ISSN NUMBER: 1938-7172
Issue 3.9 VOLUME 3 | NUMBER 9

Editor:
Michael A. Fiedler, PhD, CRNA

Associate Editor:
Joseph F. Burkard, DNSc, CRNA

Contributing Editors:
Penelope S. Benedik PhD, CRNA, RRT
Mary A. Golinski, PhD, CRNA
Gerard T. Hogan, Jr., DNSc., CRNA
Alfred E. Lupien, PhD, CRNA
Dennis Spence, PhD, CRNA
Steven R. Wooden, MS, CRNA

Guest Editor:
Lisa Osborne, PhD, CRNA

Assistant Editor
Jessica Floyd, BS

A Publication of Lifelong Learning, LLC © Copyright 2009

New health information becomes available constantly. While we strive to provide accurate information, factual and typographical errors may occur. The authors, editors, publisher, and Lifelong Learning, LLC is/are not responsible for any errors or omissions in the information presented. We endeavor to provide accurate information helpful in your clinical practice. Remember, though, that there is a lot of information out there and we are only presenting some of it here. Also, the comments of contributors represent their personal views, colored by their knowledge, understanding, experience, and judgment which may differ from yours. Their comments are written without knowing details of the clinical situation in which you may apply the information. In the end, your clinical decisions should be based upon your best judgment for each specific patient situation. We do not accept responsibility for clinical decisions or outcomes.

Table of Contents

EDITORIAL
  2009 PONV EVIDENCE BASED CONSENSUS GUIDELINES UPDATE
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GENERAL
  MONITORING OF NEUROMUSCULAR BLOCKADE AT THE P6 ACUPUNCTURE POINT REDUCES THE INCIDENCE OF POSTOPERATIVE NAUSEA AND VOMITING
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  P6 ACUSTIMULATION EFFECTIVELY DECREASES POSTOPERATIVE NAUSEA AND VOMITING IN HIGH-RISK PATIENTS
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  PATIENTS? WILLINGNESS TO PAY FOR ANTI-EMETIC TREATMENT
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  THE RELATIONSHIP BETWEEN PATIENT RISK FACTORS AND EARLY VERSUS LATE POSTOPERATIVE EMETIC SYMPTOMS
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PHARMACOLOGY
A RANDOMIZED, DOUBLE-BLIND STUDY TO EVALUATE THE EFFICACY AND SAFETY OF THREE DIFFERENT DOSES OF PALONSETRON VERSUS PLACEBO FOR PREVENTING POSTOPERATIVE NAUSEA AND VOMITING
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ANTIEMETIC PROPHYLAXIS FOR POSTDISCHARGE NAUSEA AND VOMITING AND IMPACT ON FUNCTIONAL QUALITY OF LIVING DURING RECOVERY IN PATIENTS WITH HIGH EMETIC RISKS: A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND COMPARISON OF TWO PROPHYLACTIC ANTIEMETIC REGIMENS
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COMPARISON OF THE EFFECTIVENESS OF METOCLOPRAMIDE, ONDANSETRON, AND GRANISETRON ON THE PREVENTION OF NAUSEA AND VOMITING AFTER LAPAROSCOPIC CHOLECYSTECTOMY
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DO CURRENT ANTIEMETIC PRACTICES RESULT IN POSITIVE PATIENT OUTCOMES? RESULTS OF A NEW STUDY
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DROPERIDOL AND ONDANSETRON-INDUCED QT INTERVAL PROLONGATION
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  HALOPERIDOL FOR POSTOPERATIVE NAUSEA AND VOMITING: ARE WE REINVENTING THE WHEEL?
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HALOPERIDOL PLUS ONDANSETRON VERSUS ONDANSETRON ALONE FOR PROPHYLAXIS OF POSTOPERATIVE NAUSEA AND VOMITING
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HALOPERIDOL VERSUS ONDANSETRON FOR PROPHYLAXIS OF POSTOPERATIVE NAUSEA AND VOMITING
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  ONDANSETRON VS. METOCLOPRAMIDE FOR THE PREVENTION OF NAUSEA AND VOMITING AFTER GYNECOLOGIC SURGERY
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THE DOSE-RESPONSE OF NITROUS OXIDE IN POSTOPERATIVE NAUSEA IN PATIENTS UNDERGOING GYNECOLOGIC LAPAROSCOPIC SURGERY: A PRELIMINARY STUDY
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THE IMPACT OF CURRENT ANTIEMETIC PRACTICES ON PATIENT OUTCOMES: A PROSPECTIVE STUDY ON HIGH-RISK PATIENTS
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THE PROPHYLACTIC EFFECT OF HALOPERIDOL PLUS DEXAMETHASONE ON POSTOPERATIVE NAUSEA AND VOMITING IN PATIENTS UNDERGOING LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY
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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
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QUALITY IMPROVEMENT
COMPARISON OF TWO INSTRUMENTS FOR ASSESSING RISK OF POSTOPERATIVE NAUSEA AND VOMITING
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  DECISION SUPPORT INCREASES GUIDELINE ADHERENCE FOR PRESCRIBING POSTOPERATIVE NAUSEA AND VOMITING PROPHYSAXIS
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SPECIAL ISSUE

This is a special Single Topic Issue of Anesthesia Abstracts. This issue contains a comprehensive, evidence based review of PostOperative Nausea and Vomiting prepared exclusively for Anesthesia Abstracts subscribers by Joseph F. Burkard, DNSc, CRNA. Dr. Burkard is an associate professor in the Hahn School of Nursing & Health Science, University of San Diego, San Diego, CA.

This issue contains Pharmacology specific CE. (May meet requirements for Alabama, Alaska, Idaho, Kentucky, Nevada, and New Mexico.)


Editorial

2009 PONV Evidence Based Consensus Guidelines Update

Guest Editorial 

It is generally accepted that emetic sequelae such as post-operative nausea, post-operative vomiting, and post-operative nausea and vomiting (PONV) are of multifactorial origin and that the incidence of PONV after balanced anesthesia—despite the advances in the last decades—is still between 20% and 30%. Several organizations over the last five years have established practice guidelines to assist the anesthesia provider in making appropriate health care decisions in specific clinical circumstances. This issue of Anesthesia Abstracts will examine the gaps in the 2006-2007 practice guidelines developed by the American Society of Anesthesiologist (ASA), American Society of Post Anesthesia Nurses (ASPAN), and the Society for Ambulatory Anesthesia (SAMBA).

David Sackett was credited with the definition of evidence-based practice:

“Evidence-based practice (EBP) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based practice means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”(1)

In 2001, the Institute of Medicine (IOM), in its Crossing the Quality Chasm series: A New Health Care System for the 21st Century, laid out its ten “new rules” for the future of health care. (2) The take home message was that “patients should receive care based on the best available scientific knowledge” and that “clinical practice should be based on evidence-based decision making.” However, many questions arose from this IOM statement:

-How are decisions made in the practice areas where EBP will be implemented?

-What types of system changes will be needed?

-Who is involved in decision making?

-Who is likely to lead and champion implementation of EBP?

-Who can influence the decision to proceed with implementation of EBP?

-What type of cooperation do you need from stakeholders to be successful?

-What system changes are necessary to sustain the change in practice?

 

To make this change process easier and to move forward, the Iowa Model of Research-Based Practice was selected to promote quality and to address several of the above questions.(3) The Iowa model was followed when developing the current 2006-2007 PONV practice guidelines. The process of evidenced-based practice starts with several core steps that will help the provider in making appropriate clinical decisions. These steps include:

Step 1:  Construct well-built and answerable clinical questions using a PICO format:  Population, Intervention, Comparison, Outcome.

Step 2:  Locate the best evidence to answer these questions.

Step 3:  Critically appraise findings using appraisal tools.

Step 4:  Integrate findings with clinical expertise and patient needs.

Step 5:  Evaluate  performance of these steps; seek ways to improve, and look for gaps.

 

Anesthesia providers are faced with clinical problems on a daily basis. After establishing the clinical problem, the anesthesia provider uses step 1 to format the PICO question. P: population at risk, I: interventions, C: comparison, and O: outcomes desired.(4) Step 2 involves locating the best evidence to answer these questions. Systematic reviews and practice guidelines are ideal and desirable for clinical decision making.(5). Locating the best evidence and sources of information may include colleagues, textbooks, journals, systematic reviews, guidelines and electronic databases. Where to start searching may depend on available time, available databases, and foreground versus background knowledge required.

Critically appraising the evidence is Step 3 and involves answering the following questions. Can I trust this information?  Are the study methods sound?  Are the valid results of the study important? Can the results be applied to my patient?(6)

Steps 4 and 5 integrate findings with clinical expertise and patient needs along with evaluating performance and seeking ways to improve. (7)

Practice Guidelines

In 2005, ASPAN convened an EBP guideline workgroup to develop practice recommendations for PONV and post discharge nausea and vomiting (PDNV). These guidelines were approved, adopted, and published in August 2006. The Iowa model and the Stetler “strength of evidence levels” for practice guideline development model were used. Risk factors for the development of PONV were agreed upon.(8) The Apfel and Koivuranta tools were adopted. All anesthesia departments were encouraged to screen for PONV / PDNV risk factors before surgery. (9, 10)

Gaps in the Literature

Were there other risk factors that should be included in pre-operative assessment of adults or children? Is the cost of antiemetic medications worth the risk? Will droperidol continue to have a black box warning? Will rescue medications impact PDNV? Does supplemental oxygen impact therapy, and do complementary modalities impact PDNV?

