1
|
Wang L, Huang J, Hu H, Chang X, Xia F. Commonly used antiemetics for prophylaxis of postoperative nausea and vomiting after Caesarean delivery with neuraxial morphine: a network meta-analysis. Br J Anaesth 2024; 132:1274-1284. [PMID: 38627136 DOI: 10.1016/j.bja.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Dopamine antagonists, 5-HT3 antagonists, and dexamethasone are frequently used in obstetrics to prevent postoperative nausea and vomiting (PONV). However, the superiority of any drug class is yet to be established. This network meta-analysis aimed to compare the efficacy of these antiemetics for PONV prophylaxis in women receiving neuraxial morphine for Caesarean delivery. METHODS We searched PubMed, Embase, CENTRAL, Web of Science, and Wanfang Data for eligible randomised controlled trials. Primary outcomes were the incidences of postoperative nausea (PON) and postoperative vomiting (POV) within 24 h after surgery. We used a Bayesian random-effects model and calculated odds ratios with 95% credible intervals for dichotomous data. We performed sensitivity and subgroup analyses for primary outcomes. RESULTS A total of 33 studies with 4238 women were included. In the primary analyses of all women, 5-HT3 antagonists, dopamine antagonists, dexamethasone, and 5-HT3 antagonists plus dexamethasone significantly reduced PON and POV compared with placebo, and 5-HT3 antagonists plus dexamethasone were more effective than monotherapy. In the subgroup analyses, similar results were seen in women receiving epidural morphine or intrathecal morphine alone but not in women receiving intrathecal morphine with fentanyl or sufentanil. However, most included studies had some concerns or a high risk of bias, and the overall certainty of the evidence was low or very low. CONCLUSIONS Combined 5-HT3 antagonists plus dexamethasone are more effective than monotherapy in preventing PONV associated with neuraxial morphine after Caesarean delivery. Future studies are needed to determine the role of prophylactic antiemetics in women receiving intrathecal morphine and lipophilic opioids. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023454602.
Collapse
Affiliation(s)
- Lizhong Wang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China.
| | - Jiayue Huang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Huijing Hu
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Xiangyang Chang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Feng Xia
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| |
Collapse
|
2
|
Lin C, Li J, Wu Q, Luo T, Zheng Z. Postoperative Nausea and Vomiting in Female Patients Undergoing Laparoscopic Gastrointestinal Surgery with Double Prophylactic Therapy. Surg J (N Y) 2024; 10:e25-e30. [PMID: 38835494 PMCID: PMC11147651 DOI: 10.1055/s-0044-1787305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/08/2024] [Indexed: 06/06/2024] Open
Abstract
Purpose Postoperative nausea and vomiting (PONV) is a major problem after surgery. This study aimed to demonstrate the incidence of PONV and the potential associated factors in female patients undergoing laparoscopic gastrointestinal surgery against the background of double prophylactic therapy. Methods Our retrospective study recruited 109 female patients undergoing laparoscopic gastrointestinal surgery with double prophylactic therapy, combining palonosetron with dexamethasone, from October 2020 to March 2021, at the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. Patient characteristics and perioperative management factors were included in univariate and multivariate analyses to identify factors influencing PONV. Results Four patients lacked complete records, and of the 105 patients included in the final analysis, 53 (50.5%) patients developed PONV. Two influencing factors for PONV were identified: a history of chemotherapy (odds ratio [OR] 0.325, 95% confidence interval [CI] 0.123-0.856; p = 0.023) and dosage of hydromorphone ≥ 0.02 mg/kg (OR 2.857, 95% CI 1.247-6.550; p = 0.013). The performance of the multivariate logistic regression was evaluated by analyzing receiver operating characteristic curves, resulting in an area under the curve value of 0.673. Conclusion The incidence of PONV remains high in female patients undergoing laparoscopic gastrointestinal surgery, even with double prophylactic therapy. A dosage of hydromorphone ≥ 0.02 mg/kg may increase risk of PONV, whereas a history of chemotherapy might be a protective factor.
