Treating "rebound" emesis following outpatient gynecologic laparoscopy: the efficacy of a two-dose regimen of droperidol and ondansetron.

STUDY OBJECTIVE: To evaluate the efficacy of a two-dose combination of droperidol and ondansetron as compared with single-dose droperidol alone, single-dose combined droperidol and ondansetron, and two-dose droperidol alone, for management of postoperative nausea and vomiting (PONV) among gynecologic laparoscopy outpatients. DESIGN: Randomized, double-blind comparison trial. SETTING: Tertiary outpatient gynecologic unit. PATIENTS: A total of 120 female patients scheduled for gynecologic laparoscopy were enrolled. Patients who had experienced nausea or vomiting, or who had taken drugs with antiemetic action in the 24-hour period prior to the study, as well as breast-feeding mothers, were excluded from participation. INTERVENTIONS: Patients were assigned to four treatment groups: i) single dose of droperidol 1.25 mg, ii) two doses of droperidol 1.25 mg, iii) single dose of droperidol 1.25 mg and ondansetron 4 mg in combination, and iv) two doses of droperidol 1.25 mg and ondansetron 4 mg in combination. The first dose of antiemetic was administered prior to induction and the second dose was given by infusion 4 hours later, prior to discharge. MEASUREMENTS AND MAIN RESULTS: A visual analogue scale (VAS, 10 cm) was used to obtain patients' experience of nausea, vomiting, and pain at 0.5, 1.5, 2.5, and 3.5 hours after arrival at the postanesthetic care unit (PACU). Following discharge, approximately 24 hours after arrival at the PACU, the same measures were obtained by a follow-up interview using a verbal 10-point scale. No significant differences in incidence of PONV were noted among the four treatment groups (p = 0.419). However, both single- and two-dose droperidol and ondansetron combination therapy demonstrated attenuation of PONV severity in the 3.5- to 24-hour postinduction period (p < 0.05). CONCLUSIONS: The findings of this study suggest that prophylactic two-dose combined ondansetron and droperidol offers no added benefit over single-dose therapy for routine use in the gynecologic outpatient population.     

Antiemetic efficacy of prophylactic dimenhydrinate (Dramamine) vs ondansetron (Zofran)

BACKGROUND: The prophylactic administration of dimenhydrinate (Dramamine) is as effective as the use of ondansetron (Zofran) in preventing postoperative nausea and vomiting (PONV) in patients undergoing elective laparoscopic cholecystectomy. A prospective double-blind randomized study was performed in a tertiary care referral center. METHODS: For this study, 128 American Society of Anesthesiology (ASA) physical statuses I, II, and III patients were randomly assigned to receive either ondansetron 4 mg intravenously (IV) at $17 per dose (group 1) or dimenhydrinate 50 mg IV at $2.50 per dose (group 2) before induction of anesthesia. The end points evaluated were frequency of PONV, need for rescue antiemetics, need for overnight hospitalization secondary to persistent nausea and vomiting, and frequency PONV 24 h after discharge. RESULTS: Chi-square tests and student's t-test were used to determine the significance of differences among groups. Of the 128 patients enrolled in this study, 20 were excluded: 15 patients received an additional antiemetic preoperative; 4 were converted to open cholecystectomies; and 1 procedure was aborted due to carcinomatosis. Of the 108 remaining participants, 50 received ondansetron (group 1) and 58 received dimenhydrinate (group 2). Both groups were well matched for demographics including gender, ASA class, and history of motion sickness. The need for rescue antiemetics occurred in 34% of group 1 and 29% of Group 2 (p = 0.376), postoperative vomiting in 6% of group 1 and 12% of group 2 (p = 0.228), and postoperative nausea in 42% of group 1 and 34% of group 2 (p = 0.422). One group 1 patient and two group 2 patients required overnight hospitalization for persistent nausea, a difference that was not significant. Rates of PONV 24 h after discharge were similar between groups 1 and 2 (10% vs 14%, p = 0.397 and 2% vs 5%, p = 0.375, respectively). CONCLUSIONS: Prophylactic administration of dimenhydrinate is as effective as the use of ondansetron in preventing PONV in patients undergoing elective laparoscopic cholecystectomy. Dimenhydrinate is the preferred drug because it is less expensive. With more than 500, 000 laparoscopic cholecystectomies performed in the United States each year, the potential drug cost savings from the prophylactic administration of dimenhydrinate instead of ondansetron exceed $7.25 million per year.     