In 2006, SAMBA convened an EBP guideline workgroup to develop practice recommendations for PONV and PDNV. These guidelines were approved, adopted, and published in December 2007. The Iowa model and the Stetler “strength of evidence levels” for practice guideline development model were utilized. Risk factors for development of PONV were identified(11) and an algorithm for management of PONV was developed.

The panel focused on six guidelines for clinical providers to follow:

Identify patients at risk for PONV: The simplified models by Apfel et al. and Koivuranta et al. continue to show some usefulness for the prediction of PONV.

Reduce baseline risk factors for PONV: use regional anesthesia / propofol; avoid nitrous oxide; avoid volatile anesthetics; minimize opioids; give adequate hydration.

Administer PONV prophylaxis using one to two interventions in adults at moderate risk for PONV: current evidence does not support giving  prophylactic antiemetics to all patients. The black-box warning on droperidol continues to be a problem, and there is an emergence of research on the use of haloperidol as a substitute. There continues to be a discussion on the cost effectiveness of antiemetic therapy. This is the first guideline that is starting to show evidence on the use of NK1 receptor antagonist in clinical practice. The results are showing that the NK1 antagonist aprepitant 40 mg decreased nausea better than ondansetron in the 24 to 48 hour post-op period.

Administer prophylactic therapy with combination / multimodal therapy in patients at high risk for PONV:  multimodal therapy showed a 98% response rate compared to 76% for mono-therapy.

Administer prophylactic antiemetic therapy to children at increased risk for PONV. As in adults, use of combination therapy is most effective: PONV can be twice as high as in adults. 5-HT3 drugs appear to be more effective in children.

Provide antiemetic treatment to patients with PONV who did not receive prophylaxis or in whom prophylaxis failed.

 

Although there have been vast improvements in the anesthetic management of PONV / PDNV patients, further research must address optimal timing of antiemetic drug therapy and drug combination protocols. Practice guideline development should follow. Numerous gaps in the PONV / PDNV literature still need to be identified and addressed by reviewing current literature. To start this process, a systematic review of current literature was completed using the following search engines: PubMed, Cochrane Library, clinical practice guidelines, MD consult and EBMR reviews. Six hundred thirty-eight articles were reviewed for content key words and focused triggers. Eighty-nine articles were evaluated for best evidence to support the topic of PONV / PDNV. Thirty-seven articles were critically appraised and given a rank using the Sackett 2000 guides. Twenty-one articles were finally evaluated and reviewed for this Anesthesia Abstracts PONV Update.

 

Joseph F. Burkard, DNSc, CRNA

 

1. Sackett, D.L., Straus, S.E. Finding and applying evidence during clinical rounds:  The “evidence Cart”. JAMA. 1998;280:1336-1338.

2. Institute of Medicine (US). (2001). Crossing the quality chasm:  A new health system for the 21st century. Committee on Quality of Health Care in America. Washington, D.C.:  National Academies Press.

3. Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., et al. The Iowa model of evidence-based practicee to promote quality care. Critical Care Nursing Clinics of North America. 2001;13:497-509

4. Levin, R.L. & Feldman, H.R. (2006). Teaching evidence-based practice in nursing: A guide for academic and clinical settings. New York: Springer.

5. Malloch, K. & Porter-O’Grady, T. (2006). Introduction to evidenced-based practice in nursing and health care. Massachusetts: Jones and Bartlett.

Kerger, H.,Turan, A., Kredel, M., Stuckert, U., Alsip, N., Gan,T.J., et al. Patients’ willingness to pay for anti-emetic treatment. Aca Anaesthesiol Scand. 2007;51:38-43.

6. Polit, D.E. & Beck, C. T. (2004). Nursing Research:  Generating and assessing evidence for nursing practice. (8th ed.). Philadelphia: Lippincott Williams & Wilkins.

7. Sackett, D.L., Rosenberg, W.M., Muir Gray, J.A., Haynes, R.B. et al. Evidenced based medicine: What it is and what it isn’t. BMJ. 1996;312:71-72.

8. ASPAN. ASPAN’s evidence-based clinical practice guideline for the prevention and / or management of PONV / PDNV. Journal of PeriAnesthesia Nursing 2006;21:230-250.

9. Apfel CC, Greim CA, Haubitz I, et al. A risk score to predict the probability of postoperative vomiting in adults. Acta Anaesthesiol Scand. 1998;42:495-501.

10. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91:693–700

11. Gan, T.J., Meyer, T.A., Apfel, C.C., Chung, F. et al Society for ambulatory anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth & Analg. 2007;105:1615-1628.

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009




General

Arnberger M, Stadelmann K, Alischer P, Ponert R, Melber A, Grief R


 

Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting

Anesthesiology 2007;107:903-908

Arnberger M, Stadelmann K, Alischer P, Ponert R, Melber A, Grief R

 

Abstract

Purpose            This double-blinded, randomized, controlled trial evaluated the effects of electrical stimulation of the P6 acupuncture point on the dominant wrist using a conventional neuromuscular blockade monitor for the evaluation of muscle relaxation during general anesthesia on the incidence of PONV.

Background            Various antiemetic drugs reduce but do not eliminate postoperative nausea and vomiting (PONV). There is no completely effective therapy, and even newly investigated drugs do not abolish PONV. The PONV-reducing effects of acupuncture and its different approaches are well described and recently reviewed. Stimulation of the P6 acupuncture point has been shown to markedly reduce the incidence of PONV. This study was triggered by the idea that a constant electrical stimulus over the median nerve at the region of the well-known P6 acupuncture point might have an advantageous effect on PONV while measuring neuromuscular blockade at the same time.

Methodology            A total of 220 ASA I-III women were enrolled in this IRB approved study. Patients were assigned to one of two groups using a set of random numbers. The control group had pregelled electrodes placed at the standard Ulnar site. The treatment group - P6 acupuncture group had the same electrodes placed to stimulate the median nerve at the P6 acupuncture point. The only difference between groups was where the electrodes were placed. Anesthetic management was standardized. Rescue treatment for PONV, using 4 mg of ondansetron was given if two or more episodes of vomiting occurred or if persistent nausea was reported. As a primary endpoint, PONV was defined as the presence of nausea and/or vomiting throughout the observation period.

Result            Two-hundred twenty patients were recruited for this study without any dropout over the observation period. There was a significant difference between both groups for the primary endpoint, experiencing postoperative nausea and vomiting over a 24 h observation period. Nausea but not vomiting was significantly lower in the P6 acupuncture group. In the early postoperative period (0-6 h), combined PONV was much lower in the P6 group (33% vs. 56%; P=0.009).

Conclusion            Transcutaneous electrical stimulation of the P6 acupuncture point has been shown effective for the prevention of PONV. Combined unilateral stimulation of the P6 acupuncture point while measuring neuromuscular blockade reduceed PONV overall in the early period after surgery. The relative reduction of PONV by 25% in this study was comparable to the effect of well established drug treatments. On the other hand, P6 acupuncture point stimulation with a standard neuromuscular blockade monitor had a more profound effect on the incidence of postoperative nausea than on postoperative vomiting. The major reduction factor was the effect of acupuncture stimulation on early nausea. The number needed to treat was 5 for early PONV and 6 for 24-h PONV.

 

Comment

This prospective, double-blind study concluded that intraoperative transcutaneous electrical stimulation of the P6 acupuncture point with the conventional nerve stimulator to monitor neuromuscular blockade significantly reduced the incidence of PONV over 24 hours. In fact, this study showed promising results in reducing nausea by 51% as compared to placebo of 33%. It also showed a total decrease in the incidence of PONV over 24 h. This study showed that the P6 acupuncture site can be combined with the standard neuromuscular blockade technique to reduce the incidence of PONV.  This was a promising study since this technique could be combined with other multi-modal prophylaxis for the high-risk PONV patient.

 

Joseph F. Burkard, DNSc, CRNA

 

For another perspective on this study by another contributing editor see the June, 2008 issue of Anesthesia Abstracts at http://www.anesthesiaabstracts.com/abstracts.asp?issueID=29#280

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Frey UH, Scharmann P, Lohlein C, Peters J


P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients

Br J Anaesth 2009;102:620-625

Frey UH, Scharmann P, Lohlein C, Peters J

Abstract

Purpose            This study was performed to evaluate the effects of P6 acupuncture point stimulation on the incidence of postoperative nausea and vomiting (PONV). Specifically, the primary hypothesis that acustimulation results in PONV reduction that is dependent on known risk factors was tested.

Background            PONV occurs in up to 30% of unselected patients and is the most frequent side effect after anesthesia. Recent studies have shown that stimulation at the P6 acupuncture point is associated with a decreased PONV incidence. However, no data are available on the effectiveness of acupuncture in different risk factor groups for PONV.