Collapse
Affiliation(s)
- Chunmeng Lin
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Center for Surgery and Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Wu
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Center for Clinical Research, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tongfeng Luo
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhinan Zheng
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
3
|
Cadd M, Jackson P, Ewnetu B. Ondansetron for the Prevention of Pruritus in Women Undergoing Cesarean Delivery With Intrathecal Opioid: A Systematic Review and Meta-Analysis. Anesth Analg 2024; 138:70-84. [PMID: 37167702 DOI: 10.1213/ane.0000000000006526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Pruritus is a frequently reported and unpleasant side effect following intrathecal opioid use with frequency further increased among parturients. We have performed a systematic review to assess the overall efficacy of ondansetron for the prevention of pruritus in patients receiving intrathecal opioid as part of spinal anesthesia for cesarean delivery. METHODS A literature search of MEDLINE, Embase, Cochrane, and Web of Science databases was conducted from date of inception to September 2022. Studies that included patients undergoing cesarean delivery with spinal anesthesia using intrathecal opioid were included. The primary outcome was the presence of pruritus, and the secondary outcome was time to onset of pruritus. Data from included studies were pooled for analysis using an appropriately determined random-effects model. Outcomes were presented using forest plots and 95% confidence intervals. Additional sensitivity and subgroup analysis were performed. Trial sequential analysis was conducted for the primary outcome. RESULTS Twenty-three randomized controlled trials with a total of 2586 patients were included: 1219 received ondansetron, 1030 received a placebo, and a further 337 received a different study drug and were excluded from analysis. Opioids used in the included studies were morphine, fentanyl, and sufentanil. Patients who received ondansetron showed a significant reduction in the incidence of pruritus compared to the control group (RR, 0.81; 95% confidence interval [CI], 0.71-0.92; I 2 = 64%). There was no significant difference in pruritus onset between the groups (mean difference [MD], 17.54 minutes; 95% CI, -2.18 to 37.26; I 2 = 83%). The overall Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment of quality of evidence was low. CONCLUSIONS This systematic review has demonstrated a significant reduction in the incidence of pruritus following the use of ondansetron. This is in contrast to previously published meta-analyses. Studies included were of varying quality and some at high risk of bias with a high degree of statistical heterogeneity. Furthermore, high-quality and well-powered studies are required to confirm these findings.
Collapse
Affiliation(s)
- Matthew Cadd
- From the Anaesthetics Department, Conquest Hospital, East Sussex Healthcare Trust, United Kingdom
| | | | | |
Collapse
|
4
|
Singh PM, Sultan P, O'Carroll J, Blake L, Carvalho B, Singh NP, Monks DT. Pharmacological agents for prevention of pruritus in women undergoing Caesarean delivery with neuraxial morphine: a systematic review and Bayesian network meta-analysis. Br J Anaesth 2023; 131:556-571. [PMID: 37455197 PMCID: PMC10515090 DOI: 10.1016/j.bja.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed. Our objective was to perform an updated systematic review and network meta-analysis to provide clinicians with a comparison of relative efficacy of available interventions to reduce the incidence of pruritus, induced by either intrathecal or epidural single-shot morphine, in women undergoing Caesarean delivery. METHODS Databases systematically searched (up to January 2022) included PubMed MEDLINE, Web of Science, EBSCO CINAHL, Embase, LILACS, and two Cochrane databases. We included randomised, controlled trials involving adult female patients undergoing Caesarean delivery. We pooled trials comparing interventions used for preventing pruritus after Caesarean delivery and performed a Bayesian model network meta-analysis. RESULTS The final primary network included data from comparisons of 14 distinct interventions (including placebo) used to reduce the incidence of pruritus in 6185 participants. We judged five interventions to be 'definitely superior' to placebo: propofol, opioid agonist-antagonists (neuraxial), opioid antagonists, opioid agonist-antagonists (systemic), and serotonin antagonists. For the network evaluating the incidence of severe pruritus (warranting additional therapeutic treatment of pruritus), data were available for 14 interventions (including placebo) in 4489 patients. For this outcome, we judged three interventions to be 'definitely superior' to placebo: dopamine antagonists (neuraxial) and systemic and neuraxial opioid agonist-antagonists. CONCLUSION Our analysis found several interventions to be effective in reducing the incidence of pruritus. Although sub-hypnotic doses of propofol appear to have an antipruritic effect, replication of this finding and further investigation of optimal dosing are warranted. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022367058).
