PONV in patients who had already received prophylactic ondansetron before surgery.

METHODS

A multicentre, randomized, single-blind (sponsor-open), parallel group study. Of 527 surgical patients, 130 (25%) had breakthrough PONV and were equally randomized to one of six i.v. doses of vestipitant (4-36 mg) or ondansetron 4 mg. The primary endpoint was the rate of patients exhibiting complete response, defined as no emesis and no further rescue medication from 10 min after infusion up to 24 h after surgery or hospital discharge.

RESULTS

All doses of vestipitant were non-inferior to ondansetron in treating PONV after failed prophylaxis with ondansetron. However, vestipitant was superior to ondansetron in decreasing episodes of postoperative emesis and retching. The complete response rate analysis using Bayesian model averaging indicated that no vestipitant dose was superior to ondansetron. Nausea numerical rating scale scores and the times-to-PONV or discharge were similar between the vestipitant and ondansetron treatment groups.

CONCLUSIONS

Although overall efficacy was non-inferior between vestipitant and ondansetron, the rate of emesis was lower with vestipitant. These data suggest that vestipitant may be a useful agent for the management of PONV, similar to other NK-1 antagonists.

CLINICAL TRIAL REGISTRATION

NCT01507194.

Palonosetron has superior prophylactic antiemetic efficacy compared with ondansetron or ramosetron in high-risk patients undergoing laparoscopic surgery: a prospective, randomized, double-blinded study

Background

Postoperative nausea and vomiting (PONV) continues to be a major problem, because PONV is associated with delayed recovery and prolonged hospital stay. Although the PONV guidelines recommended the use of 5-hydroxy-tryptamine (5-HT₃) receptor antagonists as the first-line prophylactic agents in patients categorized as high-risk, there are few studies comparing the efficacies of ondansetron, ramosetron, and palonosetron. The aim of present study was to compare the prophylactic antiemetic efficacies of three 5HT₃ receptor antagonists in high-risk patients after laparoscopic surgery.

Methods

In this prospective, randomized, double-blinded trial, 109 female nonsmokers scheduled for elective laparoscopic surgery were randomized to receive intravenous 4 mg ondansetron (n = 35), 0.3 mg ramosetron (n = 38), or 75 µg palonosetron (n = 36) before anesthesia. Fentanyl-based intravenous patient-controlled analgesia was administered for 48 h after surgery. Primary antiemetic efficacy variables were the incidence and severity of nausea, the frequency of emetic episodes during the first 48 h after surgery, and the need to use a rescue antiemetic medication.

Results

The overall incidence of nausea/retching/vomiting was lower in the palonosetron (22.2%/11.1%/5.6%) than in the ondansetron (77.1%/48.6%/28.6%) and ramosetron (60.5%/28.9%/18.4%) groups. The rescue antiemetic therapy was required less frequently in the palonosetron group than the other groups (P < 0.001). Kaplan-Meier analysis showed that the order of prophylactic efficacy in delaying the interval to use of a rescue emetic was palonosetron, ramosetron, and ondansetron.

Conclusions

Single-dose palonosetron is the prophylactic antiemetics of choice in high-risk patients undergoing laparoscopic surgery.

Postoperative nausea and vomiting in a gynecological and obstetrical population in South Eastern Nigeria

BACKGROUND

To determine the incidence of Postoperative nausea and vomiting (PONV) in a high risk surgical group following studies in other predominately black populations that showed a lower rate of postoperative nausea and vomiting than that reported from Caucasian and Oriental populations.

METHODS

A retrospective observational survey was conducted in the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria to determine the incidence of PONV within forty-eight hours of anesthesia in an obstetrical (caesarean sections only) and gynecological population that underwent regional and general anesthesia. The study took place from December 2007-April 2009 (16 months) for the gynecological population and from May 2008 to May 2010 (25 months) for the obstetrical population. The folders of 300 patients were randomly reviewed for demographics, anesthetic technique, diagnosis and documented records of PONV within 48 hours of anesthesia.

RESULTS

A total of 300 obstetrical and gynecological patients were used in this study. Twelve women vomited within forty-eight hours of anesthesia (12/300 or 4.0%). Nine patients vomited in the gynecological population (9/112) or 8% of the gynecological population and (3/186) or 1.6% in the obstetric population. All patients were American Society of Anesthesiologists (ASA) 1-4 including surgical emergencies.

CONCLUSION

The incidence of PONV in this surgical population is lower than that from most of the studies reviewed. This might be due to an inherent ethnic/racial variation. The economic implication of spending on expensive anti-emetics means more money can diverted to other needs.

Mechanisms underlying postoperative nausea and vomiting and neurotransmitter receptor antagonist-based pharmacotherapy

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications following surgery, and understanding the mechanism(s) underlying PONV is essential to providing optimal prophylaxis and/or treatment of PONV. The knowledge base of PONV physiology has significantly expanded over the past decade. This article reviews the risk factors for the development of PONV and the mechanisms of action of pharmacological agents (including antagonists of serotonin 5-HT(3), dopaminergic D(2), histamine H(1), muscarinic cholinergic, opioid and neurokinin NK(1) receptors) for the management (i.e. prophylaxis and treatment) of PONV. NK(1) receptor antagonists, with their unique mechanism of action, are a particularly promising area of research as they appear to be efficacious in preventing PONV during both the early and the late postoperative periods. A successful PONV management strategy includes: (i) identifying patients at risk; (ii) keeping the baseline risk low; and (iii) using a combination of antiemetics acting on different receptors in moderate- to high-risk patients.