Methodology            A total of 214 patients were screened and randomized into this single center, prospective, observer-blind study. Patients were allocated to an acustimulation group and to a sham group. These groups were further subdivided into the following subgroups: A: acustimulation before induction of anesthesia, B: acustimulation after induction of anesthesia, C: sham before, D: sham after induction.

Result            There was a significant difference in PONV experienced between acustimulation and placebo patients. The incidence of PONV was significantly lower in the acustimulation group compared with the sham group. This was true for early and late PONV. Relative risk reduction of P6 acustimulation calculated for every risk factor group, showed that acustimulation was effective on nausea in patients with three or four risk factors. Acustimulation was effective on vomiting only when four risk factors were present.

Conclusion            A history of motion sickness and usage of acustimulation were independent predictors for risk reduction of nausea in this study. Both history of PONV and motion sickness increased and acustimulation both pre- and post-induction decreased the requirements for rescue treatment. This study showed that acustimulation was effective in reducing the incidence of PONV in high-risk patients. The relative risk reduction of 50%-60% in this study with three or more risk factors was higher than with other studies showing a relative risk reduction of PONV by 25% which is comparable with the effect of well-established drug treatments.

Comment

This study indicated that acustimulation may reduce PONV in patients with a high risk. They also suggest an effective relative risk reduction of nausea with at least three risk factors, whereas acustimulation was significantly effective on the reduction of retching or vomiting when four risk factors were present. These authors suggested that to have effective PONV treatment, you will have to utilize the acustimulation for more than 24 hours to be effective.

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Kerger H, Turan A, Kredel M, Stuckert U, Alsip N, Gan TJ, Apfel CC


 

Patients’ willingness to pay for anti-emetic treatment

Acta Anaesthesiol Scand 2007;51:38-43

Kerger H, Turan A, Kredel M, Stuckert U, Alsip N, Gan TJ, Apfel CC

 

Abstract

Purpose            In this study, the authors attempted to identify the predictors for willingness to pay (WTP), and to estimate the amount patients would be willing to pay, to avoid experiencing postoperative nausea and vomiting.

Background            Post-operative nausea and vomiting (PONV) remains a frequent problem. PONV can lead to serious medical complications, such as wound dehiscence, esophageal rupture and retinal detachment. More frequently, it is a significant concern to patients and can impair patient satisfaction. This is important, as some patients who suffer from PONV rate it as more uncomfortable than post-operative pain. Previous studies in the USA have indicated that, in order to avoid PONV, patients would be willing to pay more to prevent it.

Methodology            After obtaining IRB approval, 100 adult patients each from Germany and Turkey were enrolled in this willingness to pay study. All participants were scheduled for elective day surgery under general anesthesia. After meeting discharge criteria from the post-anesthetic care unit, they were asked to complete an interactive computer questionnaire on their WTP. The detailed questionnaire, which had been used before, consisted of three sets of questions. The first, introduced the patient to the format of the questionnaire. The second, dealt with the value participants placed on the avoidance of PONV and the amount of money they would be willing to pay. The third set of questions assessed demographic data, health status, income and educational level. In the questionnaire, patients were also asked how important they deemed the prevention of nausea and vomiting. This was accomplished using a visual analog scale (VAS) graded from 0 to 100.

Result            All 200 patients enrolled in the study completed the computer questionnaire. The patients in the two countries were similar in terms of their history of PONV. They differed with regard to previous surgery experience, with patients from Germany having a higher surgical past history. On average, the WTP values to avoid PONV were 65 Euro’s in Germany and 68 Euro’s in Turkey. These values increased to 96 Euro’s and 99 Euro’s respectively, when nausea or vomiting occurred post-operatively. In contrast, age, previous surgery, history of PONV, household income, and health status did not play a significant role. According to this multivariate analysis, independent predictors for WTP were non-smoking status, history of motion sickness and educational level.

Conclusion            Patients in Germany and Turkey were willing to pay 65 Euro’s and 68 Euro’s, respectively to prevent PONV. Patients who actually suffered from PONV were willing to pay substantially more. Furthermore, the WTP value of 65 Euro’s or more was significantly related to a history of motion sickness, non-smoking status, female sex, and educational level. To the surprise of these authors, the WTP value was in the same range as reported previously for the USA. The WP method has shown that patients are willing to pay 65-68 Euro’s for total prevention of PONV and this study correlates with previous work done in the USA.

 

Comment

It is clear from this article that PONV continues to be a major concern for anesthesia providers. This article, combined with the work done by Gan et al. in 2001, highlights the fact that patients are willing to continue to pay on an average of $51-$68 for PONV prophylaxis. What is not clear in this European study was how much preoperative education was given to the patients about PONV. Did they know the risks and benefits before they went into surgery? Risk factor assessment was important and indicated that non-smoking patients and patients with history of motion sickness were willing to pay more for the prevention of PONV. The strongest predictor of willingness to pay was educational level, highlighting the importance of the anesthesia provider’s preoperative assessment of PONV baseline risk.

 

Joseph F. Burkard, DNSc, CRNA

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





White PF, Sacan O, Nuangchamnong N, Sun T, Eng MR


 

The relationship between patient risk factors and early versus late postoperative emetic symptoms

Anesth Analg 2008;107:459-463

White PF, Sacan O, Nuangchamnong N, Sun T, Eng MR

 

Abstract

Purpose            This prospective, observational study was designed to assess the relationship between the patients’ Apfel risk score for developing postoperative nausea and vomiting (PONV) and the occurrence of early (<24h) and late (24-72 h) emetic symptoms in “at risk” surgical populations receiving frequent multimodal antiemetic prophylaxis.

Background            The incidence of PONV remains high despite the frequent use of prophylactic antiemetics, shorter-acting anesthetics and analgesics, and less invasive surgical techniques. With the increasing emphasis on earlier mobilization and discharge after both minor and major operations, postural hypotension and oral opioid containing analgesics may become more important contributors to PONV. Therefore, antiemetic drugs are now commonly administered both at the start and end of surgery to patients considered to be at increased risk of developing PONV. Apfel et al. have developed a simplified scoring system which has favorable discriminating and calibrating properties for predicting an individual patient’s risk for developing PONV.

Methodology            One hundred thirty healthy patients (18-75 yr) undergoing major laparoscopic or plastic surgery under general anesthesia were enrolled in this IRB-approved prospective observational study. All patients entered into this study were expected to receive postoperative opioid analgesics, and had at least one additional risk factor. Patients with an Apfel score of three or four were considered to be at “high risk” for developing PONV. Using a structured questionnaire format, all patients were asked if the occurrence of PONV had any impact on their ability to resume normal activities of daily living.

Result            Demographic characteristics for patients with two risk factors were significantly different from those in the Apfel three or four risk factor groups. All patients received opioid analgesics in the postoperative period. Prophylactic antiemetics were administered to 88%, 90% and 95% of the patients in the two, three, and four risk factor groups, respectively. Postoperative vomiting was reported in 11% and 22% of the three and four risk factor groups, respectively, compared to only 6% in the two risk factor group. The occurrence of moderate or severe nausea at 0-6 h was also more frequent in the two higher risk groups. All the patients in the three or four risk factor groups who required rescue antiemetics received either no or only one prophylactic antiemetic drug. In assessing the percentage of patients who reported that PONV negatively impacted their recovery within the first 24 h after surgery, a greater impact was observed in the groups with higher risk factor scores.

Conclusion            These prospective data suggested that PONV remains a common problem for high-risk surgical populations despite the frequent use of two or more antiemetic drugs for prophylaxis. The Apfel scoring system was highly predictive of emetic symptoms within 24 h after surgery. However, these data failed to find a correlation between incidence of late PONV and patients’ Apfel risk score. This study suggested that a potentially confounding effect of patients self-administering oral-opioid containing analgesics may explain the significant contributing factor of late PONV. This data suggested that there remains a need to develop improved antiemetic and anti-nausea therapeutic regimens which are effective during both the early postoperative period, as well as the late postoperative period. The inability to discriminate among the various risk groups after 24 h may be related to the overall low incidence of emetic symptoms and the confounding effect of oral opioid use.

 

Comment

This follow-up study showed that when considering “pay for performance” proposals, patients were prevented from performing activities due to PONV up to 72 hrs post-surgery. Consideration must be given to the PDNV guidelines. These studies also showed that risk factor screening tools were very good for PONV but were not predictive of post-discharge emetic symptoms. Preoperative assessment tools such as the Apfel risk scoring system appear not to be very effective after the 24 h period. This could be due to the self-administration of opioid analgesics. Anesthesia providers need to consider this postoperative phenomena and consult with their surgical colleagues to pharmacologically manage PDNV.

 

Joseph F. Burkard, DNSc, CRNA

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009




Pharmacology

Candioti KA, Kovac AL, Melson TI, Clerici G, Gan TJ


 

A randomized, double-blind study to evaluate the efficacy and safety of three different doses of palonsetron versus placebo for preventing postoperative nausea and vomiting

Anesth Analg 2008;107:445-451

Candioti KA, Kovac AL, Melson TI, Clerici G, Gan TJ

 

Abstract

Purpose            The current study was conducted to evaluate the hypothesis that IV palonosetron provides safe and effective prevention of postoperative nausea and vomiting (PONV) and explore its duration of action across multiple dose levels for up to 3 days in patients undergoing laparoscopic surgery who were expected to be discharged on the same day as their surgical procedure.