Collapse
Affiliation(s)
- Preet M Singh
- Washington University in Saint Louis, Anesthesiology, Barnes Jewish Hospital, Saint Louis, MO, USA.
| | - Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - James O'Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Lindsay Blake
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Narinder P Singh
- Department of Anesthesia, Mount Sinai Hospital, Toronto, ON, Canada
| | - David T Monks
- Washington University in Saint Louis, Anesthesiology, Barnes Jewish Hospital, Saint Louis, MO, USA
| |
Collapse
|
5
|
Sadhoo N, Prakash J, Kumar V, Kharwar RK, Ahmad S, Sethi BK. A comparison of prophylactic antiemetic therapy with palonosetron and dexamethasone as single-agents or in combination in adult patients undergoing laparoscopic surgery: A randomized trial. Int J Crit Illn Inj Sci 2023; 13:4-10. [PMID: 37180300 PMCID: PMC10167812 DOI: 10.4103/ijciis.ijciis_150_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/19/2020] [Accepted: 11/20/2020] [Indexed: 05/16/2023] Open
Abstract
Background The incidence of postoperative nausea and vomiting (PONV) is quite high after laparoscopic surgeries. This study endeavors to compare the efficacy of the combination of palonosetron and dexamethasone with that of either drug alone in the prevention of PONV in patients undergoing laparoscopic surgeries. Methods This randomized, parallel-group trial was done on ninety adults of American Society of Anesthesiologists Grade I and II patients aged 18-60 years undergoing laparoscopic surgeries under general anesthesia. The patients were randomly divided into three groups of thirty patients each. Group P (n = 30) received palonosetron 0.075 mg intravenously (iv), Group D (n = 30) received dexamethasone 8 mg iv and Group P + D (n = 30) received palonosetron 0.075 mg and dexamethasone 8 mg iv. The primary outcome was incidence of PONV in 24 h, and the secondary outcome was a number of rescue antiemetics required. To compare the proportions in the groups, unpaired t-test, Mann-Whitney U-test, Chi-square test, or Fisher's exact test was applied. Results We found that the overall incidence of PONV was 46.7% in Group P, 50% in Group D, and 43.3% in Group P + D during the first 24 h. Rescue antiemetic was required in 27% of the patients in Group P and Group D compared to 23% of the patients in Group P + D and twice in 3% of the patients in Group P, 7% of the patients in Group D, and none in Group P + D which were not significant. Conclusions The combination therapy of palonosetron plus dexamethasone did not significantly reduce the incidence of PONV when compared with either drug alone.
Collapse
Affiliation(s)
- Neha Sadhoo
- Department of Anaesthesiology, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Vishwanath Kumar
- Department of Trauma Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Ramesh Kumar Kharwar
- Department of Intensive Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Sabih Ahmad
- Department of Anaesthesia, Batra Hospital and Medical Research Centre, New Delhi, India
| | - Bijaya Kumar Sethi
- Department of Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| |
Collapse
|
6
|
Becker LM, Teunissen AJW, Koopman JSHA. Prevention and Treatment of Neuraxial Morphine-Induced Pruritus: A Scoping Review. J Pain Res 2022; 15:1633-1645. [PMID: 35694199 PMCID: PMC9176241 DOI: 10.2147/jpr.s361225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/21/2022] [Indexed: 11/23/2022] Open
Abstract
The addition of morphine to neuraxial anaesthesia leads to improved postoperative analgesia and lower opioid consumption, but is often accompanied by pruritus. Studies on preventing or treating pruritus show contradictory results. Our objective was to identify effective drugs for the prevention or treatment of pruritus by a scoping review of clinical trials. A systematic literature search was conducted in PubMed, Embase and Web of Science. We identified clinical trials investigating the prevention or treatment of neuraxial morphine-induced pruritus in adults. Systematic reviews and meta-analyses were screened for eligible studies. One-hundred-and-four articles were included covering 13 pharmacological groups. We conclude that dopamine antagonists, µ-opioid agonist/antagonists and neuraxial or orally administered µ-opioid antagonists prevent pruritus caused by neuraxial morphine regardless of the timing of administration. In the reviewed literature, 5HT3-antagonists prevent neuraxial morphine-induced pruritus when administered before morphine administration. For the treatment of neuraxial morphine-induced pruritus, only nalbuphine appears to be consistently effective. More research is needed to find the most effective doses and the optimal timing of the effective medication.
