Management Of Postoperative Nausea And Vomiting Research Articles

PRO: The Food and Drug Administration Black Box Warning on Droperidol Is Not Justified

PRO: The Food and Drug Administration Black Box Warning on Droperidol Is Not Justified

The use of droperidol before and after the Food and Drug Administration black box warning: a survey of the members of the Society of Ambulatory Anesthesia

Study Objective To determine the practice of members of the Society of Ambulatory Anesthesia (SAMBA) in the management of postoperative nausea and vomiting (PONV) before and after the Food and Drug Administration (FDA) black box warning on droperidol. Design Survey questionnaire. Setting The Society of Ambulatory Anesthesia. Measurements After institutional review board approval, a survey was posted on the SAMBA Web site from June 1, 2005, until October 30, 2005. Visitors of the Web site were invited to participate in the survey. The survey was designed to elicit information about the management of PONV, particularly the use of droperidol, before and after the FDA black box warning. Participants were also asked about reasons for not using droperidol in their current practice and whether they believed that the black box warning was justified. Main Results Two hundred ninety-five physicians of 1,179 eligible SAMBA members completed the survey for a 25% response rate. For PONV prophylaxis, the choice of droperidol as a first-line agent decreased from 47% to 5% after the black box warning appeared ( P < 0.0001). Similarly, for treatment of established PONV, the choice of droperidol decreased from 38% to 8% during this same period ( P < 0.0001). A total of 261 (92%) of responders did not believe that the black box warning was justified. Conclusions Although most surveyed practitioners believed that the FDA black box warning on droperidol is not justified, the use of this cost-effective agent has significantly declined.

Current Prevention and Treatment of Postoperative Nausea and Vomiting after Gynecological Laparoscopic Surgery

Postoperative nausea and vomiting (PONV) are two of the commonest and most distressing complications of general anesthesia and surgery, with a remarkably high incidence after gynecological laparoscopic surgery. Numerous antiemetics have been studied for the prevention of PONV after gynecological laparoscopic surgery. Traditional antiemetics, including butyrophenones (e.g., droperidol) and benzamide (e.g., metoclopramide), are used for preventing PONV. The available non-traditional antiemetics for the prophylaxis against PONV are propofol, dexamethasone, and ephedrine. Serotonin receptor antagonists (ondansetron, granisetron, and dolasetron), compared with traditional antiemetics, are highly effective for PONV prophylaxis. None of the available antiemetics is entirely effective, perhaps because most of them act through the blockade on one type of receptor. There is a possibility that combined antiemetics with different sites of activity would be more effective than one drug alone for preventing PONV Combination antiemetic therapy with ondansetron and droperidol or dexamethasone is highly effective in the prevention of PONV. P6 acupoint injection is non-pharmacological technique and is as effective as droperidol for preventing PONV. Management of PONV after gynecological laparoscopic surgery depends on the prophylaxis. If the prophylactic therapy fails, treatment would be required. Ondansetron is effective in the treatment of established PONV. Knowledge regarding antiemetics is necessary to completely prevent and treat PONV in women undergoing gynecological laparoscopic surgery. Keywords: Butyrophenones, Droperidol, chemoreceptor trigger zone, Propofol, serotonin receptor antagonists

Recent advances, trends and economic considerations in the risk assessment, prevention and treatment of postoperative nausea and vomiting

During the last two decades there have been considerable achievements regarding the management of postoperative nausea and vomiting (PONV). Due to the importance of these symptoms in the aim to streamline clinical processes and to improve patient satisfaction, the debate on the best strategies and also research that focuses on PONV continues. This review summarises the recent developments with respect to the management of PONV. Following a brief review on what is already known on the risk assessment, prevention and treatment of PONV, newer trends in the pharmacological prevention (dexamethasone, neurokinin-1 antagonists, multimodal prevention) will be discussed as well as new insights regarding the value of algorithms for the prevention of PONV. Further, pharmacogenetically based algorithms (according to the metaboliser status) as well as new treatment strategies (dexamethasone, multimodal treatment) will be covered. No drug so far can achieve a reduction of PONV of more than one third. Furthermore, all clinical studies consistently demonstrated that a combination treatment has a simple additive effect without any relevant interaction between different drugs or classes of drugs. The relative reduction of ∼ 30% can also be expected from dexamethasone and it is likely that the substances presently in development and in an early clinical use (e.g., neurokinin-1 antagonists) will not represent the new panacea. However, they will probably replenish the existing antiemetic portfolio to better cope with high risk patients. Stratified prevention using pharmacogenetic knowledge is still in the early stages. Algorithms need to be customised to the local settings in order to prove efficient. Treatment remains a most important pillar and there is evidence that the principles of combining antiemetics to prolong effects and improve protection can be similarly applied to treatment. Recent developments in the area of PONV are more related to implementing the already existing evidence than based on the introduction of new molecules. New molecules replenish the pharmacological antiemetic portfolio, which is needed due to the limited efficacy of any single agent available so far. The new neurokinin-1 receptor antagonist, aprepitant, and the long lasting 5-HT3 receptor antagonist palonosetron are the latest developments in this context. Treatment is most important and can also be regarded as a secondary prevention. Due to limited efficacy of single treatment interventions, combination therapy may gain more widespread use in the future.