Background            Palonosetron is a unique 5-HT3 receptor antagonist approved for use in the prevention of chemotherapy induced nausea and vomiting. Palonosetron was clinically and statistically superior to ondansetron in reducing the incidence of emesis and the impact of nausea and vomiting on patient function during the acute (0-24 h) and delayed (24-120 h) phase after chemotherapy. The findings demonstrated that palonosetron has allosteric binding and positive cooperativity that, in contrast with older drugs, confers a long-lasting functional effect which inhibits serotonin-mediated Ca2 influx.

Methodology            ASA I-III patients scheduled for elective laparoscopic abdominal or gynecological surgery of at least 1 h duration were enrolled. All patients had at least two risk factors for PONV. A single dose of palonosetron (0.025 mg, 0.050 mg, or 0.075 mg), with an adequate volume of saline solution added to bring the total injectable volume to 2 mL, was administered as a IV bolus immediately before induction of anesthesia. Subjects in the placebo group received a 2 mL saline bolus. Emetic episodes, intensity of nausea, and interference with daily life activities were measured at the time points of 2, 6, 24, 48, and 72 h. The primary efficacy hypotheses were that at least one dose of palonosetron was superior to placebo, for the complete response (CR) rate, in the 0 to 24 h and 24 to 72 h time periods.

Result            Six hundred thirty-nine patients were screened for this study, of which 65 were screening failures. Five hundred forty-seven patients were treated. Compared with placebo, a dose-response trend for CR was observed with increasing doses of palonosetron. In the 0 to 24 h postoperative time interval, CR rates were: placebo, 26%; P-0.025 mg, 33%; P-0.050 mg, 39%; P-0.075 mg, 43%. Overall, the greatest effect was noted in the 0-24 h period with a clear dose-response trend. In the 24-72 h range, no dose reached statistical significance compared to placebo. The proportion of patients in the placebo group who experienced vomiting was smaller than expected in a population at increased risk of PONV.

Conclusion            This randomized, double-blind, multicenter, stratified phase three study evaluated the dose-response of three different, single IV doses of palonosetron compared with placebo for the prevention of PONV. Only the highest dose (0.075 mg) of palonosetron demonstrated a statistically significant treatment effect compared with placebo over the first 24 hours. The treatment effect of palonosetron in this trial is most pronounced during the first 24 h. Larger trials with an active comparator will be required to determine the relevance of these observations.

 

Comment

The Candiotti et al. (2008) study addressed the delayed phase of PONV after 24-hours and found that the newer, long acting 5-HT3 treatment effect was most pronounced during the first 24 hours. Drug administration approval of palonosetron 0.075 mg for the prevention of PONV up to 24 hours after surgery will give practitioners the opportunity to gain clinical experience with this new drug. This study is disappointing in the fact that palonosetron was supposed to be the first long acting antiemetic for post discharge control of PONV. Its limited effectiveness in the 24-72 h period seems to make this a less desirable cost effective drug.

 

Joseph F. Burkard, DNSc, CRNA

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Pan PH, Lee SC, Harris LC


 

Antiemetic prophylaxis for postdischarge nausea and vomiting and impact on functional quality of living during recovery in patients with high emetic risks: a prospective, randomized, double-blind comparison of two prophylactic antiemetic regimens

Anesth Analg 2008;107:429-438

Pan PH, Lee SC, Harris LC

 

Abstract

Purpose            The goal of this study was to compare the efficacy of preventing post-discharge nausea and vomiting (PDNV) between a commonly used single drug prophylaxis regimen versus a more aggressive multidrug combination with sequential administration regimen. The authors hypothesized that IV dexamethasone and ondansetron followed by oral disintegration tablet (ODT) ondansetron are more effective than IV ondansetron alone in preventing PDNV between 24 and 120 h postoperatively in high-risk patients having gynecological laparoscopic surgery.

Background            Postoperative nausea and vomiting (PONV) and PDNV are among the most common complications of ambulatory surgery. Apfel et al. evaluated a factorial trial of six interventions for prevention of PONV and showed that the average incidence of PONV was 34%, or as high as 70%-80% in high-risk patients without prophylactic antiemetics. Few studies have evaluated the efficacy of prophylaxis on PDNV or its impact on quality of living (QOL) during recovery. Literature reviews have shown that only 19 articles had sufficient data on PDNV, and that most data were only on the first 24 postoperative hours. Other authors found similar results with reported postdischarge nausea (PDN) incidences that varied from 0% to 55% and postdischarge vomiting (PDV) incidences from 0% to 16%. Patients with PDNV are significantly more likely to have problems performing activities of daily living, have a lower satisfaction score, and experience a higher negative economic impact than are those not experiencing PDNV.

Methodology            After obtaining IRB approval, informed consent was obtained for this prospective double-blind, randomized control study from 64 healthy ASA I or II women undergoing outpatient laparoscopic gynecological surgeries with general anesthesia. Patients were randomized in a double-blind fashion preoperatively to one of two prophylactic antiemetic treatment groups according to a computer-generated table. The study treatment group received IV dexamethasone 8 mg in 2 mL volume immediately after successful intubation, and IV ondansetron 4 mg within 15 min before tracheal extubation at the end of the anesthesia. They also received an ODT of ondansetron 8 mg, at the time of discharge from the PACU, and on the morning of postoperative day (POD) #1 and #2 at home. Patients in the control group received IV placebo of 2 mL normal saline after intubation, and IV ondansetron 4 mg within 15 min before tracheal extubation at the end of anesthesia and then received placebo ODT at discharge and on the morning of POD #1 and #2, as in the study group.

Result            The worst nausea intensity was scored significantly higher in the control group when compared with the study group. The time to discharge from the PACU was longer in the control group than the study group. The incidence of any nausea rated >3 of 10 in severity was 53% and 40%; for any vomiting or retching was 23% and 10%; and for rescue medication was 40% and 27%, in the control group and study group respectively without statistically significant differences between groups. The incidences of PDN and the number of patient days of emetic symptoms between 24 h postanethesia and 120 h postanesthesia were both significantly higher in the control group when compared with the study group. The incidences of any PDN were 73% in the control and 57% in the study group, whereas the incidences of PDV were 20% and 10%. The magnitude of emetic symptoms affecting the different aspects of patients QOL during the period from discharge to 120 h after anesthesia was significantly higher in the control group.

Conclusion            PDNV has become a growing problem that has not been fully recognized, in part because the patients often choose to wait for resolution of emetic symptoms on their own rather than contacting their provider for interventions. The study treatment regimen seemed to have significantly reduced the incidence of PDNV and improved quality of functional living between POD #1 and #4, as well as between 8 and 120 hours after the end of anesthesia.

 

Comment

This study by Pan, Lee, and Harris (2008) looked at the complications of PDNV in an ambulatory setting, focusing on quality of life in two groups of patients receiving anti-emetics. The multi-modal group had lower nausea scores and better long-term outcomes but was not powered to show results for the PDNV five-day period. This is the first study that looks at quality of life in the PDNV period. Unfortunately, this study did not address patient risk stratification and cost-benefit ratio. It has been shown in other studies that it is not cost effective to treat all patients undergoing general anesthesia. At the same time, it would have been interesting if they had stratified their PONV / PDNV risk.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Oksuz H, Zencirci B, Ezberci M


 

Comparison of the effectiveness of metoclopramide, ondansetron, and granisetron on the prevention of nausea and vomiting after laparoscopic cholecystectomy

J Laparoendosc Adv Surg Tech 2007;17:803-808

Oksuz H, Zencirci B, Ezberci M

 

Abstract

Purpose            This prospective, randomized, double-blind study was conducted to compare the antiemetic activity of the prophylactic administration of ondansetron and granisetron with metoclopramide in patients undergoing a laparoscopic cholecystectomy.

Background            Apart from pain, postoperative nausea and vomiting (PONV), remains the most distressing complication in the postoperative period that a patient can go through. PONV can cause not only significant morbidity, but also longer stays in the recovery room, particularly in patients undergoing a laparoscopic cholecystectomy. Ondansetron, dolasetron, granisetron, and tropisetron are known to act on the 5-HT3 receptor, with a receptor specificity and binding ratio higher than 100:1. The anti-emetic effect of metoclopramide is attributed to its affinity for the dopaminergic D2 receptors. Moreover, metoclopramide is known to have a prokinetic effect, which causes an increase in the lower esophageal sphincter tone and gastric and small bowel motility by means of its action on the 5-HT4 receptors.

Methodology            After obtaining informed consent, 75 ASA I and II patients (26 male, 49 female) 21-72 years of age and weighing 52-102 kg were studied. Patients without premedication were randomized into three different subgroups and treated with drugs 30 minutes before induction as follows: group M - 10 mg metoclopramide, group K - 40 mcg per kg granisetron, and group Z - 15 mcg per kg ondansetron. The bellvile PONV four-stage score chart was used to evaluate PONV. The incidence and severity of PONV and eventual side effects were assessed by asking patients if they had experienced nausea and vomiting at four hour intervals.

