Comparison of post-operative nausea and vomiting with intravenous versus inhalational anesthesia in laparotomic abdominal surgery: a randomized clinical trial / Comparação entre anestesia intravenosa e inalatória na náusea e vômito pós-operatórios em laparotomia: estudo clínico randomizado

Abstract Background: Postoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients' characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV. Methods: A single-blinded prospective randomized clinical trial on 105 patients aged 18 − 65 years was carried out. Patients were divided into two groups of Total Intravenous Anesthesia (TIVA) and inhalational anesthesia. The incidence and the severity of PONV were examined at 0, 2, 6, 12 and 24 hours after the surgery. The use of a rescue antiemetic was also evaluated. Results: 50.9% of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p < 0.001). The incidence of vomiting was reported in 11.3% of the inhalational group and 3.8% of the TIVA group (p = 0.15). 24.5% of patients in the inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p = 0.043). Conclusion: The incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug and the severity of nausea in patients were significantly lower in the TIVA group.

Resumo Justificativa: Náusea e Vômito no Pós-Operatório (NVPO) é uma complicação multifatorial com etiologia não esclarecida. A técnica anestésica, as características dos pacientes e o tipo de cirurgia são considerados fatores que afetam a NVPO. O presente estudo foi desenhado para comparar o efeito da anestesia inalatória com anestesia intravenosa na incidência e gravidade de NVPO na cirurgia abdominal. Método: Foi realizado estudo clínico mono-cego prospectivo randomizado com 105 pacientes com idades de 18 − 65 anos. Os pacientes foram divididos em dois grupos, Anestesia Total Intravenosa (TIVA) e anestesia inalatória. A incidência e gravidade de NVPO foram avaliadas em cinco momentos: 0, 2, 6, 12 e 24 horas pós-cirurgia. O uso de antiemético de resgate também foi avaliado. Resultados: NVPO ocorreu em 50,9% dos pacientes no grupo inalatória e 17,3% dos pacientes no grupo TIVA (p< 0,001). A incidência de vômitos relatados foi 11,3% no grupo Inalatória e 3,8% no grupo TIVA (p = 0,15). Necessitaram de medicação antiemética 24,5% dos pacientes no grupo Inalatória e 9,6% dos pacientes no grupo TIVA (p = 0.043). Conclusão: A incidência de náusea e vômito no pós-operatório, a necessidade de administração de droga antiemética de resgate e a gravidade da náusea foram significantemente mais baixas no grupo TIVA.

Comparison of palonosetron-dexamethasone and ondansetron-dexamethasone for prevention of postoperative nausea and vomiting in middle ear surgery: a randomized clinical trial / Comparação entre palonosetrona-dexametasona e ondansetrona-dexametasona na prevenção de náuseas e vômitos no pós-operatório de cirurgia do ouvido médio: estudo clínico randomizado

Abstract Background: Postoperative nausea and vomiting is the second most common complaint in the postoperative period after pain. The incidence of postoperative nausea and vomiting was 60-80% in middle ear surgeries in the absence of antiemetic prophylaxis. Because of this high incidence of postoperative nausea and vomiting, we aimed to assess the effect of palonosetron-dexamethasone and ondansetron-dexamethasone combination for the prevention of postoperative nausea and vomiting in patients of middle ear surgery. Methods: Sixty-four patients, scheduled for middle ear surgery, were randomized into two groups to receive the palonosetron-dexamethasone and ondansetron-dexamethasone combination intravenously before induction of anesthesia. Anesthesia technique was standardized in all patients. Postoperatively, the incidences and severity of nausea and vomiting, the requirement of rescue antiemetic, side effects and patient satisfaction score were recorded. Results: Demographics were similar in the study groups. The incidence difference of nausea was statistically significant between groups O and P at a time interval of 2-6 hours only (p = 0.026). The incidence and severity of vomiting were not statistically significant between groups O and P during the whole study period. The overall incidence of postoperative nausea and vomiting (0-24 hours postoperatively) was 37.5% in group O and 9.4% in group P (p = 0.016). Absolute risk reduction with palonosetron-dexamethasone was 28%, the relative risk reduction was 75%, and the number-needed-to-treat was 4. The patient's satisfaction score was higher in group P than group O (p = 0.016). The frequency of rescue medication was more common in group O than in group P patients (p = 0.026). Conclusion: The combination of palonosetron-dexamethasone is superior to ondansetron-dexamethasone for the prevention of postoperative nausea and vomiting after middle ear surgeries.