Collapse
Affiliation(s)
- Leonie M Becker
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
- Department of Anaesthesiology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
- Correspondence: Leonie M Becker, Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM, The Netherlands, Tel +31 88 320 09 22, Email
| | | | | |
Collapse
|
7
|
Dexmedetomidine as an adjunct to peripheral nerve blocks in pediatric patients. World J Pediatr 2022; 18:251-262. [PMID: 35006581 DOI: 10.1007/s12519-021-00507-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Combining local anesthetics with dexmedetomidine (DEX) for nerve blocks has been tested and confirmed as an alternative technique to strengthen analgesia in adults, but the evidence supported this proposal in pediatrics was not convincing enough. Thus, we intend to conduct a meta-analysis to make an appraisal of the effects of DEX as a local anesthetic adjuvant on peripheral nerve blocks in children. METHODS The analysis has been registered on https://www.crd.york.ac.uk/prospero/ with the registration number CRD42021254029 on June 10th, 2021. PubMed, Ovid MEDLINE, Embase and Cochrane central register were searched for the randomized controlled trials (RCTs) that are relevant to child/pain/DEX or block up to April 30, 2021. RESULTS Eight RCTs were included for data analysis. The pooled results showed a significantly reduced number of patients who required postoperative analgesics within DEX groups [odds ratio = 0.1, 95% confidence interval (CI) 0.03-0.32, P < 0.001]. And DEX significantly prolonged the duration of analgesia of local anesthetics in the meantime [standardized mean difference (SMD) = 4.93, 95% CI 3.02-6.83, P < 0.001]. Nevertheless, adding DEX as an adjunct to local anesthetics would significantly decrease heart rate (SMD = - 0.95, 95% CI - 1.45 to - 0.45, P < 0.001) and increase sedation score (SMD = 1.6, 95% CI 0.53-2.66, P = 0.003) simultaneously. CONCLUSIONS Adding DEX as an adjunct to peripheral nerve blocks can prolong analgesia until postoperative 8 hours in pediatric patients. However, the benefits should be weighed against the increasing risk of bradycardia and sedation in critical children.
Collapse
|
8
|
Griffiths JD, Gyte GM, Popham PA, Williams K, Paranjothy S, Broughton HK, Brown HC, Thomas J. Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. Cochrane Database Syst Rev 2021; 5:CD007579. [PMID: 34002866 PMCID: PMC8130052 DOI: 10.1002/14651858.cd007579.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Nausea and vomiting are distressing symptoms which are experienced commonly during caesarean section under regional anaesthesia and in the postoperative period. OBJECTIVES: To assess the efficacy of pharmacological and non-pharmacological interventions versus placebo or no intervention given prophylactically to prevent nausea and vomiting in women undergoing regional anaesthesia for caesarean section. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (16 April 2020), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of studies and conference abstracts, and excluded quasi-RCTs and cross-over studies. DATA COLLECTION AND ANALYSIS Review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Our primary outcomes are intraoperative and postoperative nausea and vomiting. Data entry was checked. Two review authors independently assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Eighty-four studies (involving 10,990 women) met our inclusion criteria. Sixty-nine studies, involving 8928 women, contributed data. Most studies involved women undergoing elective caesarean section. Many studies were small with unclear risk of bias and sometimes few events. The overall certainty of the evidence assessed using GRADE was moderate to very low. 5-HT3 antagonists: We found intraoperative nausea may be reduced by 5-HT3 antagonists (average risk ratio (aRR) 0.55, 95% confidence interval (CI) 0.42 to 0.71, 12 studies, 1419 women, low-certainty evidence). There may be a reduction in intraoperative vomiting but the evidence is very uncertain (aRR 0.46, 95% CI 0.29 to 0.73, 11 studies, 1414 women, very low-certainty evidence). There is probably a reduction in postoperative nausea (aRR 0.40, 95% CI 0.30 to 0.54, 10 studies, 1340 women, moderate-certainty evidence), and these drugs may show a reduction in postoperative vomiting (aRR 0.47, 95% CI 0.31 to 0.69, 10 studies, 1450 women, low-certainty evidence). Dopamine antagonists: We found dopamine antagonists may reduce intraoperative nausea but the evidence is very uncertain (aRR 