Victims of Our Own Success or Quo Vadis Pediatric Anesthesia?

Victims of Our Own Success or Quo Vadis Pediatric Anesthesia?

Management of Postoperative Nausea and Vomiting in Children

Postoperative nausea and vomiting (PONV) continues to be a frequent and important cause of morbidity in children. Postoperative vomiting (POV) is more commonly studied in children than postoperative nausea because of a child's inability to effectively express distress after experiencing nausea. POV is problematic in children and is one of the leading postoperative complaints from parents and the leading cause of readmission to the hospital. POV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult incidence rates. Gender differences are not seen before puberty. POV remains a main cause of morbidity in children because severe vomiting can be associated with dehydration, postoperative bleeding, pulmonary aspiration, and wound dehiscence. While children have an increased potential for dehydration and the resulting physiologic impairments, other associated results such as a delay in hospital discharge or an overnight or longer hospital admission also must be considered. The two most common emetogenic surgical procedures evaluated in children are strabismus repair and adenotonsillectomy. The approach to the management of PONV and POV in children is similar to that in adults. However, as the rate of POV is more frequent in children than in adults, more children are candidates for antiemetic prophylaxis. The management approach is multifactorial and involves proper preoperative preparation, risk stratification, rational selection of antiemetic prophylaxis, choice of anesthesia technique, and a plan for postoperative antiemetic therapy. It is important to identify children at moderate-to-high risk for POV as prophylactic antiemetic therapy is useful in these children. Antiemetics of choice for POV in children include dexamethasone, dimenhydrinate, perphenazine, ondansetron, dolasetron, granisetron, and tropisetron. The serotonin (5-hydroxytryptamine; 5-HT(3)) antagonists are the antiemetic drugs of first choice for POV prophylaxis in children because as a group they have greater efficacy for preventing vomiting than nausea. The 5-HT(3) antagonists can be effectively combined with dexamethasone with an increase in efficacy. If possible, regional anesthesia should be considered. For those undergoing general anesthesia, the baseline POV risk should be reduced. Children at moderate-to-high PONV risk should receive combination therapy with two or three prophylactic antiemetics from different antiemetic drug classes. Reference to and the use of PONV guidelines and management algorithms help improve cost-effective postoperative care.

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.

Identification of Risk Factors for Postoperative Nausea and Vomiting in the Perianesthesia Adult Patient

Postoperative nausea and vomiting (PONV) is a common and potentially debilitating complication of surgery. The preoperative assessment of PONV using established risk assessment tools enables the identification of patients at risk and potentially decreases the incidence of PONV in adult surgical patients. The identification of risk factors associated with PONV and the factors that are independent predictors of PONV preoperatively can facilitate the effective prophylactic treatment and management of PONV in adult surgical patients.

The Role of 5-HT 3 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.

Cost-effectiveness analysis of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting.