Resumo Justificativa: Náusea e vômito no pós-operatório é a segunda queixa pós-operatória mais frequente após a dor. Sem profilaxia antiemética, a incidência de náusea e vômito no pós-operatório foi de 60−80% após cirurgia do ouvido médio. Dada a alta incidência relatada de náusea e vômito no pós-operatório, nosso objetivo foi avaliar o efeito da combinação de palonosetrona-dexametasona e ondansetrona-dexametasona na prevenção de náusea e vômito no pós-operatório em pacientes submetidos a cirurgia do ouvido médio. Método: Sessenta e quatro pacientes programados para cirurgia de ouvido médio foram aleatoriamente divididos em dois grupos. Um recebeu a combinação de palonosetrona-dexametasona (grupo P) e o outro ondansetrona-dexametasona (grupo O) por via intravenosa antes da indução anestésica. A técnica anestésica foi padronizada em todos os pacientes. No pós-operatório, foram registradas incidência e gravidade das náuseas e vômitos, necessidade de antiemético de resgate, efeitos colaterais e índice de satisfação dos pacientes. Resultados: As características demográficas foram semelhantes nos grupos estudados. A diferença na incidência de náusea foi estatisticamente significante entre os grupos O e P apenas no intervalo de tempo entre 2 e 6 horas (p = 0,026). A incidência e gravidade de vômito não foram estatisticamente significantes entre os grupos O e P durante todo o período do estudo. A incidência geral de náusea e vômito no pós-operatório (0−24 horas de pós-operatório) foi de 37,5% no grupo O e de 9,4% no grupo P (p = 0,016). A combinação palonosetrona-dexametasona associou-se com redução do risco absoluto de 28%, redução do risco relativo de 75%, e o número necessário para tratar foi 4. O escore de satisfação do paciente foi maior no grupo P (p = 0,016). A frequência da medicação de resgate foi mais comum no grupo O (p = 0,026). Conclusão: A combinação de palonosetrona-dexametasona é superior à ondansetrona-dexametasona na prevenção da náusea e vômito no pós-operatório após cirurgia de ouvido médio.

Effect of palonosetron, ondansetron and dexamethasone in the prevention of postoperative nausea and vomiting in video cholecystectomy with total venous anesthesia with propofol-remifentanil - randomized clinical trial / Efeito da palonosetrona, ondansetrona e dexametasona na prevenção de náusea e vômito pós-operatório em videocolecistectomia com anestesia venosa total com propofol-remifentanil - ensaio clínico randomizado duplo cego

Abstract Introduction and objectives: The incidence of Postoperative Nausea and Vomiting (PONV) after video cholecystectomy is high. Progress in pharmacological PONV prophylaxis includes a new generation of 5-HT3 antagonists. This study aims to assess the effect of the 5-HT3 antagonist in postanesthetic antiemetic management of patients submitted to laparoscopic cholecystectomy with total intravenous anesthesia. Methods: Sixty individuals who underwent video cholecystectomy were randomized into three groups of 20 individuals according to the treatment administered: 0.125 mg of palonosetron (Group 1); 4 mg of ondansetron associated with 4 mg of dexamethasone (Group 2); 4 mg of dexamethasone (Group 3). General intravenous anesthesia was performed with propofol, remifentanil and rocuronium. The group to which the participant belonged was concealed from the investigator who assessed drug effect. PONV was assessed using the Rhodes Scale at 12 and 24 hours after surgery. Rescue medication was 0.655 to 1.5 mg of droperidol. Results: Group 1 presented a lower incidence of PONV and required less rescue medication in the first postoperative hour. There was no significant difference among the three groups regarding PONV incidence in the first 12 postoperative hours. Groups 1 and 2 were superior to Group 3 regarding the control of PONV from 12 to 24 hours, and after rescue medication from 12 to 24 hours. Group 1 showed significantly superior nausea control in the first 12 postoperative hours. Conclusions: The present study showed evidence that palonosetron is superior to the drugs compared regarding a protracted antiemetic effect and less requirement of rescue drugs, mainly related to its ability to completely inhibit the uncomfortable symptom of nausea.