0.38, 95% CI 0.27 to 0.52, 15 studies, 1180 women, very low-certainty evidence). Dopamine antagonists may reduce intraoperative vomiting (aRR 0.41, 95% CI 0.28 to 0.60, 12 studies, 942 women, low-certainty evidence) and postoperative nausea (aRR 0.61, 95% CI 0.48 to 0.79, 7 studies, 601 women, low-certainty evidence). We are uncertain if dopamine antagonists reduce postoperative vomiting (aRR 0.63, 95% CI 0.44 to 0.92, 9 studies, 860 women, very low-certainty evidence). Corticosteroids (steroids): We are uncertain if intraoperative nausea is reduced by corticosteroids (aRR 0.56, 95% CI 0.37 to 0.83, 6 studies, 609 women, very low-certainty evidence) similarly for intraoperative vomiting (aRR 0.52, 95% CI 0.31 to 0.87, 6 studies, 609 women, very low-certainty evidence). Corticosteroids probably reduce postoperative nausea (aRR 0.59, 95% CI 0.49 to 0.73, 6 studies, 733 women, moderate-certainty evidence), and may reduce postoperative vomiting (aRR 0.68, 95% CI 0.49 to 0.95, 7 studies, 793 women, low-certainty evidence). Antihistamines: Antihistamines may have little to no effect on intraoperative nausea (RR 0.99, 95% CI 0.47 to 2.11, 1 study, 149 women, very low-certainty evidence) or intraoperative vomiting (no events in the one study of 149 women). Antihistamines may reduce postoperative nausea (aRR 0.44, 95% CI 0.30 to 0.64, 4 studies, 514 women, low-certainty evidence), however, we are uncertain whether antihistamines reduce postoperative vomiting (average RR 0.48, 95% CI 0.29 to 0.81, 3 studies, 333 women, very low-certainty evidence). Anticholinergics: Anticholinergics may reduce intraoperative nausea (aRR 0.67, 95% CI 0.51 to 0.87, 4 studies, 453 women, low-certainty evidence) but may have little to no effect on intraoperative vomiting (aRR 0.79, 95% CI 0.40 to 1.54, 4 studies; 453 women, very low-certainty evidence). No studies looked at anticholinergics in postoperative nausea, but they may reduce postoperative vomiting (aRR 0.55, 95% CI 0.41 to 0.74, 1 study, 161 women, low-certainty evidence). Sedatives: We found that sedatives probably reduce intraoperative nausea (aRR 0.65, 95% CI 0.51 to 0.82, 8 studies, 593 women, moderate-certainty evidence) and intraoperative vomiting (aRR 0.35, 95% CI 0.24 to 0.52, 8 studies, 593 women, moderate-certainty evidence). However, we are uncertain whether sedatives reduce postoperative nausea (aRR 0.25, 95% CI 0.09 to 0.71, 2 studies, 145 women, very low-certainty evidence) and they may reduce postoperative vomiting (aRR 0.09, 95% CI 0.03 to 0.28, 2 studies, 145 women, low-certainty evidence). Opioid antagonists: There were no studies assessing intraoperative nausea or vomiting. Opioid antagonists may result in little or no difference to the number of women having postoperative nausea (aRR 0.75, 95% CI 0.39 to 1.45, 1 study, 120 women, low-certainty evidence) or postoperative vomiting (aRR 1.25, 95% CI 0.35 to 4.43, 1 study, 120 women, low-certainty evidence). Acupressure: It is uncertain whether acupressure/acupuncture reduces intraoperative nausea (aRR 0.55, 95% CI 0.41 to 0.74, 9 studies, 1221 women, very low-certainty evidence). Acupressure may reduce intraoperative vomiting (aRR 0.52, 95% CI 0.33 to 0.80, 9 studies, 1221 women, low-certainty evidence) but it is uncertain whether it reduces postoperative nausea (aRR 0.46, 95% CI 0.27 to 0.75, 7 studies, 1069 women, very low-certainty evidence) or postoperative vomiting (aRR 0.52, 95% CI 0.34 to 0.79, 7 studies, 1069 women, very low-certainty evidence). Ginger: It is uncertain whether ginger makes any difference to the number of women having intraoperative nausea (aRR 0.66, 95% CI 0.36 to 1.21, 2 studies, 331 women, very low-certainty evidence), intraoperative vomiting (aRR 0.62, 95% CI 0.38 to 1.00, 2 studies, 331 women, very low-certainty evidence), postoperative nausea (aRR 0.63, 95% CI 0.22 to 1.77, 1 study, 92 women, very low-certainty evidence) and postoperative vomiting (aRR 0.20, 95% CI 0.02 to 1.65, 1 study, 92 women, very low-certainty evidence). Few studies assessed our secondary outcomes including adverse effects or women's views. AUTHORS' CONCLUSIONS This review indicates that 5-HT3 antagonists, dopamine antagonists, corticosteroids, sedatives and acupressure probably or possibly have efficacy in reducing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. However the certainty of evidence varied widely and was generally low. Future research is needed to assess side effects of treatment, women's views and to compare the efficacy of combinations of different medications.
