Abstract
Objectives: Current prophylactic interventions fail to completely eliminate postoperative nausea and vomiting (PONV) for a substantial number of patients. A new antiemetic (aprepitant) has been effective in preventing chemotherapy induced nausea and vomiting (CINV). We hypothesized that adding aprepitant to our current prophylactic regimen of dexamethasone and ondansetron would reduce the incidence of PONV in our elective hysterectomy population. Methods: 256 patients undergoing elective hysterectomy were enrolled in this prospective, randomized, double blinded, placebo controlled trial. Subjects received either oral aprepitant 40 mg or oral placebo 30 minutes prior to induction of standardized anesthesia. The primary outcome was vomiting within the first 24 hours after surgery. Postoperative nausea, vomiting, and use of rescue antiemetics were documented over a 24 h period. Additionally, adverse events, hospitalization days, and readmissions for PONV were compared. Results: There was a trend towards reduction of postoperative nausea and vomiting in the aprepitant group. Nausea and vomiting were noted for 24% and 17% of women in the aprepitant group versus 38% and 29% of women in the Placebo group, respectively. Supplemental antiemetic medication was used by 42% of women in the aprepitant group versus 60% of women in the Placebo group. No adverse events were substantially more common in the aprepitant group than the Placebo group. Conclusions: Preemptive use of aprepitant prior to elective hysterectomy may reduce the incidence of PONV and diminish the need for rescue antiemetics postoperatively. Further studies with larger power are needed to confirm the trends observed in this study.
Highlights
Postoperative nausea and vomiting (PONV) is defined as nausea or vomiting within 24 hours of surgery
Eligible participants signed written informed consents and met all the following criteria: female greater than 18 years old, fluent in English language, scheduled for inpatient elective hysterectomy requiring general anesthesia of at least 30 minutes duration, and classified as Class I, II or III according to the American Society of Anesthesiologists (ASA) physical status classification system
The primary outcome measure was recorded for 35 women in the Aprepitant group and 59 women in the Placebo group
Summary
Postoperative nausea and vomiting (PONV) is defined as nausea or vomiting within 24 hours of surgery. It is the most frequent side effect after anesthesia, occurring in approximately 30% of unselected patients, and can be increased up to 70% in certain populations and procedures [1]. Intraabdominal surgery, gynecologic surgery, and prolonged duration of anesthesia are risk factors for experiencing PONV. The pathophysiology of PONV is complex and multifactorial with several different receptors and stimuli contributing to the process. The role of “substance P” in eliciting PONV is of particular interest as it is the most abundant neurokinin found in the central and peripheral nervous system [4]. The substrate activates the neurokinin-1 (NK-1) receptors in the nucleus tractus solitaries, which in turn transmits the signal for a vomiting response [5]
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