Aprepitant prophylaxis effectively reduces preventing postoperative nausea and vomiting in patients receiving opioid based intravenous patient-controlled analgesia

BACKGROUND: Aprepitant is effective in prevention of chemotherapy-induced nausea and vomiting, when administrated with other antiemetics. We compared the effectiveness of aprepitant to ondansetron for prevention of post-operative nausea and vomiting (PONV) in patients who received a patient-controlled analgesia (PCA) containing opioids. METHODS: 198 patients were randomized into two groups. The treatment group was received an aprepitant, 80 mg, and the control group received a placebo. General anesthesia with inhalational anesthetics–N2O was performed, and PCA was supplied, which contained opioids-NSAIDs-ondansetron. The primary end-point was the incidence of PONV for postoperative 48 hours, and the secondary end-point was the changes in the relationship between PONV incidence and risk factors. RESULTS: PONV incidence in the treatment group was lower than in the control group (18.6% [95% CI: 10.8–26.3], 33.3% [95% CI: 23.6–43.1], respectively, P = 0.021). Relative risk of PONV in the control group was 1.80 (95% CI: 1.08–3.00, P = 0.010). PONV scores peaked at around postoperative 6 hours, then gradually decreased in the control group but not in the treatment group, which showed lower values than the control group (P = 0.001), and no changing patterns were observed (P < 0.001). Risk factors analyzed were sex, surgery type, history of motion sickness or PONV, and smoking habits. Their effects of all risk factors except sex were abolished in the treatment group. CONCLUSIONS: Prophylactic aprepitant with ondansetron was more effective than ondansetron-only regimen in preventing PONV after volatile anesthesia with opioid-containing PCA. Aprepitant abolished the effects of most of risk factors, so it could be efficacious in a high-risk PONV group.

The Cardiovascular Effects of Thoracic Bolus Epidural Injection of Lidocaine, Morphine and Fentanyl during Sevoflurane General Anesthesia / 대한마취과학회지

BACKGROUND: Sevoflurane is an inhalational anesthetic that produces rapid induction, emergence and little cardiovascular depression. Elevated sympathetic activity during surgery produces undesirable effects on the cardiovascular system, such as hypertension, tachycardia or arrhythmias. So combined general and epidural anesthesia have been used recently for the operation, especially the abdominal surgery. This study was performed to evaluate the cardiovascular effects of thoracic epidural anesthesia during sevoflurane general anesthesia. METHODS: Forty patients of ASA class 1-2 undergoing elective subtotal gastrectomy were divided into 5 groups. Thoracic epidural bolus injection was administered via an epidural catheter during sevoflurane general anesthesia in a double-blind random manner: Group 1; normal saline (N/S) 10 ml (placebo), Group 2; morphine 0.1 mg/kg mixed with N/S in 10 ml, Group 3; fentanyl 1 mcg/kg mixed with N/S in 10 ml, Group 4; 1% lidocaine 10 ml, and Group 5; 1% lidocaine 10 ml mixed with morphine 0.1 mg/kg and fentanyl 1 mcg/kg. Systolic and diastolic blood pressures, pulse rates, peripheral oxygen saturation levels (SpO2) and end-tidal carbon dioxide partial pressures (ETCO2) were measured every 5 minutes. RESULTS: Systolic and diastolic blood pressures were significantly reduced from 10 minutes after epidural bolus injection in groups 4 and 5, but these decreases in blood pressure were not severe enough to require treatment in either group. Pulse rates were significantly decreased from 10 minutes after injection in groups 3, 4, and 5, but these decreases in pulse rate were not so severe enough to require treatment in 3 groups. SpO2 and ETCO2 were stable, and arrhythmia was not observed. CONCLUSIONS: The thoracic epidural injection of 1% lidocaine mixed with morphine 0.1 mg/kg and fentanyl 1 mcg/kg can be safely used during sevoflurane anesthesia without severe cardiovascular complications during upper abdominal surgery in ASA 1-2 patients.