Result            Prophylactic antiemetic treatment with granisetron resulted in a lower incidence of PONV than with ondansetron or metoclopramide. No differences were observed between the ondansetron and metoclopramide groups among the incidence of PONV in the first 3-hour period. Although the cost effectiveness of metoclopromide was lower, its dose repetition and nausea-vomiting scores were high.

Conclusion            Vomiting is a complicated procedure controlled by the vomiting center near the tractus solitarius in the brain stem. The activity of the CTZ is mediated by dopaminergic, histaminic, muscarinic, and serotonergic receptors. PONV is widely encountered complication, which is seen in 30% of patients not receiving antiemetic drugs and 40%-75% of the patients who have undergone laparoscopic surgery. The prophylactic administration of granisetron (40 mcg per kg) reduced the incidence of PONV in patients following a laparoscopic cholecystectomy, compared with that of ondansetron or metoclopramide. When mean total costs were compared, 12.5 mg of dolasetron was the most cost effective for preventing PONV. In this study, cases treated with metoclopramide had a higher PONV incidence and required additional drug administration.

 

Comment

Oksuz et al. looked at a comparison of the effectiveness of ondansetron, granisetron and metoclopramide. The information found in this study is not new. When determining cost effectiveness of the three drugs, it was clear that granisetron was the most expensive drug compared to the other two drugs. Granisetron did result in lower incidence of PONV compared to the two other drug profiles. When the cost effectiveness of both graniseton and ondansetron was reviewed, the high repeated dose numbers of ondansetron offset the added cost of granisetron.

 

Joseph F. Burkard, DNSc, CRNA

 

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Wender RH


Do current antiemetic practices result in positive patient outcomes? Results of a new study

Am J Health Syst Pharm 2009;66:S3-S10

Wender RH

Abstract

Purpose            This study was designed to assess the incidence and time course of postoperative nausea and vomiting (PONV) and post discharge nausea and vomiting (PDNV), as well as the impact of emetic sequelae on the patients’ functional recovery, and the current clinical treatment patterns associated with the management of high-risk patients. Secondary to these primary objectives, the study endeavored to characterize the patterns of antiemetic use for prophylaxis and rescue of PONV before, during, and after surgery.

Background            As the most common postsurgical complications, PONV and PDNV affect approximately 25 million patients worldwide yearly, with an estimated annual financial impact of several million dollars. Although the incidence of PDNV is likely underreported due to lack of surveillance following hospital discharge, the most current available randomized trial evidence suggests that approximately 30% of patients experience PDNV. According to risk model analyses, the presence of one or two risk factors is associated with 20%-40% of patients developing PONV, while three to four risk factors increases the number to 60%-80%. Using risk scores as a guide to determine which patients would benefit from prophylaxis has been shown to reduce the incidence of nausea and vomiting. Until now, no study has specifically analyzed the compliance of practitioners with practice guidelines for PONV and PDNV in their routine practice, nor the impact of recommendations for prophylaxis and treatment on emetic outcomes after general anesthesia.

Methodology            The Prospective Observational Study of Treatments, Outcomes, and Patterns of care (POSTOP) for PONV study was designed to assess the incidence and time course of PONV and PDNV. ASA I to III patients undergoing a surgical procedure lasting a minimum of one hour with general anesthesia were enrolled in this study. The multicenter trial had a prospective design; patient outcomes were observed as they occurred in usual practice at 11 U.S. sites. The PONV related outcome data was captured via recordings over a 72 hour postoperative observation period.

Result            This observational study noted the patterns of behavior of patients at high risk for developing PONV. Despite the enhanced risk of PONV within the population studied, 8% of patients did not receive any antiemetic prophylaxis. Thirty-four percent received one antiemetic prophylactic agent while 35% were administered two and 23% were given three or more. Overall, there was a wide variation in the number of antiemetic agents given to high-risk patients.

Conclusion            Nausea and vomiting rescue medications were required in 45% of participants in the first 72 hours. Despite the frequent administration of multiple antiemetic agents, 51% of patients did not experience a complete response to antiemetics and 61% did not have complete control during the 72-hour study interval.

 

Comment

Despite the availability of PONV / PDNV guidelines, a large number of high-risk patients suffered from PONV and PDNV during the POSTOP study. This study showed that during the 72-hour period, only 61% of patients were given prophylaxis and rescue medications in accordance with ASA and ASPAN guidelines. When clinical practice failed to comply with guidelines, 17% had a complete response, and 67% experienced moderate-to-severe nausea in the 72 hours following surgery. It is clear in this study that compliance with ASA and ASPAN guidelines led to a decrease in PONV and PDNV.

 

Joseph F. Burkard, DNSc, CRNA

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Charbit B, Alvarez JC, Dasque E, Abe D, Demolis JL, Funck-Brenatano C


Droperidol and ondansetron-induced QT interval prolongation

Anesthesiology 2008;109:209-212

Charbit B, Alvarez JC, Dasque E, Abe D, Demolis JL, Funck-Brenatano C

Abstract

Purpose            The aim of this study was to assess the effects of droperidol and ondansetron alone or in combination on QTc interval duration according to the principles of the E14 guideline.

Background            In 2001, the US Food and Drug Administration issued a “black box” warning regarding the potential for proarrhythmic events related to QT interval prolongation with droperidol use. As a consequence, 5-HT3 antagonists became the most used antiemetics in the United States. However, 5-HT3’s share with droperidol the property to block the human ether-a-go-go related gene (HERG) cardiac potassium channel underlying their theoretical proarrhythmic potential.

There is increasing evidence that antiemetics should be combined in patients at high risk of emesis in the perioperative period. Moreover, in case of failure of one antiemetic, it is recommended to add an agent of another pharmacologic class in combination with the first agent. Therefore, if droperidol and ondansetron prolong the QT interval, their combination could theoretically increase the risk of cardiac arrhythmia.

Methodology            The study protocol was approved by the committee for the protection of human subjects. Only subjects with a normal corrected QT interval and resting heart rate between 55 and 70 beats/min were included in the study. This was a prospective, placebo-controlled, double-blind study with four randomized crossover periods where volunteers were given a single dose of droperidol alone, ondansetron alone, droperidol and ondansetron in combination, or a placebo. It was calculated that 15 subjects were necessary to detect QTc prolongation of at least 15 ms between droperidol or ondansetron alone or in combination compared with placebo.

Result            Sixteen volunteers entered the study. Compared with placebo, both droperidol and ondansetron significantly prolonged the QTc interval. Maximal QTc prolongation was significantly greater in the droperidol and droperidol-ondansetron groups compared with ondansetron alone. Maximal QTc prolongation was not different between droperidol and droperidol-ondansetron.

Conclusion            Significant QTc interval prolongation was observed during droperidol and ondansetron administration at low antiemetic doses. This study was the first report showing significant QTc prolongation after low doses of droperidol and ondansetron measured under conditions recommended by the international conference on harmonization E14 guideline on the evaluation of proarrhythmic risk for noncardiac drugs. Other studies have found a 22 ms QT prolongation with 1.25 mg droperidol. This QT prolongation was not statistically different from the 12 ms lengthening observed in the placebo group. The current study did not find an additive effect of droperidol and ondansetron on QTc prolongation. In fact, the addition of droperidol to ondansetron did not increase the extent of maximal QTc prolongation. Although ondansetron seems to bear a less toxic potential than droperidol, both drugs should be cautiously administered in patients with a prolonged QT interval.

 

Comment

This study by Charbit et al. looked at the effects of droperidol and ondansetron on QT interval duration in three combinations. Compared with placebo, they found that both droperidol and ondansetron significantly prolonged the QTc interval with the maximal prolongation being found in the droperidol group. The multi-modal combination of droperidol and ondansetron did not have an additive effect on the QTc interval.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Habib AS, Gan TJ


Haloperidol for postoperative nausea and vomiting: are we reinventing the wheel?

Anesth Analg 2008;106:1343-1345

Habib AS, Gan TJ

Abstract

Purpose            This systematic review was done to find an alternative drug for postoperative nausea and vomiting (PONV) after the FDA placed a “black box” warning on droperidol.

Background            The search for an alternative to replace droperidol led to the logical choice of an older member of the butyrophenone family:  haloperidol. This drug received FDA approval as an antipsychotic in 1967. Haloperidol has a long half-life of 18 h. Small doses of haloperidol are used for the management of PONV. It has a number of potential side effects that are associated with higher doses used to treat psychosis.

Methodology            This systematic review used published and unpublished data from 1962 to 1988 and suggested that haloperidol, at 1-2 mg, doses considerably lower than those used for the treatment of psychosis and agitation, might be effective for prophylaxis and treatment of PONV.

Result            Several recent studies have investigated the efficacy and safety of haloperidol when used for the management of PONV. Wang et al. reported that both haloperidol 1 mg and droperidol 0.625 mg were better than placebo for PONV prophylaxis with no significant differences between the two drugs. Studies by Rosow et al. reported on the use of haloperidol 1 mg alone and the combination of haloperidol 1 mg with ondansetron 4 mg for prophylaxis of PONV. The results confirmed the antiemetic efficacy of the combination of haloperidol with ondansetron compared with ondansetron alone.