Comparison of ondansetron, dimenhydrinate versus placebo as PONV prophylaxis for outpatient gynecological laparoscopy

This is a study comparing ondansetron, dimenhydrinate versus placebo as PONV prophylaxis for outpatient gynecologic laparascopy. Postoperative nausea and vomiting (PONV) is very common following ambulatory gynecological laparoscopy. Prophylactic antiemetic therapy if safe, effective and affordable may reduce the incidence of PONV, expedite hospital discharge and improve patient satisfaction. After institutional review board approval, informed written consent was obtained form 87 ASA I–II women undergoing ambulatory gynecological laparoscopy. In a random and double blind fashion the women were divided into three groups receiving either ondansetron 8 mg, dimenhydrinate 50 mg or placebo. A standard anesthetic technique with propofol, fentanyl, mivacurium, nitrous oxide and isoflurane was used. Measurements of nausea, emesis, pain, drowsiness, and satisfaction and recovery milestones were recorded. Psychomotor recovery was evaluated using p deletion and digit symbol substitution (DSS) test. There was no difference in the groups with respect to demographic data. Dimenhydrinate prolonged immediate recovery and impaired psychomotor recovery, but there was no difference in postanesthesia care unit (PACU) or hospital discharge. The incidence of PONV was minimal. The visual analogue score (VAS) for nausea was only 1 on a scale from 0–10 cm in all groups. Only one patient in the placebo group experienced PACU emesis. The incidence and severity of PONV was so low, even in the placebo group that the use of prophylactic antiemetic therapy cannot be justified.     

Additive anti-emetic efficacy of prophylactic ondansetron with droperidol in out-patient gynecological laparoscopy

PURPOSE: To determine the efficacy of ondansetron and droperidol, alone and in combination, administered for prophylaxis of postoperative nausea and vomiting (PONV) in women undergoing general anesthesia for outpatient gynecological laparoscopy. METHODS: Following Institutional Ethics Board approval and patient consent, 160 female out- patients scheduled for laparoscopy were randomly allotted in a double-blind fashion to receive: i) saline (placebo), ii) 4 mg ondansetron, iii) 1.25 mg droperidol, or iv) 4 mg ondansetron and 1.25 mg droperidol combination intravenously on induction. Following a standardized general anesthesia, patients were interviewed and assessed for PONV at various times. RESULTS: During the first 24 hr after surgery, the incidence of PONV in the placebo group was 71%. This was reduced to 61% with droperidol alone (P = 0.334), to 46% with ondansetron alone (P = 0.027), and to 23% with the combination group (P<0.001). A statistically significant difference was observed between combination and droperidol (P<0.001) and between combination and ondansetron (P = 0.036). There were fewer requests for rescue medication from the combination group (7.7%) than from the ondansetron and placebo groups. CONCLUSION: The results of this study suggest that the combination of 4 mg ondansetron and 1.25 mg droperidol is more efficacious as a prophylactic anti-emetic than either agent alone during the 24 hr post-surgery. This additive effect may be due to the different mechanisms of action of ondansetron and droperidol.     