Collapse
Affiliation(s)
- James D Griffiths
- Department of Anaesthesia, Royal Women's Hospital, Parkville, Australia
| | - Gillian Ml Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Kacey Williams
- Department of Anaesthesia, Monash Medical Centre, Monash Health, Clayton, Australia
| | - Shantini Paranjothy
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Hannah K Broughton
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Heather C Brown
- Department of Obstetrics and Gynaecology, Royal Sussex County Hospital, Brighton, UK
| | - Jane Thomas
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| |
Collapse
|
9
|
Jin Z, Kowa CY, Gan S, Lin J, Gan TJ. Efficacy of palonosetron-dexamethasone combination compared to palonosetron alone for prophylaxis against postoperative nausea and vomiting. Curr Med Res Opin 2021; 37:711-718. [PMID: 33617380 DOI: 10.1080/03007995.2021.1893677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Postoperative nausea and vomiting (PONV) is a common complication following surgery, and may be one of the most distressing parts of the surgical journey. With combination pharmacological therapy recommended for PONV prophylaxis, this systematic review and meta-analysis evaluates whether perioperative palonosetron and dexamethasone is more efficacious than palonosetron administered alone. METHODS We searched CENTRAL; EMBASE; CINAHL; Google Scholar; Web of Science citation index; the US clinical trials register; UK clinical trials register; Australia and New Zealand Clinical trials register; and conference abstracts for major anaesthesia conferences in the last three years.We included randomized controlled trials that compared adult patients undergoing surgery who received palonosetron and dexamethasone, against those who received palonosetron. RESULTS A total of 12 studies (1152 patients) were included. Medium-grade evidence showed that the palonosetron and dexamethasone combination significantly reduced 24-hour rescue anti-emetic requirement (RR: 0.59, 95% confidence interval (CI): 0.41-0.86). There was however no significant difference in the 6-hour (RR: 0.82, 95% CI: 0.61-1.09) and 24-hour PONV incidences (RR: 0.60, 95% CI: 0.33-1.10). Similarly, PONV incidences after 24 h did not differ between groups (RR:0.82, 95% CI: 0.59-1.14). Headache and dizziness were the most common side-effects reported. CONCLUSIONS Combination prophylaxis with palonosetron and dexamethasone reduces post-operative anti-emetic requirement, although is not associated with a significant difference in PONV. There was considerable heterogeneity in the studies, and trial sequential analysis indicates that further studies are needed to strengthen the clinical evidence.
Collapse
Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Chao-Ying Kowa
- Paediatric Critical Care Unit, The Royal London Hospital, London, United Kingdom
| | - Sophie Gan
- Thomas Jefferson School of Nursing, Philadelphia, PA, USA
| | - Jun Lin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| |
Collapse
|
10
|
Mohd Daut FN, Seevaunnamtum SP, Nik Mohamad NA, Che Omar S, Wan Hassan WMN. Granisetron vs. Granisetron and Dexamethasone on The Reduction of Postoperative Nausea and Vomiting (PONV) After Caesarean Section With Intrathecal Morphine: A Randomised Controlled Trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1916860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- FN Mohd Daut
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - SP Seevaunnamtum
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - NA Nik Mohamad
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - S Che Omar
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - WMN Wan Hassan
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| |
Collapse
|
11
|
Ankouni T, Kanawati S, El Khatib R, El Hassan J, Itani SE, Rajab O, Naja Z. Ondansetron versus ondansetron with dexamethasone to prevent intrathecal-morphine pruritus for caesarean patients: randomised double-blind trial. J OBSTET GYNAECOL 2021; 41:1080-1086. [PMID: 33650930 DOI: 10.1080/01443615.2020.1852538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The objective of this randomised, double blinded clinical trial was to evaluate the efficacy of prophylactic administration of 4 mg ondansetron as monotherapy versus combination therapy of 4 mg ondansetron plus 8 mg dexamethasone for the prevention of intrathecal morphine-associated pruritus in caesarean section within 24 h. A total of 194 patients were included, 96 patients in the monotherapy group and 98 in the combination group. One hour after the operation, 11.5% of patients in ondansetron group had failure of prophylaxis for pruritus compared to 13.5% of patients in the combination group (p = .66). This decreased throughout the follow-up to reach 0.0% and 1.0% at 24 h in the ondansetron vs. the combination groups respectively. There was no superiority of combining ondansetron with dexamethasone over the use of ondansetron as prophylactic antipruritic in parturients receiving intrathecal morphine for caesarean section.IMPACT STATEMENTWhat is already known on this subject? The incidence of pruritus has been reported to be between 36% and 60% in patients undergoing caesarean section with intrathecal morphine. Ondansetron has been identified as possible antipruritic agent while the antipruritic effect of dexamethasone is inconclusive.What do the results of this study add? The study demonstrated that there was no superiority of combining ondansetron with dexamethasone over the use of ondansetron as prophylactic antipruritic in parturients receiving intrathecal morphine for caesarean section. Moreover, it seems that there is no effect of combining ondansetron with dexamethasone over ondansetron alone on antiemetic consequences.What are the implications of these findings for clinical practice and/or further research? Ondansetron could be an effective antipruritic if used solely for patients undergoing caesarean section.