Conclusion            The available evidence would suggest that small doses of haloperidol appears to be safe and effective when given as a single dose of 1-2 mg for PONV prophylaxis. However, well designed, adequately controlled studies are needed to confirm those findings, and to provide additional safety and efficacy information before widespread use of this drug can be recommended.

 

Comment

Habib and Gan concluded that the combination of multiple drugs now seems ideal. They go on to state that in a systematic review of haloperidol it seems that small doses of 1-2 mg appear ideal for combination therapy. Since the mechanism of action of haloperidol and its effect on QTc are probably very similar to those of droperidol, it appears that the FDA’s black box warning on droperidol, a drug that has been well studied and widely used, has caused the anesthesia community to reinvent the wheel. Whether or not we will move to a drug from the same butyrophenone family, with the same side effect profile, is still to be seen.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Grecu L, Bittner EA, Kher J, Smith SE, Rosow CE


Haloperidol plus ondansetron versus ondansetron alone for prophylaxis of postoperative nausea and vomiting

Anesth Analg 2008;106:1410-1413

Grecu L, Bittner EA, Kher J, Smith SE, Rosow CE

Abstract

Purpose            The present study compares ondansetron alone with the combination of haloperidol and ondansetron in a mixed surgical population.  The hypothesis was that the combination would significantly reduce nausea and, possibly a have a longer duration.

Background            Large trials of single-drug postoperative nausea and vomiting (PONV) prophylaxis rarely indicate more than 65%-70% complete response.  Combining droperidol and ondansetron generally improves efficacy, although some studies claim only a weak benefit.  It has been previously reported that PONV prophylaxis with 1 mg of haloperidol was comparable in efficacy to 4 mg ondansetron.  The combination of these two drugs may present a significantly more effective outcome for PONV.

Methodology            This randomized, double-blind trial compared 4 mg IV ondansetron versus the combination of 1 mg haloperidol plus 4 mg ondansetron for PONV prophylaxis.  Unlike the first trial completed by these investigators, those at high risk for PONV were included in this study.  To review QTc intervals, a screening electrocardiogram was obtained, and those with QTc intervals >450 ms were excluded.

Result            Two-hundred and sixty-eight subjects were enrolled, and 263 could be evaluated for efficacy.  The combination was significantly more effective by almost every measure.  There was more complete response, less nausea, and less rescue.  Approximately 40% of patients in each group met discharge criteria upon PACU entry and the mean time to discharge was not different.  The average preoperative QTc was 417.5 +/- 15.8 ms.  There was no difference in the incidence of postoperative QTc prolongation, and no serious dysrhythmias occurred.

Conclusion            A sizable fraction of the surgical population is at high risk for PONV and deserves prophylaxis with more than one antiemetic.  These data indicate that combining haloperidol with ondansetron has a substantial effect on early PONV.  Over the first 8 h after surgery, there was a 17% absolute reduction in PONV compared with ondansetron alone.  This data suggested that haloperidol does not produce significant sedation or other toxicity, and the QTc effect is impossible to distinguish from other perioperative factors.

Comment

Grecu et al. has looked at combination therapy of haloperidol and ondansetron and found that haloperidol plus ondansetron significantly reduced PONV and nearly eliminated persistent nausea as a factor preventing discharge from the PACU.  This study also addressed the anesthetic complications associated with droperidol and haloperidol and found that they were non-existent in this study.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Rosow CE, Haspel KL, Smith SE, Grecu L, Bittner EA


Haloperidol versus ondansetron for prophylaxis of postoperative nausea and vomiting

Anesth Analg 2008;106:1407-1409

Rosow CE, Haspel KL, Smith SE, Grecu L, Bittner EA

Abstract

Purpose            This study hypothesized that the efficacy of 1 mg of haloperidol and 4 mg ondansetron would not be significantly different for prohylaxis of postoperative nausea and vomiting (PONV) and, at this dose, the risk of adverse effects would be extremely low.

Background            In multiple studies, the antiemetic effects of haloperidol were reviewed. In doses of 1 to 4 mg, haloperidol prevented or treated nausea and vomiting due to chemotherapy, irradiation, and gastrointestinal disorders. Very few studies have compared the effects of haloperidol and ondansetron for prophylaxis or treatment of PONV.

Methodology            This was a randomized, third-party blinded, parallel-group comparison of 1 mg haloperidol versus 4 mg ondansetron. Elective ASA I-III patients scheduled for general anesthesia were consented to participate in this IRB approved protocol. Since the efficacy and sedative effects of haloperidol 1 mg were uncertain, outpatients and those with a history of severe PONV were excluded. The study restricted measurements to early-onset PONV, so efficacy data were obtained until post-anesthesia care unit (PACU) discharge or until rescue treatment was administered.

Result            Two hundred forty-four subjects were evaluated. There was no statistical difference between haloperidol and ondansetron in complete response, nausea, retching, emesis, or subjects rescued. Those in the haloperidol group received rescue almost 30 minutes later than those getting ondansetron. The incidence of prolonged QTc was 5.8% to 7.3% preoperatively, and the postoperative incidence increased approximately fourfold in both groups. There was no difference between groups in the average QTc change, and no serious dysrhythmias occurred.

Conclusion            This study reported higher efficacy of both drugs for early PONV, probably because patients at highest risk were excluded. Sedation was minimal, and no extrapyramidal effects were detected despite intensive search. As expected, the QTc effect of haloperidol is impossible to distinguish from the effects of anesthesia, hypothermia, and other perioperative factors. Measurements included only early-onset PONV, and no attempt was made to determine the duration of effect. Haloperidol 1 mg and ondansetron 4 mg had similar safety and efficacy for PONV prophylaxis in a mixed surgical population.

Comment

This study hypothesized that 1 mg of haloperidol and 4 mg of ondansetron would not be significantly different. They found minimal sedation side effects, no extra-pyramidal effects and early success in the prevention of PONV. It is not clear in the study when patients were dosed with haloperidol or ondansetron. The dosing of antiemetic prophylaxis has been key in other studies.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Krobbuaban B, Pitakpol S, Diregpoke S


Ondansetron vs. metoclopramide for the prevention of nausea and vomiting after gynecologic surgery

J Med Assoc Thai 2008;91:669-674

Krobbuaban B, Pitakpol S, Diregpoke S

Abstract

Purpose            The present study evaluated the efficacy and safety of administering 4 mg of ondansetron for prophylaxis of postoperative nausea and vomiting (PONV) in patients undergoing major gynecological surgery under general anesthesia.

Background            The incidence of PONV ranges from 20 to 30% during the first 24 hours after surgery. PONV occurs frequently after gynecologic surgery, with an incidence as high as 88%. PONV is now one of the greatest concerns that patients express regarding anesthesia and surgery. When surveyed preoperatively, 72% of patients stated that prevention of PONV should be given highest priority. Moreover, persistent nausea and vomiting may result in electrolyte imbalance. Because antiemetics are not always effective, a routine prophylactic antiemetic cannot be recommended.

Methodology            The authors studied 383 ASA I-II females scheduled to undergo elective major gynecologic surgery under general anesthesia. Patients were randomly allocated to receive one of two intravenous treatment regimens; 4 mg ondansetron or 10 mg metoclopramide. In this study, the anesthesia provider, patients, and PACU staff were all blinded to the identity of the prophylactic treatment. Two symptoms were assessed separately: nausea was recorded as none, mild, or severe, and vomiting was recorded as either present or absent. The choice of rescue antiemetic was dimenhydrinate (Dramamine) 50 mg.

Result            Three hundred and eighty two patients were enrolled in the study. The incidence of PONV during the period 0-1 h after anesthesia was 14% with ondansetron and 14% with metoclopramide. The corresponding incidences during the period 1-6 h after anesthesia were 20% and 32%. Corresponding incidences during the period 6-24 h after anesthesia were 39% and 47%. The overall incidence of PONV during the whole 24 h period was 47% in the ondansetron group, compared with 60% in the metoclopramide group.

Conclusion            Prophylactic administration of 4 mg of intravenous ondansetron given immediately prior to induction of anesthesia reduced the incidence of PONV during the first 24 h postoperatively, with no increase in adverse side effects or delay in PACU discharge, when compared with the intravenous metoclopramide.

Comment

This study confirmed that prophylactic administration of 4 mg intravenous ondansetron given immediately prior to induction of anesthesia reduces the incidence of PONV during the first 24 hours post-operatively. This study tried to address the timing of ondansetron. The ideal study would have included another group that was dosed thirty minutes before the end of the surgical procedure. This study did not address preoperative risk for PONV or type of anesthetic provided.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Mraovic B, Simurina T, Sonicki Z, Skitarelic N, Gan TJ


The dose-response of nitrous oxide in postoperative nausea in patients undergoing gynecologic laparoscopic surgery: a preliminary study

Anesth Analg 2008;107:813-823

Mraovic B, Simurina T, Sonicki Z, Skitarelic N, Gan TJ

 

Abstract

Purpose            The experimental hypothesis was that the incidence of postoperative nausea and vomiting (PONV) would increase as the inspired concentration of nitrous increased from 50% and 70%, when compared with air / oxygen control group in gynecologic laparoscopic surgery under general anesthesia.