To compare the cost-effectiveness of 2 antiemetic agents, ondansetron and prochlorperazine, for the prevention of postoperative nausea and vomiting (PONV) in patients undergoing total hip replacement or total knee replacement procedures. The cost-effectiveness analysis model was applied to data derived from a previous clinical study conducted in 1995 and 1996. This study involved 78 adult patients (62.8% female and 37.2% male) undergoing total hip replacement or total knee replacement procedures. Patients were enrolled in a randomized, double-blind manner to receive either ondansetron 4 mg intrvenously (n=37) or prochlorperazine 10 mg intramuscularly (n=41) immediately upon completion of surgery and were monitored for occurrences of PONV during the subsequent 48 hours. In our analysis, we measured the cost-effectiveness ratio (C/E ratio), defined as the cost per successfully treated patient, for each antiemetic agent using the clinical data obtained from the previous study. The incidence of PONV and use of rescue antiemetics was significantly greater in the ondansetron group compared with the prochlorperazine group. The mean total costs of PONV management per patient in the prochlorperazine and ondansetron groups were dollar 13.99 and dollar 51.98, respectively (based on 2004 average wholesale prices [AWP]). The cost of successfully treating one patient with prochlorperazine and ondansetron was dollar 31.87 and dollar 275.01, respectively. One-way sensitivity analysis was performed adjusting the percent efficacy rate of each antiemetic and the drug cost of ondansetron (up to a 50% reduction in AWP). Prochlorperazine remained the dominant strategy across each scenario. The results indicate that prochlorperazine is a more cost-effective antiemetic compared with ondansetron for the prevention of PONV in a mixed gender, adult inpatient population undergoing total joint arthroplasty.

A Comparison of Patients??? and Health Care Professionals??? Preferences for Symptoms During Immediate Postoperative Recovery and the Management of Postoperative Nausea and Vomiting

In this study we sought to examine the differences in patients' and health care professionals' preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting (PONV). The key differences between symptoms during immediate postoperative recovery (PONV, sedation, and pain) and management of PONV (prophylaxis, efficacy of antiemetic, and extra cost) were used to develop 14 scenarios in a questionnaire. Fifty-two health care professionals (anesthesiologists and recovery room nurses) and 200 women undergoing elective gynecological surgery were recruited (overall response rate, 97%). From patients' and health care professionals' perspectives, conjoint analysis showed that the most important attribute for immediate postoperative recovery was a reduction in the risk of PONV. Health care professionals placed more importance on postoperative sedation than patients did. They were more concerned about the cost of the antiemetic to the patient than the patients were themselves. There was no preference for a policy of effective treatment versus routine prophylaxis. This study shows that there were small differences in the importance of pain, sedation, efficacy of the antiemetic, and extra cost of treatment between patients and health care professionals.

Evidence-based management of postoperative nausea and vomiting: a review.

To provide evidence-based guidelines for the prophylaxis and treatment of postoperative nausea and vomiting (PONV). Literature from randomized controlled trials, systematic reviews, logistic regression analyses and expert opinion in the management of PONV. The etiology of PONV is multifactorial. Patient, anesthesia, and surgery related risk factors have been identified. Universal PONV prophylaxis is not cost-effective. Identification of patients at high-risk of PONV allows targeting prophylaxis to those who will benefit most from it. No prophylaxis is needed for patients at low risk for PONV. For patients at moderate risk for PONV, prophylaxis using a single antiemetic or a combination of two agents should be considered. Double and triple antiemetic combinations should be considered for patients at high risk for PONV. Furthermore, a multimodal approach should be adopted incorporating steps to keep the baseline risk of PONV low. The optimum cost-effective approach to the management of PONV will differ between an ambulatory centre and an inpatient hospital setting. For the treatment of established PONV in patients who failed prophylaxis, patients should not receive a repeat dose of the prophylactic antiemetic. Rather, a drug acting at a different receptor should be used. Beyond six hours after surgery, patients can be treated with any of the agents used for prophylaxis, except dexamethasone and transdermal scopolamine. PONV are common after anesthesia and surgery. We provided evidence-based guidelines for the management of this problem based on the available literature.

Nausées et vomissements postopératoires en neurochirurgie (chirurgie infra- et supratentorielle)

To perform a synthesis regarding postoperative nausea and vomiting (PONV) after neurosurgery. A Medline search was performed to identify publications about frequency, risk factors, prevention and treatment of PONV in adults and children, after neurosurgery. After neurosurgery, the estimated frequency of nausea is around 50% and around 39% for vomiting. After neurosurgery; PONV risk factors are female sex and infratentorial surgery. Children older than two years are at higher risk for PONV. To reduce baseline risk factors, it is recommended to use propofol for induction and maintenance of anaesthesia, to avoid nitrous oxide and to use hydration (20 ml/kg of crystalloids before induction). For PONV prophylaxis, ondansetron and droperidol may be given, using one drug for a moderate risk patient and both drugs for a high-risk patient. Droperidol should not be used in children as a first choice therapy because of an increased risk of extrapyramidal symptoms. Dexamethasone has not been evaluated after neurosurgery. Metoclopramide has no clinically relevant effect for PONV. Especially in neurosurgery, after occurrence of PONV, it is recommended to rule out a possible triggering factor that should need specific treatment. A global management of PONV is proposed, based on the administration of the same drugs given at half the doses used for prophylaxis.