The efficacy of ginger root in the prevention of postoperative nausea and vomiting after outpatient gynaecological laparoscopy

To determine the anti-emetic effect of ginger as compared to droperidol, 120 patients scheduled to have gynaecological diagnostic laparoscopy as day cases were randomly allocated into placebo, droperidol, ginger and ginger plus droperidol groups to receive either 2 g of ginger or 1.25 mg of droperidol or both. There were no significant differences in the incidences of postoperative nausea which were 32%, 20%, 22% and 33%, and vomiting which were 35%, 15%, 25% and 25% in the four groups, respectively. We conclude that ginger powder, in the dose of 2 g, droperidol 1.25 mg or both are ineffective in reducing the incidence of postoperative nausea and vomiting after day case gynaecological laparoscopy.     

Antiemetic prophylaxis in cardiac surgery: comparison of metoclopramide and ondansetron

We have compared the effectiveness of ondansetron (115 patients) and metoclopramide (101 patients) for prevention of postoperative nausea and vomiting in patients undergoing cardiac surgery involving cardiopulmonary bypass. In a prospective, randomized, controlled, double-blind study, patients received oral ondansetron 16 mg or oral metoclopramide 10 mg, 1-2 h before surgery. Anaesthesia was not standardized. Assessments of the severity of nausea and occurrence of vomiting were made at intervals after extubation and until discharge from the intensive care, or for a total of 24 h. Compared with the metoclopramide group, the ondansetron group had a higher incidence of nausea (49.6% vs 33.7%; P < 0.05) and vomiting (42.6% vs 24.8%; P < 0.01). There was no difference between groups in the number of patients who accepted postoperative antiemetics (ondansetron 43.4% vs metoclopramide 32.6%) and there was no difference in the incidence of symptoms of moderate or severe nausea.      

Transdermal scopolamine reduces nausea and vomiting after outpatient laparoscopy

The authors evaluated the effect of transdermal scopolamine on the incidence of postoperative nausea, retching, and vomiting after outpatient laparoscopy in a double-blind, placebo-controlled study. A Band-Aid-like patch containing either scopolamine or placebo was placed behind the ear the night before surgery. Anesthesia was induced with fentanyl (0.5-2 micrograms/kg iv), thiopental (3-5 mg/kg iv), and succinylcholine (1-1.5 mg/kg iv) and maintained with isoflurane (0.2-2%) and nitrous oxide (60%) in oxygen. Scopolamine-treated patients had less nausea, retching, and vomiting compared with placebo-treated patients (P = 0.0029). Severe nausea and/or vomiting was present in 62% of the placebo group but only 37% of those getting the scopolamine patch. Repeated episodes of retching and vomiting were also less frequent in the scopolamine group compared with the placebo group (23% vs. 41%; P = 0.0213) as was the need for additional antiemetic therapy (13% vs. 32%; P = 0.0013). Patients in the scopolamine group were also discharged from the hospital sooner (4 +/- 1.3 vs. 4.5 +/- 1.5 h; P = 0.0487). Side effects were more frequent among those patients treated with the scopolamine patch (91% vs. 45%; P less than 0.05) but were not troublesome. The authors conclude that transdermal scopolamine is a safe and effective antiemetic for outpatients undergoing laparoscopy.     

Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy

Because no completely effective antiemetic exists for the prevention of postoperative nausea and vomiting (PONV), we hypothesize that a multimodal approach to management of PONV may reduce both vomiting and the need for rescue antiemetics in high-risk patients. After IRB approval, women undergoing outpatient laparoscopy were randomized to one of three groups. Group I (n = 60) was managed by using a predefined multimodal clinical care algorithm. Patients undergoing the same surgical procedure who received a standard balanced outpatient anesthetic with ondansetron 4 mg (Group II, n = 42) or placebo (Group III, n = 37) prophylaxis were chosen to establish baseline incidence of nausea and vomiting. None of the Group I patients vomited before discharge, compared with 7% in Group II (P = 0.07) and 22% in Group III (P = 0.0003). However, one patient (2%) in Group I required treatment for symptoms in the postanesthesia care unit, compared with 24% in Group II (P<0.0001) and 41% in Group III (P< 0.0001). Time to discharge-ready was significantly shorter in Group I (128, 118-139 min; mean, 95% confidence interval) versus Group II (162, 145-181 min; P = 0.0015) and Group III (192, 166-222 min; P = 0.0001). Patient satisfaction with control of PONV was not different between Group I and Group II. Return to normal daily activity and overall satisfaction were not different among groups. Multimodal management resulted in a 98% complete response rate and a 0% incidence of vomiting before discharge; however, this improvement did not result in an increased level of patient satisfaction when compared with routine monotherapy prophylaxis. We conclude that both multimodal management and routine monotherapy antiemetic prophylaxis resulted in an increased level of patient satisfaction than symptomatic treatment in this high-risk population.     