Background            In the absence of prophylactic antiemetics, the incidence of PONV may be as high as 40%-77%. The routine administration of antiemetics increases costs and side effects. Reducing baseline risk has been recommended as an effective strategy for reducing PONV. Nitrous oxide has analgesic and sedative properties, but may potentially increase the incidence of PONV. N2O has been demonstrated to increase the incidence of PONV in some studies, but not in others. Most of the studies concerning the influence of nitrous on PONV used 60%-70% inspiratory concentration of nitrous. It is not clear if limiting nitrous to a lower concentration decreases the risk of PONV.

Methodology            After IRB approval, 150 ASA I and II patients undergoing laparoscopic gynecological surgery were enrolled in the study. Patients were randomized to receive air and oxygen FIO2 30%, 50% N2O and oxygen, or 70% N2O and oxygen. The severity of PONV was evaluated using a 100 mm visual analog scale (VAS). Metoclopramide 20 mg IV was used as the rescue antiemetic. This was the standard clinical practice in the hospital.

Result            Of 150 patients, 137 completed the study (FIO2 30% n=46, N2O 50% n=46, and N2O 70% n=45). Thirteen patients were excluded from the analysis. There was an overall difference in the incidence of PONV for 24 h after surgery among the groups (P=0.018). FIO2 30% was significantly different from group 70% N2O, but no difference was noted between the FIO2 30% and 50% N2O groups or the 50% N2O and 70% N2O groups. The incidence of nausea showed a similar significant difference. The severity of nausea was significantly increased with increasing N2O concentrations.

Conclusion            N2O, when administered with oxygen and sevoflurane, increased the incidence of PONV. Preliminary findings indicated that N2O may increase PONV in a dose-response fashion. The FI of 70% N2O significantly increased the incidence of PONV at 24 h, nausea at 24 h, and nausea VAS scores when compared with no N2O. In contrast, FI of 50% N2O did not cause significantly increased PONV, nor nausea at 24 h compared with FIO2 30%.

 

Comment

This study was underpowered but did demonstrate that 70% N2O increased the incidence of PONV compared to air/oxygen. This study agreed with the IMPAC study that indicated that N2O increased PONV. What is unique about this study is that the duration of the surgical procedures was greater than 60 minutes. This could explain the discrepancy with other studies that were shorter than 60 minutes. The conclusion of this study was that 70% N2O increased the incidence of nausea and severity of PONV in the absence of PONV antiemetic. A larger study will have to be completed to show a dose response relationship.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





White PF, O?Hara JF, Roberson CR, Wender RH, Candiotti KA


 

The impact of current antiemetic practices on patient outcomes: a prospective study on high-risk patients

Anesth Analg 2008;107:452-458

White PF, O’Hara JF, Roberson CR, Wender RH, Candiotti KA

 

Abstract

Purpose            This multicenter, prospective, observational study was designed to estimate the effectiveness of common antiemetic therapies for the prevention and treatment of postoperative nausea and vomiting (PONV) through an assessment of practice patterns in patients at risk for PONV.

Background            Many surgical patients undergoing general anesthesia still experience PONV in the postanesthesia care unit (PACU), the hospital, and at home after discharge. Vomiting, nausea, and pain were ranked as three of the primary outcomes that patients found least desirable. Studies suggest that 25%-30% of patients undergoing elective surgery experience PONV at some point during their recovery after surgery, and rates can approach 60%-80% for patients with multiple preexisting risk factors. The most important risk factors include female gender, nonsmoking status, history of PONV or motion sickness, and perioperative use of opioid analgesics.

Current evidence on the treatment effect of prophylactic antiemetics is primarily derived from prospective, randomized, controlled, clinical trials, which typically include or exclude patients with attributes that influence the outcome. Although practice guidelines influence local institutional policies, the controlled clinical trials upon which practice guidelines are based have inherent limitations and, therefore, may not reflect the population-based effectiveness of the recommended antiemetic interventions. Due to the increased focus on quality improvement and pay for performance initiatives in health care, this observational study also provided a unique opportunity to evaluate the impact of compliance with antiemetic prophylaxis guidelines on outcomes related to PONV.

Methodology            After IRB approval at 11 sites, 392 patients were screened for study eligibility and 376 patients were consented to participate in this study. At least two major risk factors for PONV were required, as well as an anticipated discharge from the facility within 24 hours. A stratified sample of eligible patients undergoing elective abdominal laparoscopic surgery were identified by the investigators. After surgery, the investigators and patients were asked to capture PONV-related outcome data with an interactive voice recorder. Nausea was assessed using a four-point Likert scale. The ability of nausea and/or vomiting to interfere with activities of daily living were measured using a modified Osoba nausea and emesis module.

Result            The primary objective of the study was to estimate the effectiveness of current antiemetic prophylaxis for up to 72 hrs after laparoscopic or plastic surgery in patients at risk for PONV. The secondary objective was to assess the impact of compliance with organization guidelines for the management of PONV on emetic outcomes. Three hundred and seventy-six patients had complete information available for evaluation. Although all 376 patients were considered to be at risk for developing PONV symptoms, only 92% of the patients received prophylactic antiemetic. A single antiemetic was used 34% of the time, two antiemetics were used also 34% of the time, and finally 23% of the patients received three or more drugs for prophylaxis. Based on cumulative data obtained over the 3-day study period, 61% and 52% of patients were given prophylaxis and rescue medication in accordance with the ASA and ASPAN clinical practice guidelines for management of PONV.

Conclusion            High-risk patients frequently receive antiemetic drugs for the prevention and treatment of PONV. However, the choice of antiemetic drugs, the appropriate number of antiemetics to administer, and even the timing of their administration are subject to variations in practice patterns within a single institution and across centers as demonstrated in this and other recently reported observational studies. The design of this multi-center observational study allowed us to assess the clinical effectiveness of prophylactic and rescue antiemetics in high-risk patients by determining the occurrence of emetic symptoms. PONV remains an all-to-common clinical problem. Although many practitioners may believe that emesis is adequately controlled with current prophylactic techniques, 42% of these high-risk patients received either no or only one anti-emetic.

 

Comment

This study showed a 92% adherence rate to PONV guidelines but only a 42% adherence to multi-modal treatment for high risk patients and a 37% incidence of PONV in the first 24 hours post-operative. As expected in this study, the best protected patients were the ones who received three or more antiemetic drugs. The key in clinical practice is to link multi-modal therapy to high-risk patients. To accomplish this you do an effective preoperative evaluation to identify that high-risk patient. Once that has been accomplished, practice guidelines can then be utilized to effectively prevent PONV. In an era of increased importance of cost-effectiveness, we must focus prophylactic therapy on patients who are at increased risk of PONV.

 

Joseph F. Burkard, DNSc, CRNA

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Chu CC, Shieh JP, Tzeng JI, Chen JY, Lee Y, Ho ST, Wang JJ


 

 

The prophylactic effect of haloperidol plus dexamethasone on postoperative nausea and vomiting in patients undergoing laparoscopically assisted vaginal hysterectomy

Anesth Analg 2008;106:1402-1406

Chu CC, Shieh JP, Tzeng JI, Chen JY, Lee Y, Ho ST, Wang JJ

 

 

Abstract

Purpose            The aim of this study was to evaluate the prophylactic effect of haloperidol plus dexamethasone on postoperative nausea and vomiting (PONV). The hypothesis was that prophylactic haloperidol plus dexamethasone would provide a greater reduction in the incidence of PONV than either drug used alone, placebo, or droperidol.

Background            Droperidol, a major tranquilizer with dopamine 2 (D2) receptor antagonist effect, has often been tested in combination with other antiemetics for treating PONV. The FDA “black-box warning” announcement led to a marked reduction in the use of droperidol for PONV prophylaxis and has led to a search for a substitute. Haloperidol, was considered a possible substitute for droperidol. Haloperidol has been used in palliative care as an antiemetic for nausea and vomiting. Recently, haloperidol was further found to have an effect on PONV.

Methodology            This was a randomized, double-blind, placebo, and positive-control study in 400 patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH). Patients were randomly assigned to one of five groups: (1) S, saline; (2) D, droperidol 1.25 mg; (3) H, haloperidol 2 mg; (4) Dx, dexamethasone 5 mg; (5) H + Dx, haloperidol 2 mg plus dexamethasone 5 mg. Anesthesia was standardized for all patients. After surgery, all patients were observed for 24 h. Pain and sedation scales were used for 24 h.

Result            Three hundred and seventy two patients completed the study. When compared with the S group, the D, H, Dx and H + Dx groups had a lower incidence of PONV at 2-24 h and 0-24 h. The H + Dx group had the lowest incidence of PONV and the highest incidence of complete response. During anesthesia, the QTc interval after the administration of the test medication in all groups was not different from their preinjection values. Three patients (two in the droperidol and one in the haloperidol group) reported motor restlessness.

