Abstract
BackgroundWhen patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU)?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment?MethodsA questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed.ResultsThe questionnaire was completed by 106 anesthesiologists (38% response rate), who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62% – 79%) of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55% – 74%) of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an IV fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%–7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18% – 36%) of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.Conclusion5-HT3-antagonists are the most common choice for treatment of established PONV for outpatients when no prophylaxis is used, and also following prophylactic regimens that include a 5HT3 antagonist, regardless of the number of prophylactic antiemetics given. Whereas 3% – 7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.
Highlights
When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV)
The goal of this study was to assess the responses to a written questionnaire to address the following questions regarding PONV in the Post Anesthesia Care Unit (PACU): 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment?
PONV treatment choice changed depending on prophylaxis agent given. (Table 2) For example, only approximately 5% of anesthesiologists reported they would repeat dose the metoclopramide, approximately 3% would repeat the dexamethasone, and 7% would repeat the droperidol
Summary
When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Anesthesiologists agree that PONV is an important issue for patients [3]. A large number of prospective randomized clinical trials have been completed to evaluate the efficacy of drugs and non-pharmacologic interventions to prevent PONV [4,5,6,7,8]. Fewer studies investigate the efficacy of antiemetics for the treatment of PONV once it occurs in the Post Anesthesia Care Unit (PACU). A quantitative systematic review of treatment of established PONV published in 2001 found that metoclopramide, droperidol, isopropyl alcohol vapor, and midazolam were tested in one trial only, each with a limited number of patients [10]. That review found that 5-HT3 antagonists had absolute risk reductions compared with placebo of 20% – 30%, with a less pronounced anti-nausea effect
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