Anesthesia for laparoscopy with emphasis on outpatient laparoscopy

Laparoscopy has developed extremely rapidly and is currently applicable to virtually every surgical subspecialty. Most of the experience is with gynecologic laparoscopy, which has been performed for many years. Some of these procedures are simple and brief, with minimal gas insufflation. In these cases, respiratory compromise is limited, and spontaneous ventilation appears acceptable. Such procedures therefore can be performed with the patient under local or regional anesthesia, or using the LMA with general anesthesia, because the risk of aspiration is small. As laparoscopy has developed, more prolonged operations have become possible, but these normally require general anesthesia, controlled ventilation, and tracheal intubation. More sophisticated laparoscopic surgery has reduced postoperative morbidity, shortened hospital stays, and moved many procedures into the outpatient arena. These newer laparoscopic operations present many challenges, especially in the provision of adequate analgesia and the minimization of PONV. Analgesia should be multimodal, using local anesthesia and NSAIDs as first-line therapy. This combination may be sufficient for more minor procedures, and the elimination of opioids helps to reduce PONV. For more extensive operations, opioids also are required, but should not be the mainstay of analgesia. PONV should be treated effectively whenever it occurs, with consideration given to the use of prophylactic antiemetics in especially high-risk groups. Laparoscopic surgery clearly offers significant advantages in many cases. Although this technology can make some procedures technically possible on an outpatient basis, the morbidity following operations such as laparoscopic cholecystectomy is considerable. The ever-greater cost savings from the expansion of outpatient surgery is being achieved at the expense of patient discomfort and dissatisfaction. Extended care (23 h) could be a better option in some circumstances. The future will see further developments in laparoscopic surgery. Microlaparoscopy permits simple procedures to be performed with minimal analgesia and sedation in an office setting. At present, this technology allows only diagnostic and minor operative procedures, the stage at which conventional laparoscopy was in the early 1980s. Further developments in optical fibers could reduce the requirements for general anesthesia for other operations and substantially reduce postoperative morbidity. Until then, laparoscopy continues to present many challenges.     

Comparison of ondansetron with ondansetron and dexamethasone in prevention of PONV in diagnostic laparoscopy

PURPOSE: To compare the efficacy of ondansetron-dexamethasone combination with ondansetron alone for prevention of postoperative nausea and vomiting (PONV). METHODS: This double blind, randomized study was carried out in 51 female patients, aged 20-40 yr, ASA-1 physical status undergoing gynecological diagnostic laparoscopy. Group 1 (n = 26) received 4 mg ondansetron i.v. and group 2 (n = 25) received a combination of 4 mg ondansetron and 8 mg dexamethasone i.v. soon after induction of anesthesia. Postoperatively patients were assessed hourly for four hours and then at 24 hr for nausea, vomiting, pain and post anesthetic discharge score. Vomiting occurring up to two hours was considered early vomiting and from 2-24 hr as delayed vomiting. RESULTS: The postoperative nausea score was lower in patients receiving a combination of ondansetron and dexamethasone (3.76) than ondansetron alone (4.38) at 0 hr (P < 0.01), 2 hr (P < 0.05) and 24 hr (P < 0.01). In group 1, 38.5% of patients had a nausea score of > or = 5 (major nausea) compared with only 12% of patients in group 2 (P < 0.025). The overall incidence of vomiting was greater in group 1 (35%) than in group 2 (8%) (P < 0.05). The combination group showed better control of delayed vomiting compared with the ondansetron group (4% vs 35%) (P < 0.01). CONCLUSION: The combination of ondansetron and dexamethasone provides adequate control of PONV, with delayed PONV being better controlled than early PONV.     