Conclusion            A combination of haloperidol 2 mg plus dexamethasone 5 mg produced a greater reduction in the incidence of PONV than did either drug used alone, without increasing the following perioperative risks: QT prolongation, intensity of postoperative pain, level of sedation, or occurrence of motor restlessness. This study demonstrated that haloperidol alone offers no significant advantages over droperidol or dexamethasone for routine antiemetic prophylaxis. The use of a combination (i.e., haloperidol + dexamethasone) was better than any single drug alone, without increasing adverse perioperative outcomes.

 

Comment

The study confirmed that combination therapy with haloperidol 2 mg plus another anti-emetic dexamethasone 5 mg produced a greater reduction in the incidence of PONV. This study adds to the literature in support of multi-modal therapy for high risk patients and also adds another drug from the D2 family that can be used as a rescue medication.

 

Joseph F. Burkard, DNSc, CRNA

 

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Habib AS, Gan TJ


 

 

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

J Clin Anesth 2008;20:35-39

Habib AS, Gan TJ

 

 

Abstract

Purpose            The purpose of this study was to survey the members of the Society of Ambulatory Anesthesia (SAMBA) about their practice in the management of postoperative nausea and vomiting (PONV) before and after the FDA black box warning on droperidol usage.

Background            Droperidol is one of the most effective and cost-efficient antiemetics for PONV. In December 2001, the FDA issued a “black box” warning on droperidol because of concerns of serious cardiac arrhythmias secondary to QT prolongation. The warning was based on 273 cases reported over a 4-year period, of which 127 cases resulted in serious adverse outcomes. Adverse cardiac events occurred in a total of 10 cases when the dose of droperidol used was 0.625 to 1.25 mg.

Methodology            After IRB approval, a survey was posted on the SAMBA web site from June 2005, until October 2005. The survey was designed to elicit information about the management of PONV and, in particular, the use of droperidol, before and after the FDA black box warning. The 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. Logistic regression analysis was used to assess the association between choice of antiemetics made by the responder and responder’s type of practice, as well as years of experience.

Result            A total of 295 providers completed the survey (25% of SAMBA members). Some 215 of 292 respondents (74%) indicated that droperidol was available in the formulary in their hospital. However, 44 of 292 (15%) indicated that droperidol was not available in their hospital. For prophylaxis, the choice of other antiemetics and combinations not involving droperidol as a first-line agent for PONV prophylaxis was significantly less after the black box warning compared with before the warning. For the treatment of PONV, the choice of droperidol as a first-line agent for the treatment of established PONV was significantly less after the warning, whereas the choice of 5-HT3 receptor antagonists, dexamethasone, and promethazine was significantly higher. For the management of PONV, 42% of providers stated that they no longer used droperidol. Finally, 92% of 284 respondents did not believe that the black box warning on droperidol was justified and 60% indicated that they would use droperidol as their first-line agent for PONV prophylaxis if this warning were to be removed.

Conclusion            The choice of droperidol as a first-line agent for the management of PONV significantly declined after the FDA black box warning. Despite that, 92% of respondents did not believe that the black box warning was justified. There was a 10-fold decrease in droperidol use in the United States after the FDA black box warning. The survey also showed that, at the same time, choice of the more expensive 5-HT3 receptor antagonists significantly increased.

 

Comment

This study surveyed members of an anesthesia community on the use of droperidol after the FDA black box warning. The survey reflected a significant decrease in droperidol use among this community of anesthesia providers after the FDA black box warning of 2001. Ninety-two percent of respondents did not believe that the warning was justified.

 

Joseph F. Burkard, DNSc, CRNA

 

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009




Quality Improvement

Kapoor R, Hola ET, Adamson RT, Mathis AS


 

 

Comparison of two instruments for assessing risk of postoperative nausea and vomiting

Am J Health Syst Pharm 2008;65:448-453

Kapoor R, Hola ET, Adamson RT, Mathis AS

 

 

Abstract

Purpose            The purpose of this study was to evaluate the use of two different PONV risk-assessment tools and compliance with antiemetic prophylactic recommendations and to compare the subsequent rate of PONV in patients based on the assessment form used.

Background            Postoperative nausea and vomiting (PONV) is a major concern for patients undergoing surgery and for their health care team. PONV is a significant concern because it exacerbates patient discomfort; increases the risk of suture dehiscence, esophageal rupture, aspiration, and subcutaneous emphysema; and delays discharge from the postanesthesia care unit (PACU). In the United States, the annual cost of PONV is estimated to be several hundred million dollars. The frequency of PONV continues to range from 25% to 50% despite new advances in treatment care. Appropriate PONV prophylaxis should reduce the need for postoperative treatment and reduce the length of stay in the PACU. Preliminary analysis of surgical records revealed that the mandatory preoperative PONV assessment was only completed 59% of the time and this has led to the development of a new assessment protocol using evidence-based recommendations.

Methodology            Protocol one assessed PONV risk using 16 weighted risk factors and was used for both adult and pediatric patients. The form categorized patients’ risk of developing PONV as low, moderate, high, or very high. Protocol two included a form for adults and a pediatric specific form. The form for adults utilized Apfel et al.’s simplified risk score, calculated using a validated, nonweighted, 4-point scale. Adults’ risk of PONV was characterized as low, moderate, or high. The form for pediatric patients utilized a 7-point nonweighted scale and categorized patients risk as moderate or high.

Result            The risk-stratification form was completed for 64% and 38% of patients in the protocol 2 and protocol 1 groups, respectively (P=0.016). The frequency of PONV did not differ between groups, and treatment strategies were similar in both groups. Of the patients who developed PONV, 29% of the patients assessed by protocol 1 were considered high risk and 72% as moderate risk; protocol 2 characterized 75% of patients with PONV as high risk and 25% as moderate risk. This difference was not significant.

Conclusion            The effect of PONV on patient morbidity and health care costs led to the evaluation of practice patterns and outcomes related to PONV prevention. These results support the findings that simplified risk scores were easy to use. Implementation of a validated and simplified PONV risk-assessment tool appeared to improve form completion rates and appropriate risk assessment.

 

Comment

This article by Kapoor et al. looked at PONV assessment, compliance with two different tools, and a comparison with the traditional PONV tools established by Apfel et al. There was no significant difference between the Kapoor tool which assessed 16 risk factors and the Apfel tool which assessed 4 risk factors. In fact, the tool with fewer risk factors was utilized more often and may indicate that fewer patients will receive the appropriate prophylaxis if they use the more complex tool. The shorter Apfel tool appears to be a better clinical tool for the busy anesthesia provider.

 

Joseph F. Burkard, DNSc, CRNA

 

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009





Kooij FO, Klok T, Hollmann MW, Kal JE


Decision support increases guideline adherence for prescribing postoperative nausea and vomiting prophysaxis

Anesth Analg 2008;106:893-898

Kooij FO, Klok T, Hollmann MW, Kal JE

 

Abstract

Purpose            In this study the researchers hypothesized that a decision support (DS) system could significantly improve guideline adherence for the prescription of PONV prophylaxis in a preoperative screening clinic.

Background            In recent years, several studies have identified risk factors and developed risk models to predict which patients are at risk for postoperative nausea and vomiting (PONV). The effectiveness of clinical guidelines may be severely limited by poor adherence. Reasons for poor guideline adherence might include lack of attention by the attending provider responsible for the preoperative assessment of the patient. A decision support system that reminds the provider of the action suggested by the guidelines at the time and place of care may be more effective.

Methodology            The simplified risk score based on the risk stratification developed by Apfel and co-workers was utilized for the study. This instrument scores four risk factors. According to this model, 56%-61% of patients are expected to experience PONV in the presence of a least three positive risk factors. The DS system consisted of an automated reminder based on the Apfel et al. simplified risk score. The study was divided into three study periods each lasting for 8 or 16 weeks. The primary end-point of the study was guideline adherence.

Result            This study included 5,090 consecutive patients; 1,340 patients in the control period and 2,715 and 1,035 patients in the DS and post-DS periods, respectively. The percentage of patients with three or four positive risk factors increased from 28% in the control period to 32% during DS and remained at 31% in the post-DS period. The percentage of patients who were prescribed prophylaxis increased from 38% in the control period to 73% in the DS period. The increase in guideline adherence was immediate and complete after introduction of the automated reminders. After discontinuation, guideline adherence returned to control levels immediately.

Conclusion            An electronic DS system significantly improved guideline adherence for the prescription of PONV prophylaxis in the preoperative screening clinic. The present study is in agreement with earlier reports showing that DS at the time and place of care may constitute an effective option for helping physicians adhere to certain guidelines. The increasing use of electronic file systems for medical information greatly increases opportunities to use DS for quality improvement in clinical care.

 

Comment

This study by Kooij et al. addressed the issue of practice guideline adherence. Clinical guidelines have proven to be very effective in decreasing incidence of PONV along with having a cost effective impact in clinical practice. This study highlighted the use of an electronic decision support (DS) system that notified the clinical practitioner of the patient’s risk factor assessment and gave the practitioner recommendations for care. This study demonstrated that the use of an electronic DS system identified patients at high risk for PONV and enabled anesthesia providers to start prophylaxis earlier than usual. This study also identified key areas for non-adherence and suggests that anesthesia QA / PI teams look for reasons for non-adherence.

 

Joseph F. Burkard, DNSc, CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 9, September 30, 2009