Prevention of Postoperative Nausea and Vomiting
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《新英格兰医药杂志》
To the Editor: Apfel et al. (June 10 issue)1 conclude that ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. In addition, they report that propofol and nitrogen reduced the risk of postoperative nausea and vomiting by 19 percent and 12 percent, respectively. Since antiemetics have similar efficacy in the prevention of postoperative nausea and vomiting and since they act independently, according to the results of the current study, we think that the combination of dexamethasone and droperidol is a more favorable and cheaper option than other combinations of antiemetc interventions evaluated in this study for the prevention of postoperative nausea and vomiting.
Samet Yal?n, M.D.
Bülent Yal?n, M.D.
Abdullah Büyük?elik, M.D.
Ankara University School of Medicine
TR-06100 Ankara, Turkey
bulyalcin@yahoo.com
References
Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350:2441-2451.
To the Editor: Apfel and colleagues found that various antiemetic interventions have similar efficacy for the prevention of postoperative nausea and vomiting. The authors recommend using the safest or least expensive intervention but do not present safety data, such as mortality or the rates of adverse events.
Frank Hartig, M.D.
Christoph Pechlaner, M.D.
Innsbruck University Hospital
A-6020 Innsbruck, Austria
christoph.pechlaner@uibk.ac.at
The authors reply: In our study of more than 5000 patients, each tested antiemetic intervention reduced the risk of postoperative nausea and vomiting by about 26 percent. As Drs. Hartig and Pechlaner might have expected, considering the safety of modern anesthesia, none of the patients died. There were 13 serious adverse events (mainly due to intraoperative or postoperative bleeding), 43 adverse events with postoperative consequences and 453 without postoperative consequences, and 204 minor adverse events (e.g., sore throat, itching, and headache) that resolved spontaneously. As we mention in the article, the use of volatile anesthetics and remifentanil, as compared with fentanyl, required increased administration of vasoconstrictors and was associated with an increased incidence of shivering (Table 1). All other adverse events were similarly distributed among the groups. Arrhythmias were reported in 10 of 2036 patients given droperidol and 11 of 2050 who were not — an observation that is consistent with evidence that antiemetic doses of droperidol do not cause clinically significant QT prolongation.1
Table 1. Perioperative Adverse Events in 4086 Patients Randomly Assigned with Respect to All Six Antiemetic Interventions.
The clinical value of prophylactic antiemetic interventions depends critically on the baseline risk of postoperative nausea and vomiting. Patients at low risk are unlikely to benefit from prevention, whereas a single intervention should be sufficient in patients at moderate risk. Combination therapy should be reserved for patients at high risk for postoperative nausea and vomiting. We therefore encourage our colleagues to use a simplified scoring system to evaluate patients' risk2,3 and to tailor prophylactic treatment according to the anticipated risk.4,5
A critical feature of our results is that, in addition to the finding that the interventions were similarly effective, there were no interactions evident with any combination of two or three strategies. Since all combinations of two interventions were equally effective, the safest and least expensive combinations are preferable. As Dr. Yal?n and colleagues suggest, dexamethasone and droperidol are an appropriate combination, since both drugs are inexpensive and appear to be safe. However, dexamethasone combined with total intravenous anesthesia is also suitable and may even be preferable in patients at especially high risk, because it provides additional options for postoperative rescue treatment.
Christian C. Apfel, M.D.
Daniel I. Sessler, M.D.
University of Louisville
Louisville, KY 40202
apfel@ponv.org
References
Zhang Y, Luo Z, White PF. A model for evaluating droperidol's effect on the median QTc interval. Anesth Analg 2004;98:1330-1335.
Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693-700.
Pierre S, Benais H, Pouymayou J. Apfel's simplified score may favourably predict the risk of postoperative nausea and vomiting. Can J Anaesth 2002;49:237-242.
Watcha MF. The cost-effective management of postoperative nausea and vomiting. Anesthesiology 2000;92:931-933.
Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for management of postoperative nausea and vomiting. Anesth Analg 2003;97:62-71.
Samet Yal?n, M.D.
Bülent Yal?n, M.D.
Abdullah Büyük?elik, M.D.
Ankara University School of Medicine
TR-06100 Ankara, Turkey
bulyalcin@yahoo.com
References
Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350:2441-2451.
To the Editor: Apfel and colleagues found that various antiemetic interventions have similar efficacy for the prevention of postoperative nausea and vomiting. The authors recommend using the safest or least expensive intervention but do not present safety data, such as mortality or the rates of adverse events.
Frank Hartig, M.D.
Christoph Pechlaner, M.D.
Innsbruck University Hospital
A-6020 Innsbruck, Austria
christoph.pechlaner@uibk.ac.at
The authors reply: In our study of more than 5000 patients, each tested antiemetic intervention reduced the risk of postoperative nausea and vomiting by about 26 percent. As Drs. Hartig and Pechlaner might have expected, considering the safety of modern anesthesia, none of the patients died. There were 13 serious adverse events (mainly due to intraoperative or postoperative bleeding), 43 adverse events with postoperative consequences and 453 without postoperative consequences, and 204 minor adverse events (e.g., sore throat, itching, and headache) that resolved spontaneously. As we mention in the article, the use of volatile anesthetics and remifentanil, as compared with fentanyl, required increased administration of vasoconstrictors and was associated with an increased incidence of shivering (Table 1). All other adverse events were similarly distributed among the groups. Arrhythmias were reported in 10 of 2036 patients given droperidol and 11 of 2050 who were not — an observation that is consistent with evidence that antiemetic doses of droperidol do not cause clinically significant QT prolongation.1
Table 1. Perioperative Adverse Events in 4086 Patients Randomly Assigned with Respect to All Six Antiemetic Interventions.
The clinical value of prophylactic antiemetic interventions depends critically on the baseline risk of postoperative nausea and vomiting. Patients at low risk are unlikely to benefit from prevention, whereas a single intervention should be sufficient in patients at moderate risk. Combination therapy should be reserved for patients at high risk for postoperative nausea and vomiting. We therefore encourage our colleagues to use a simplified scoring system to evaluate patients' risk2,3 and to tailor prophylactic treatment according to the anticipated risk.4,5
A critical feature of our results is that, in addition to the finding that the interventions were similarly effective, there were no interactions evident with any combination of two or three strategies. Since all combinations of two interventions were equally effective, the safest and least expensive combinations are preferable. As Dr. Yal?n and colleagues suggest, dexamethasone and droperidol are an appropriate combination, since both drugs are inexpensive and appear to be safe. However, dexamethasone combined with total intravenous anesthesia is also suitable and may even be preferable in patients at especially high risk, because it provides additional options for postoperative rescue treatment.
Christian C. Apfel, M.D.
Daniel I. Sessler, M.D.
University of Louisville
Louisville, KY 40202
apfel@ponv.org
References
Zhang Y, Luo Z, White PF. A model for evaluating droperidol's effect on the median QTc interval. Anesth Analg 2004;98:1330-1335.
Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693-700.
Pierre S, Benais H, Pouymayou J. Apfel's simplified score may favourably predict the risk of postoperative nausea and vomiting. Can J Anaesth 2002;49:237-242.
Watcha MF. The cost-effective management of postoperative nausea and vomiting. Anesthesiology 2000;92:931-933.
Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for management of postoperative nausea and vomiting. Anesth Analg 2003;97:62-71.