Recovery from sevoflurane and isoflurane anaesthesia after outpatient gynaecological laparoscopy

As the low blood solubility (blood gas partition coefficient 0.69) of sevoflurane suggests a rapid emergence from anaesthesia, recovery from sevoflurane anaesthesia was compared to isoflurane in outpatient gynaecological laparoscopy. Fifty ASA I or II, consenting women participated in a randomised, controlled and single blind study. The patients received, after induction of anaesthesia with propofol, either sevoflurane or isoflurane, both with 67% nitrous oxide in oxygen, for maintenance of anaesthesia. The study drug was administered at 1 MAC (end tidal concentration 0.6% for sevoflurane and 0.5% for isoflurane) but adjusted in 0.5 MAC steps, if clinically indicated. Before the end of surgery the end tidal concentration of the study drug was reduced to 0.5 MAC. Recovery assessments were made from the time anaesthetic gases were discontinued. The subjects were able to open eyes in 2.3 (0.8–7.0) min and 4.1 (2.0–6.8) min, orientate in 2.8 (1.0–6.8) min and 4.7 (2.2–8.3) min and follow orders in 2.6 (0.7–6.8) min and 4.3 (1.2–7.3) min, in the sevoflurane and isoflurane groups, respectively ( P <0.05) [median (range)]. Walking was achieved in 72 (24–464) min and 66 (35—134) min, tolerance of oral fluids in 37 (15–88) min and 35 (45–161) min and voiding in 262 (96–459) min and 217 (52–591) min in the sevoflurane and isoflurane groups, respectively (NS). Overall home readiness was achieved in 281 (96–708) min after sevoflurane group and 242 (96–591) min after isoflurane (NS). Postoperative nausea and vomiting was common in both groups (55% for sevoflurane and 45% for isoflurane) and contributed to three subjects in the sevoflurane group and four in the isoflurane group being admitted to hospital.     

Propofol versus thiamylal-enflurane anesthesia for outpatient laparoscopy.

STUDY OBJECTIVE: To determine whether propofol anesthesia differs from thiamylal-enflurane anesthesia in induction characteristics, intraoperative hemodynamics, postoperative side effects, and postoperative psychomotor function recovery. DESIGN: A randomized, double-blind, two-group study. SETTING: A large university hospital with gynecologic outpatient operations performed in an integrated operating room suite. PATIENTS: Sixty adult women (ASA physical status I or II) undergoing an outpatient gynecologic laparoscopic operation with an anesthesia time of approximately 60 minutes. INTERVENTIONS: No pharmacologic premedication. Pretreatment with intravenous droperidol 0.6 mg and sufentanil 0.2 micrograms/kg before induction of anesthesia. Anesthesia was induced with either thiamylal 4 mg/kg (Group 1) or propofol 2.5 mg/kg (Group 2). Anesthesia was maintained with either nitrous oxide (N2O) and enflurane, 2-0.5% inspired concentrations; (Group 1) or with a continuous infusion of propofol 200-100 micrograms/kg/min and N2O (Group 2). MEASUREMENTS AND MAIN RESULTS: In psychomotor function tests (Trieger dot test and p-deletion test) administered preoperatively and postoperatively, no difference was found between the groups. No difference was found in induction time, although significantly more patients reported pain after the propofol injection, or in intraoperative hemodynamics (mean arterial pressure and heart rate). Immediate recovery time (emergence from anesthesia) and intermediate recovery time (ambulation, oral intake, and discharge time) were significantly shorter after propofol anesthesia. Fewer postoperative side effects, such as nausea and vomiting, were reported after propofol anesthesia. CONCLUSIONS: Induction and maintenance of anesthesia with propofol were comparable to those with thiamylal-enflurane, except patients experienced more pain on injection after propofol. Both immediate and intermediate recovery were more rapid after propofol anesthesia compared with enflurane-based anesthesia.     