Risk Factors for Postoperative Nausea and Vomiting

Knowledge of postoperative nausea and vomiting (PONV) risk factors allows anesthesiologists to optimize the use of prophylactic regimens. Modern PONV risk research began in the 1990s with publication of studies using logistic regression analysis to simultaneously identify multiple independent PONV predictors and publication of meta-analyses and systematic reviews. This literature shows that female gender post-puberty, nonsmoking status, history of PONV or motion sickness, childhood after infancy and younger adulthood, increasing duration of surgery, and use of volatile anesthetics, nitrous oxide, large-dose neostigmine, or intraoperative or postoperative opioids are well established PONV risk factors. Possible risk factors include history of migraine, history of PONV or motion sickness in a child's parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration, increasing duration of anesthesia, general versus regional anesthesia or sedation, balanced versus total IV anesthesia, and use of longer-acting versus shorter-acting opioids. Early-phase menstruation, obesity and lack of supplemental oxygen are disproved risk factors. Current risk scoring systems have approximately 55%-80% accuracy in predicting which patient groups will suffer PONV. Further research examining genetic and under-investigated clinical patient characteristics as potential risk factors, and involving outpatients and children, should improve predictive systems.

Meta-analysis of the safety of 5-HT3 antagonists with dexamethasone or droperidol for prevention of PONV

BACKGROUND

Antiemetic guidelines recommend a combination of serotonin (5-HT3) with a second agent such as droperidol or dexamethasone. Physicians have been reluctant to employ these guidelines due to concerns over the black-box warning of droperidol and safety concerns with a steroid.

OBJECTIVE

To assess the safety profiles of 5-HT3 receptor antagonist (5-HT3RA) monotherapy and combination therapy with a steroid or droperidol for prophylaxis of postoperative nausea and vomiting (PONV).

METHODS

A MEDLINE search of English-language reports of randomized controlled trials (RCTs) was conducted (1966-September 2005) using the key terms 5-HT3, granisetron, ondansetron, dolasetron, tropisetron, PONV, postoperative, vomiting, emesis, and nausea. RCTs with treatment arms comparing 5-HT3RA monotherapy (granisetron, ondansetron, dolasetron, or tropisetron) with dexamethasone or droperidol or 5-HT3RA combinations and providing incidence data on adverse events were identified and reviewed. Within-study odds ratios with 95% confidence intervals were calculated to determine the incidence rates of all adverse events in RCTs using 5-HT3RA monotherapy and combination therapies. Overall effect sizes for frequently reported adverse events were estimated by pooling ORs using fixed- and random-effect models.

RESULTS

Pooled ORs (OR(pooled)) for adverse events with 5-HT3RA/dexamethasone versus 5-HT3RA for PONV prophylaxis were not significant for any reported adverse events or the overall incidence of adverse events; 5-HT3RA/droperidol versus 5-HT3RA was significant only for decreased headache incidence (fixed model: OR(pooled) 0.35; 95% CI 0.18 to 0.69). The OR(pooled) for 5-HT3RA/dexamethasone versus dexamethasone was not significant for any reported adverse events except headaches (fixed model OR(pooled) 1.75; 95% CI 1.01 to 3.03), none of which was serious. OR(pooled) for 5-HT3RA/droperidol versus droperidol was not significant for any reported adverse events. Avascular necrosis, occult infection, and delayed wound healing were not observed with either combination therapy. Cardiac abnormalities were observed with 5-HT3RA/droperidol therapy.

CONCLUSIONS

This meta-analysis indicates that either therapy has a safety profile similar to that of dexamethasone, droperidol, or 5-HT3RA.

The Role of 5-HT3 Receptor Antagonists in Preventing Postoperative Nausea and Vomiting

Postoperative nausea and vomiting (PONV) is a frequent complication of surgery. Guidelines recommend using a 5-HT3 receptor antagonist (eg, ondansetron, dolasetron, granisetron) combined with a second agent (eg, dexamethasone) for patients at moderate to high risk for PONV. Although all 5-HT3 antagonists are effective, ondansetron and granisetron have been found to be effective at substantially lower doses than those approved by the US Food and Drug Administration. Metabolism of granisetron differs from metabolism of other 5-HT, antagonists, so it is less likely to adversely interact with other medications. This article explains the clinical pharmacology of 5-HT3 antagonists and provides recommendations for nursing management of PONV.

Postoperative Gastrointestinal Tract Dysfunction

Postoperative gastrointestinal (GI) tract dysfunction (PGID) is common and is associated with increased patient suffering and cost of care. The pathogenesis of PGID is complex and multifactorial. Traditional measures intended to reduce the incidence of PGID, such as the use of prokinetic drugs, nasogastric tube drainage, and the avoidance of early fluid and/or food intake, are apparently not beneficial. The administration of larger volumes of IV fluids to achieve predetermined increases in cardiac output has been shown in randomized trials to improve gut perfusion and reduce the incidence of PGID. A multimodal approach that includes limited surgical incision, regional local anesthesia, early mobilization, and enteral feeding has been associated with a dramatic reduction in postoperative complications, PGID, and length of hospital stay. However, none of these approaches has been validated in adequately powered multicenter prospective randomized controlled trials.