Does the routine prophylactic use of antiemetics affect the incidence of postdischarge nausea and vomiting following ambulatory surgery?: A systematic review of randomized controlled trials.

Does the routine prophylactic use of antiemetics affect the incidence of postdischarge nausea and vomiting following ambulatory surgery?: A systematic review of randomized controlled trials.

Pharmacotherapy of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) are two of the most common and unpleasant side effects following anaesthesia and surgery. Despite the development of new anti-emetics and a vast amount of published research, PONV continues to be a problem, especially in high-risk patients. Recent interest has focused on the use of a combination of agents, acting on different receptors and the adoption of a multimodal approach to tackle this problem. The search for the most cost-effective strategy has also been a major goal. This article will discuss the risk factors and physiology of PONV, currently available therapies, the use of a multimodal approach and the cost-effectiveness of PONV management. Finally, recommendations for the prophylaxis and treatment of PONV will be discussed.

Frequency of postoperative nausea and vomiting in patients undergoing laparoscopic foregut surgery.

Wrap disruption or intrathoracic herniation of a fundoplication is a dreaded complication of laparoscopic foregut surgery. This problem may often be related to postoperative nausea and vomiting (PONV). This study aimed to investigate the occurrence of PONV and its management in patients undergoing laparoscopic foregut procedures. Between January 31 and May 23, 2000, 104 patients undergoing laparoscopic foregut procedures (fundoplication, myotomy, or paraesophageal hernia repair) were followed prospectively. Their postoperative course was documented along with the occurrence and management of PONV. All laparoscopic foregut surgery patients are managed postoperatively with a uniform clinical pathway, and their care is focused on a nursing unit with skill and experience in postoperative management. Nausea was documented in the postanesthesia care unit (PACU) for 30.1% of the patients, and for 59.6% of the patients during their nursing unit stay. Antiemetics were given to all the patients with documented nausea. Emesis was noted in 1.9% of the patients in the PACU, as compared with 3.8% of the patients on the floor. In one of the patients with nursing unit emesis, an acute wrap herniation into the chest occurred, necessitating a return to the operating room for correction. The patients with a history of postoperative nausea did not have a higher rate of PONV than in those with no history of postoperative nausea. The use of preoperative or intraoperative antiemetics did not appear to alter the occurrence of PONV. Postoperative nausea occurred in 60% of the patients administered preoperative antiemetic, as compared with 64% of the patients who received no preoperative antiemetic. The average length of hospital stay was longer in those with PONV than in those with no PONV (2.6 vs 1.8 days). Nausea after laparoscopic foregut procedures is common, occurring twice as often on the nursing unit as in the PACU. The occurrence of PONV leads to a longer hospital stay, and can result in significant sequelae requiring reoperation. The use of preoperative or intraoperative antiemetics does not alter the frequency of postoperative nausea, suggesting the need to develop effective preemptive regimens for patients undergoing laparoscopic foregut procedures. The high rate of PONV and its potential risk of damage to a fundoplication and hiatal hernia repair should lead surgeons to consider whether laparoscopic foregut procedures should ever be performed on an outpatient basis.

Influence of standardized orders on postoperative nausea and vomiting after gynecologic surgery.

