Comparison of ramosetron and ondansetron for the treatment of established postoperative nausea and vomiting after laparoscopic surgery: a prospective, randomized, double-blinded multicenter trial

Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS®) Programs

Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.

Physical compatibility and chemical stability of dezocine and ramosetron in 0.9% sodium chloride injection for patient-controlled analgesia administration

As an antiemetic, 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist (ramosetron) is generally administered to prevent and treat postoperative nausea and vomiting induced by intravenous dezocine for patient-controlled analgesia. To date, the physicochemical stability of dezocine-ramosetron admixtures has not been assessed. The primary objective of this study was to evaluate the physicochemical stability of a combination of dezocine and ramosetron in 0.9% sodium chloride (normal saline [NS]) injections. Dezocine-ramosetron admixtures were prepared and stored in glass bottles and polyvinyl chloride (PVC) bags refrigerated at 4°C or stored at ambient temperatures (25°C) for up to 14 days. Initial concentrations were 5.0 mg/100 mL for dezocine and 0.3 mg/100 mL for ramosetron used as the diluents. Stability parameters (drug concentrations and pH values) were determined using high-performance liquid chromatography and pH measurements, respectively. Compatibility (cloudiness, discoloration, and precipitation) was assessed visually. After 14 days at 4 °C or 25 °C, the concentration losses of dezocine and ramosetron were both < 4%. Furthermore, there were no significant changes in color, turbidity, or pH values were observed in any of the batches. The results indicated that mixtures of dezocine and ramosetron in NS injections were continuously physically and chemically stable for 14 days in glass bottles or PVC bags stored at 4 °C or 25 °C.

Rescue Treatment of Postoperative Nausea and Vomiting: A Systematic Review of Current Clinical Evidence

Although prophylactic antiemetics are commonly used perioperatively, an estimated 30% of surgical patients still suffer from postoperative nausea and vomiting (PONV). Very few prospective trials have studied rescue treatment of PONV after failure of prophylaxis, providing limited evidence to support clinical management. In patients who have failed PONV prophylaxis, administering a rescue antiemetic from the same drug class has been reported to be ineffective. For many antiemetics currently used in PONV rescue, significant uncertainty remains around the effective dose range, speed of onset, duration of effect, safety, and overall risk-benefit ratio. As prompt, effective PONV rescue after failure of prophylaxis is important to optimize postoperative recovery and resource utilization, we conduct this systematic review to summarize the current evidence available on the topic.

Neurokinin-1 Antagonists for Postoperative Nausea and Vomiting

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.

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

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.

The next generation of antiemetics for the management of postoperative nausea and vomiting

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.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

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.

Comparison of ramosetron and ondansetron for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

Objective

We conducted a systematic literature search and meta-analysis to identify randomized controlled trials (RCTs) comparing the efficacy and safety of ramosetron versus ondansetron for the prevention of postoperative nausea and vomiting (PONV; PON and POV, respectively) in patients undergoing laparoscopic surgery.

Methods

The electronic databases PubMed, EMBASE, Web of Science, and Cochrane Library were searched up to March 2019 to identify relevant studies.

Results

The final pooled analysis included 6 RCTs and revealed that postoperative treatment with ramosetron at 24 to 48 hours after surgery significantly reduced the incidence of PON and POV relative to treatment with ondansetron. In a subgroup analysis, ramosetron 0.3 mg tended to reduce PON (0–2 hours) and POV (24–48 hours) more effectively than ondansetron 4 mg. However, no statistical difference was observed between ramosetron 0.3 mg and ondansetron 8 mg in terms of the reduction of PON or POV during any time interval within the first 48 hours after surgery.

Conclusions

Our results indicate that ramosetron 0.3 mg is superior to ondansetron 4 mg and comparable to ondansetron 8 mg for PONV prophylaxis after laparoscopic surgery.