Collapse
Affiliation(s)
- Thaer Ankouni
- Anaesthesia Department, Makassed General Hospital, Beirut, Lebanon
| | - Saleh Kanawati
- Anaesthesia Department, Makassed General Hospital, Beirut, Lebanon
| | - Rania El Khatib
- Anaesthesia Department, Makassed General Hospital, Beirut, Lebanon
| | - Janah El Hassan
- Obstetrics and Gynaecology Department, Makassed General Hospital, Beirut, Lebanon
| | - Saad Eddine Itani
- Obstetrics and Gynaecology Department, Makassed General Hospital, Beirut, Lebanon
| | - Omar Rajab
- Anaesthesia Department, Makassed General Hospital, Beirut, Lebanon
| | - Zoher Naja
- Anaesthesia Department, Makassed General Hospital, Beirut, Lebanon
| |
Collapse
|
12
|
Jin Z, Gan TJ, Bergese SD. Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies. Ther Clin Risk Manag 2020; 16:1305-1317. [PMID: 33408475 PMCID: PMC7780848 DOI: 10.2147/tcrm.s256234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.
Collapse
Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA.,Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| |
Collapse
|
13
|
The next generation of antiemetics for the management of postoperative nausea and vomiting. Best Pract Res Clin Anaesthesiol 2020; 34:759-769. [PMID: 33288125 DOI: 10.1016/j.bpa.2020.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022]
Abstract
Postoperative nausea and vomiting (PONV) afflict approximately 30% of patients overall and up to 80% of high-risk patients after surgery. Optimal pharmacological prophylaxis of PONV is challenging as it necessitates the consideration of PONV risk, drug efficacy, and potential adverse effects. Despite significant advances in our understanding of the pathophysiology and risk factors of PONV, its incidence has remained largely unchanged. Newer antiemetics have been introduced that may have improved safety profiles, longer duration of action, and better efficacy. This review aims to summarize the recent developments pertaining to these new agents and their potential application toward the management of PONV.
Collapse
|
14
|
Jacobs NF, Veronese LR, Okano S, Hurst C, Dyer RA. The incidence of postoperative nausea and vomiting after caesarean section in patients with hyperemesis gravidarum: a retrospective cohort study. Int J Obstet Anesth 2020; 44:81-89. [PMID: 32823251 DOI: 10.1016/j.ijoa.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/22/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative nausea and vomiting is one of the most common anaesthetic complications of caesarean section. This study examined the association between hyperemesis gravidarum during pregnancy and nausea and vomiting after caesarean section. METHODS A single-centre, retrospective cohort study, using electronic databases of patients with and without hyperemesis gravidarum, undergoing caesarean section from 2015 to 2019. The incidence and severity of postoperative nausea and vomiting were established by a review of the documentation of administration of postoperative anti-emetics within the 24-h period after surgery, and examined using univariable, multivariable binary and ordered logistic regression models. RESULTS Data were compared for 76 patients with hyperemesis gravidarum and 315 patients without the condition. The incidence of postoperative nausea and vomiting in the hyperemesis group versus the non-hyperemesis group was 43.4% vs 29.6%, respectively. The odds of experiencing postoperative nausea and vomiting was 1.95 times higher in women with hyperemesis gravidarum than in those without (aOR 1.95, 95% CI 1.13 to 3.36, P=0.016). The odds of having more severe postoperative nausea and vomiting were greater in the hyperemesis gravidarum group (aOR 1.91, 95% CI 1.14 to 3.20, P=0.014). CONCLUSION Patients with hyperemesis gravidarum are more likely to develop nausea and vomiting after caesarean section, and this is likely to be of greater severity than in those without the condition. This finding should assist the effective provision of intra-operative and postoperative anti-emetics for patients with hyperemesis gravidarum undergoing caesarean section.