The risk of postoperative nausea and vomiting (PONV) after gynecologic surgery remains high, despite effective prophylactic medications. Thus, the objectives of this study were to determine whether standardized orders for the prophylaxis and treatment of PONV in gynecologic surgery patients (1) reduce PONV occurrence, (2) reduce total costs, and (3) influence the choice of medications used for PONV prophylaxis and treatment. A retrospective design was employed in which a random sample of 200 patients was selected from each of the two 6-month phases before (pre) and after (post) the implementation of standardized orders for PONV prophylaxis and treatment. The primary outcome was the occurrence of any PONV episode. Logistic regression was used to adjust for potential confounding factors. All costs were in 1999 Canadian dollars (Canadian dollar = US$0.673 in 1999). Characteristics were similar except for surgical and anesthesia length between phases. The proportion of patients who received PONV prophylaxis increased from 31% (pre) to 47% (post; p = 0.002). There was a reduction in the risk of a PONV event in the post-phase (odds ratio [OR] 0.67, 95% CI 0.67 to 0.97; p = 0.04). The risk of PONV was significantly reduced with the administration of prophylactic medications (OR 0.46, 95% CI 0.46 to 0.67; p = 0.001). There was a reduction in the mean number of PONV episodes in the post-phase (1.47 events) versus the pre-phase (1.81 events; p = 0.02). A reduction in mean PONV management costs was observed in the post-phase ($8.31, SD +/- 8.50) compared with the pre-phase ($10.23, SD +/- 8.25; p = 0.02). For mean prophylactic costs, these were significantly higher in the postimplementation phase compared with the preimplementation phase ($1.64, SD +/- 3.36 vs. $0.91, SD +/- 2.43; p = 0.013). For mean total PONV costs (prophylaxis plus management costs), there was a nonsignificant reduction in the postimplementation phase compared with the preimplementation phase ($9.95, SD +/- 9.20 vs. $11.15, SD +/- 8.51, respectively; p = 0.18). Univariate sensitivity analyses revealed that the economic results were sensitive to several parameters. The implementation of preprinted order forms for PONV prophylaxis and treatment appears to be an effective and economically attractive strategy.

Postoperative nausea and vomiting in the perioperative setting.

Postoperative nausea and vomiting (PONV) is reported to occur in up to 92% of surgical cases. In this article, Agnes Arnold defines the terms, identifies a range of therapies and risk factors, examines the dangers and discusses the management of PONV. The article was originally produced as a study for ENB 183.

Postoperative nausea and vomiting (PONV). Clinical significance, basic principles, prevention and therapy

The incidence of postoperative nausea and vomiting (PONV) of in- and outpatient surgical patients is about 30% (range 2-45%). Based on etiology, anatomy and physiology, this review article provides a critical evaluation of the present PONV literature with the aim of outlining current prophylaxis and treatment strategies. PONV is often associated with postoperative pain and its treatment. Patients are often more compromised by PONV than by postoperative pain. Surveys demonstrate that 78% of the surgeons consider PONV to be a relevant problem in clinical practice; 82% argue for better management of PONV. However, only 28% of the general surgical patients with PONV received sufficient antiemetic therapy. Studies demonstrate that the prophylactic use of antiemetics in patients at risk can lead to complete symptom control in 85% of the cases. Combination therapy of different antiemetic strategies can further increase the rate up to 96%. There is a need for surgeons to pay more attention to patient-related symptoms.

PWM7: THE EFFECT AND ECONOMIC IMPACT OF STANDARDIZED ORDERS ON THE PREVENTION AND TREATMENT OF PONV IN HOSPITALIZED GYNECOLOGICAL SURGERY PATIENTS

OBJECTIVES: The risk of post-operative nausea and vomiting (PONV) following gynecological surgery remains high despite effective prophylactic medications. Thus, the objectives of this study were to determine if standardized orders for the prophylaxis and treatment of PONV in gynecological surgery patients: 1) reduce PONV occurrence; 2) reduce total costs; and 3) influence the choice of medications used for PONV prophylaxis and treatment. METHODS: A retrospective design was employed in which a random sample of 200 patients was selected from each of the two 6 month phases before (pre) and after (post) the implementation of standardized orders for PONV prophylaxis and treatment. The primary outcome was the occurrence of any PONV episode. Logistic regression was used to adjust for potential confounding factors. RESULTS: Characteristics were similar except for surgical and anesthesia length between phases. The proportion of patients receiving PONV prophylaxis increased from 31% (pre) to 47% (post, p = 0.002). There was a reduction in the risk of a PONV event in the post phase (OR = 0.67, 95% CI 0.67 to 0.97, p = 0.04). The risk of PONV was significantly reduced with the administration of prophylactic medications (OR = 0.46, 95% CI 0.46 to 0.67). There was a reduction in the mean number of PONV episodes in the post phase (1.81 events) versus the pre phase (1.47 events, p = 0.02). A reduction in mean PONV management costs was observed in the post phase ($8.31, SD 8.50) as compared to the pre-phase ($10.23, SD 8.25, p = 0.02). For mean prophylactic costs, these were significantly higher in the post-implementation phase when compared to the pre-implementation phase ($1.64, SD 3.36 vs. $0.91, SD 2.43, p = 0.013). Univariate sensitivity analyses revealed that the economic results were sensitive to several parameters. CONCLUSION: The implementation of pre-printed order forms for PONV prophylaxis and treatment appears to be an effective and economically attractive strategy.