Resumo Justificativa e objetivo: Náuseas e Vômitos no Pós-Operatório (NVPO) têm alta incidência após videocolecistectomia. Avanços na profilaxia farmacológica de NVPO incluem a nova geração de antagonista 5-HT3. O objetivo deste estudo foi avaliar o efeito do antagonista 5-HT3 no controle antiemético pós-anestésico em videocolecistectomia com anestesia venosa total. Método: Estudo realizado no HC-UFU (Hospital Terciário). Sessenta indivíduos submetidos a videocolecistectomia foram randomizados em três grupos de igual número, sendo administrados 0,125 mg de palonosetrona (Grupo 1); 4 mg de ondasetrona e 4 mg de dexametasona (Grupo 2); ou 4 mg de dexametasona (Grupo 3). A anestesia geral venosa foi realizada com propofol, remifentanil e rocurônio. O avaliador do efeito da droga desconhecia o grupo ao qual o indivíduo pertencia. NVPO foi avaliada aplicando a Escala de Rhodes após 12 e 24 horas do término da cirurgia. Para resgate terapêutico, foi estabelecido 0,655−1,5 mg de droperidol. Resultado: Observou-se no Grupo 1 menor incidência de NVPO e de resgate terapêutico na primeira hora de PO. Não foi observada diferença significativa entre os três grupos com relação a ocorrência de NVPO nas primeiras 12 horas de pós-operatório. Os grupos 1 e 2 foram superiores ao Grupo 3 no que se refere ao controle de NVPO de 12 a 24 horas e após o resgate de 12−24 horas. Observou-se que o controle de náuseas nas primeiras 12 horas de pós-operatório do Grupo 1 foi significantemente superior. Conclusão: O presente estudo mostrou evidências da superioridade da palonosetrona às demais drogas empregadas no que se refere ao efeito antiemético prolongado e menor necessidade de resgate, principalmente na capacidade de inibir completamente o desconfortável sintoma de náusea.

Effect of acupuncture on the prevention of nausea and vomiting after laparoscopic cholecystectomy: a randomized clinical trial / Efeitos da acupuntura para a prevenção de náuseas e vômitos após colecistectomia laparoscópica: estudo clínico randomizado

Abstract Background and objectives: Postoperative nausea and vomiting (PONV) is a common and undesirable complication observed after laparoscopic cholecystectomy (LC). We investigated the effects of auriculoacupuncture (AA) on the prevention of postoperative nausea and vomiting in the immediate postoperative period of uncomplicated laparoscopic cholecystectomy. Methods: Sixty-eight patients were randomly divided into two groups, auriculoacupuncture (n = 35) and control (n = 33), and then they were evaluated prospectively. The needle was placed before anaesthesia induction and remained for 20 minutes. Nausea intensity was evaluated using an analogic visual scale and PONV events were registered immediately after anaesthesia care unit admission and in the second, fourth and sixth hours after the surgery. Results: The auriculoacupuncture group had a significantly smaller incidence of nausea and vomiting than the control group throughout the whole postoperative period (16/35 vs. 27/33, p= 0.03 and 4/35 vs. 15/33, p= 0.005, respectively); the AA group had fewer nausea events 2 h (p= 0.03) and 6 h (p= 0.001) after surgery and fewer vomiting events 2 h (p= 0.01) and 6 h (p= 0.02) after surgery. Conclusions: Auriculoacupuncture can partially prevent postoperative nausea and vomiting when compared to metoclopramide alone after uncomplicated laparoscopic cholecystectomy. Auriculoacupuncture can be recommended as an adjuvant therapy for postoperative nausea and vomiting prevention in selected patients.