Collapse
Affiliation(s)
- N F Jacobs
- Department of Anaesthesia, Mater Health Services, South Brisbane, QLD, Australia.
| | - L R Veronese
- Department of Anaesthesia, Redland Hospital, Cleveland, QLD, Australia
| | - S Okano
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia; Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - C Hurst
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia; Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - R A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
15
|
The Quality of Recovery after Dexamethasone, Ondansetron, or Placebo Administration in Patients Undergoing Lower Limbs Orthopedic Surgery under Spinal Anesthesia Using Intrathecal Morphine. A Randomized Controlled Trial. Anesthesiol Res Pract 2020; 2020:9265698. [PMID: 32518560 PMCID: PMC7256731 DOI: 10.1155/2020/9265698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/02/2023] Open
Abstract
Intrathecal morphine is widely and successfully used to prevent postoperative pain after orthopedic surgery, but it is frequently associated with side effects. The aim of this study was to evaluate the effect of dexamethasone or ondansetron when compared to placebo to reduce the occurrence of these undesirable effects and, consequently, to improve the quality of recovery based on patient's perspective. Methods. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline. On the morning following surgery, a quality of recovery questionnaire (QoR-40) was completed. Results. No differences were detected in the global and dimensional QoR-40 scores following surgery; however, following postanesthesia care unit (PACU) discharge, pain scores were higher in patients receiving ondansetron compared with patients who received dexamethasone. Conclusion. Neither ondansetron nor dexamethasone improves the quality of recovery after lower limbs orthopedic surgery under spinal anesthesia using intrathecal morphine.
Collapse
|
16
|
|
17
|
Gouveia de Araujo Ferreira N, Cavalcanti IL, Assad AR, Barrucand L, Braga ELC, Verçosa N. A prospective, randomized, double-blind trial to compare body weight-adjusted and fixed doses of palonosetron for preventing postoperative nausea and vomiting in obese female patients. PLoS One 2020; 15:e0227490. [PMID: 31935249 PMCID: PMC6959980 DOI: 10.1371/journal.pone.0227490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/18/2019] [Indexed: 12/29/2022] Open
Abstract
Background Postoperative nausea and vomiting (PONV) is a common postsurgical complication. Palonosetron is effective for PONV prevention at the usual dose of 75 μg, but the ideal dose for obese patients has not yet been investigated. The aim of this study was to compare body weight-adjusted and fixed doses of palonosetron for preventing PONV in obese female patients. Materials and methods We performed a prospective, randomized, double-blind trial involving 80 female patients, aged 18–80 years with an American Society of Anesthesiologists physical status of 2 and 3 and a body mass index (BMI) ≥ 30 kg m-2 who were scheduled to undergo elective breast surgery. Patients received an intravenous body weight-adjusted dose of palonosetron (1 μg kg -1, GI = 40 patients) or a fixed dose of palonosetron (75 μg, GII = 40 patients). All patients received dexamethasone (4 mg). The incidence of PONV, complete response rate (CR), severity of nausea and need for rescue antiemetics and analgesics were assessed at: 0–1 h, 1–6 h, 6–24 h and 24–48 h postoperatively. Results The mean (± SD) BMI was 35.0 (±5.2) kg m-2 for GI and 35.7 (±3.6) kg m-2 for GII. There was no significant difference between groups in PONV incidence, CR, severity of nausea, and need for rescue antiemetics or analgesics. The incidence of PONV for GI and GII was 15% and 27.5%, respectively, during the first 48 h (P = 0.17). Conclusions A body weight-adjusted dose of palonosetron was as effective as 75 μg for preventing PONV for 48 h in obese female patients who underwent breast surgery. Hence, the fixed dose may be preferable to the body weight-adjusted dose.
Collapse
Affiliation(s)
- Nathalia Gouveia de Araujo Ferreira
- Department of Anesthesiology, National Cancer Institute (HCIII), Rio de Janeiro, Rio de Janeiro, Brazil.,Postgraduate Program Surgical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ismar Lima Cavalcanti
- Department of General and Specialized Surgery/Anesthesiology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Alexandra Rezende Assad
- Department of General and Specialized Surgery/Anesthesiology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Louis Barrucand
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nubia Verçosa
- Department of Surgery/Anesthesiology, Postgraduate Program Surgical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|