Antiemetic effect of ondansetron 0.2 mg mL-1 in PCA morphine solution

BACKGROUND AND OBJECTIVES: To study the effect of 0.2 mg mL-1 of ondansetron added to morphine patient-controlled analgesia solution after a 4 mg loading dose on the incidence and severity of postoperative nausea and vomiting. METHODS: One hundred and sixty patients scheduled for elective surgery, between 18 and 65 yr old, were studied. Patients who smoked, received antiemetics and hormonal therapy, had a history of motion sickness or gastrointestinal disease, a body mass index >35 or menstruation at the time of the study were excluded. Patients were assigned to the ondansetron and control groups by block randomization. At the end of anaesthesia, all patients received 4 mg of ondansetron intravenously and the same patient-controlled analgesia regimen of morphine. The ondansetron group (n = 80) received 0.2 mg of ondansetron per 1 mg of morphine. The nausea score, vomiting score and the requested ondansetron dose were evaluated at 1, 2, 6, 12 and 24 h. Patient-satisfaction for nausea/vomiting was recorded at the end of the study. RESULTS: Patient characteristics and cumulative morphine consumption were similar but ondansetron group had higher pain scores (P = 0.006). The ondansetron group had a lower nausea and vomiting scores, and more patients were free from nausea and vomiting than the control group (41 vs. 26, respectively, P = 0.025). The ondansetron group had fewer cumulative ondansetron doses than the control group and better patient satisfaction than the control group (P < 0.05).CONCLUSION(S): Ondansetron 4 mg plus 0.2 mg mL-1 given with PCA morphine can reduce nausea and vomiting thus improving patient satisfaction.     

Comparison of ondansetron and cyclizine for prevention of nausea and vomiting after day-case gynaecological laparoscopy

We have compared ondansetron 4 mg i.v. and cyclizine 50 mg i.v., in a double-blind, randomized, placebo-controlled study for the prevention of postoperative nausea and vomiting (PONV) for 24 h after day-case gynaecological laparoscopy. Compared with placebo (n = 58), ondansetron (n = 60) and cyclizine (n = 57) reduced significantly the incidence of moderate or severe nausea (30% and 23% vs 52%; P = 0.02 and P = 0.001, respectively) and requirement for escape antiemetic (28% and 16% vs 47%; P = 0.04 and P < 0.001, respectively) before discharge from hospital. There were no significant differences in PONV after discharge. Significantly more patients suffered no PONV before and after discharge after ondansetron and cyclizine compared with placebo (31% and 33% vs 12%; P = 0.02 and P < 0.01, respectively). For diagnostic laparoscopy (n = 74), fewer patients received escape antiemetic after cyclizine than after ondansetron (4% vs 37%; P < 0.01); for laparoscopic sterilization (n = 101), both antiemetics were equally effective. Ondansetron and cyclizine both reduced severe and moderate nausea and the need for antiemetic therapy after day-case gynaecological laparoscopy.      

Fast-tracking after outpatient laparoscopy: reasons for failure after propofol, sevoflurane, and desflurane anesthesia.

IMPLICATIONS: In this study, although 41%-94% of the patients were fast-track eligible after laparoscopic surgery, only 35%-53% of the patients actually bypassed the postanesthesia care unit (PACU) because of anesthetic-related factors and surgical complications. Residual sedation was the most common anesthetic-related cause of failure to bypass thePACU.