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Antiemetic Prophylaxis for Post-Operative Nausea and Vomiting

Luciana Frighetto, B.Sc. (Pharm), Carlo Marra, Pharm.D., Peter Loewen, Pharm.D.
February 1999 Drug & Therapeutics Newsletter
(C) 1999, CSU-Pharmaceutical Sceinces
Vancouver Hospital & Health Sciences Centre

 

Post-operative nausea and vomiting (PONV) are commonly reported adverse events after surgery and can contribute to the development of aspiration, wound dehiscence, and increased bleeding.1,2 Prophylaxis with antiemetics has been shown to reduce the incidence of PONV as well as improve patient satisfaction, decrease recovery and discharge times, and reduce hospital readmissions.3-10 There are many studies supporting the use of prophylactic antiemetics to reduce the incidence of PONV in patients at high risk for PONV.3,7-9,11-18 Several different antiemetics have been studied for the prevention of PONV including metoclopramide, perphenazine, droperidol, ondansetron and dolasetron.3-5,7,11,19-21 These agents have all been associated with varying degrees of success.

Currently, there are no standard guidelines for the prophylactic use of antiemetics in the management of PONV in our institution. CSU Pharmaceutical Sciences, in collaboration with the Department of Anesthesia, have developed standard protocols for the prevention and immediate post-operative treatment of patients with nausea and vomiting for both the ambulatory and inpatient settings. For the prevention of PONV, preprinted orders for anesthesia and Surgical Daycare Centre (SDCC) have been created for patients considered at high risk for PONV and include various antiemetic agents such as droperidol, dolasetron, and metoclopramide. Dolasetron, a Limited Access Drug at VHHSC, has now been approved by the Drugs and Therapeutics Committee and Medical Academic and Advisory Committee for use in the prophylaxis of PONV. This agent can be prescribed using a preprinted anesthesia or SDCC pre-op order form. Preprinted orders have also been created for the treatment of PONV in the post anaesthesia recovery and surgical daycare settings. These orders reflect a standard approach for the treatment of PONV in these settings.

References

  1. Burns K. Postoperative care and review of complications. Ambulatory Anesthesia Care. Woo SW (ed.). Boston. Little, Brown & Co. 1982:27-34.

  2. Haigh CG et al. Nausea and vomiting after gynaecological surgery: A meta-analysis of factors affecting their incidence. Br J Anaesth 1993;71:517-22.

  3. Malins AF et al. Nausea and vomiting after gynaecological laparoscopy: comparison of premedication with oral ondansetron, metoclopramide, and placebo. Br J Anaesth 1994;72:231-233.

  4. Graczyk SG et al. Intravenous dolasetron for the prevention of postoperative nausea and vomiting after outpatient laparoscopic surgery. Anesth Analg 1997;84:325-30.

  5. Helmers JH et al. A single IV dose of ondansetron 8 mg prior to induction of anaesthesia reduces postoperative nausea and vomiting in gynaecological patients. Can J Anaesth 1993;40:1155-61.

  6. Orkin FK. What do patients want? - preferences for immediate postoperative recovery (abstract). Anesth Analg 1992;74:S225.

  7. Tang J et al. A comparison of costs and efficacy of ondansetron and droperidol as prophylactic antiemetic therapy for elective outpatient gynecologic procedures. Anesth Analg 1996;83:304-13.

  8. Gold BS et al. Unanticipated admission to the hospital following ambulatory surgery. JAMA 1989;262:3008-10.

  9. Fancourt-Smith PF et al..Hospital admissions from the surgical daycare centre of Vancouver General Hospital 1977-1987. Can J Anaesth 1990;37:699-704.

  10. Fortier J et al. Unanticipated admission after ambulatory surgery - a prospective study. Can J Anaesth 1998;45:612-19.

  11. Paxton LD et al. Prevention of nausea and vomiting after day case gynaecological laparoscopy: A comparison of ondansetron, droperidol, metoclopramide, and placebo. Anaesth 1995;50:403-6.

  12. Wrench IJ et al. The prevention of postoperative nausea and vomiting using a combination of ondansetron and droperidol. Anaesth 1996;51:776-8.

  13. Khalil SN et al. Ondansetron prevents postoperative nausea and vomiting in women outpatients. Anesth Analg 1994;79:845-51.

  14. Pearman MH. Single dose intravenous ondansetron in the prevention of postoperative nausea and vomiting. Anaesthesia 1994;49:11-15.

  15. Lopez-Olaondo L et al. Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting. Br J Anaesth 1996;76:835-40.

  16. Desilva PHDP et al. The efficacy of prophylactic ondansetron, droperidol, perphenazine, and metoclopramide in the prevention of nausea and vomiting after major gynecologic surgery. Anesth Analg 1995;81:139-43.

  17. Gan TJ et al. Double-blind comparison of ondansetron, droperidol and saline in the prevention of postoperative nausea and vomiting. Bri J Anesth 1994;72:544-7.

  18. Naguib M et al. Prophylactic antiemetic therapy with ondansetron, tropisetron, granisetron and metoclopramide in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind comparison with placebo. Can J Anesth 1996;43:226-31.

  19. Madej TH, Simpson KH. Comparison of the use of domperidone, droperidol, and metoclopramide in the prevention of nausea and vomiting following major gynaecological surgery. Br J Anaesth 1986;58:884-87.

  20. Sniadach MS et al. A comparison of the prophylactic antiemetic effect of ondansetron and droperidol on patients undergoing gynecologic laparoscopy. Anesth Analg 1997;85:797-800.

  21. Diemunsch P et al. Intravenous dolasetron mesilate ameliorates postoperative nausea and vomiting. Can J Anaesth 1997;44:173-81.