Resumo Justificativa e objetivos: Náuseas e vômitos são complicações comuns e indesejáveis no pós-operatório de colecistectomia laparoscópica (CL). Nós investigamos os efeitos da auriculoacupuntura (AA) para a prevenção de náuseas e vômitos no período pós-operatório (NVPO) imediato da CL não complicada. Métodos: 68 pacientes foram aleatoriamente divididos em dois grupos, auriculoacupuntura (n = 35) e controle (n = 33), e foram avaliados prospectivamente. A agulha foi aplicada antes da indução anestésica e permaneceu no lugar por 20 minutos. A intensidade da náusea foi avaliada mediante escala visual analógica e episódios de NVPO foram registrados imediatamente após a admissão na unidade de recuperação anestésica e duas, quatro e seis horas após a cirurgia. Resultados: O grupo AA apresentou significativamente menos episódios de NVPO do que o grupo controle durante todo o período pós-operatório (16/35 vs. 27/33, p = 0,03 e 4/35 vs. 15/33, p = 0,005, respectivamente). O grupo auriculoacupuntura apresentou episódios de náuseas menos intensos às 2 horas (p = 0,03) e 6 horas (p = 0,001) após a cirurgia e menos episódios de vômitos 2 horas (p = 0,01) e 6 horas (p = 0,02) após a cirurgia. Conclusão: A auriculoacupuntura aliviou náuseas e vômitos no pós-operatório em número significante de pacientes, mas não foi capaz de prevenir náuseas e vômitos no pós-operatório em todos os pacientes. Ela pode ser recomendada como terapia adjuvante para prevenção de náuseas e vômitos no pós-operatório no pós-operatório de colecistectomia laparoscópica em pacientes selecionados.

Neurokinin-1 receptor antagonists for postoperative nausea and vomiting: a systematic review and meta-analysis / Antagonistas do receptor da neurocinina-1 no tratamento de náusea e vômito no pós-operatório: Revisão sistemática e meta-análise

Abstract Background: Postoperative Nausea and Vomiting (PONV) is a common complication of general anesthesia. Several kinds of antiemetics, including 5-Hydroxytryptamine3 (5-HT3) receptor antagonists, and Neurokinin-1 (NK-1) receptor antagonists have been used to treat PONV. Objectives: To compare the antiemetic effect of NK-1 receptor antagonists, including fosaprepitant. Data sources: Online databases (PubMed, MEDLINE, Scopus, The Cochrane Library databases) were used. Study eligibility criteria, participants, and interventions: Randomized Controlled Trials (RCTs) performed in patients over 18 years with ASA-PS of I‒III, aimed to assess the efficacy of antiemetics including NK-1 receptor antagonists and 5-HT3 receptor antagonists, and compared the incidence of PONV were included. Study appraisal and synthesis methods: All statistical assessments were conducted by a random effect approach, and odds ratios and 95% Confidence Intervals were calculated. Results: Aprepitant 40 mg and 80 mg significantly reduced the incidence of vomiting 0‒24 hours postoperatively (Odds Ratio [OR = 0.40]; 95% Confidence Interval [95% CI 0.30‒0.54]; p < 0.001, and OR = 0.32; 95% CI 0.19‒0.56; p < 0.001). Fosaprepitant could also reduce the incidence of vomiting significantly both 0‒24 and 0‒48 hours postoperatively (OR = 0.07; 95% CI 0.02‒0.24; p < 0.001 and OR = 0.07; 95% CI 0.02‒0.23; p < 0.001). Limitations: Risk factors for PONV are not considered, RCTs using multiple antiemetics are included, RCTs for fosaprepitant is small, and some bias may be present. Conclusions and implications of key findings: Aprepitant and fosaprepitant can be effective prophylactic antiemetics for postoperative vomiting. However, more studies are required for higher-quality meta-analyses. Systematic review registration number: CRD42019120188.

Resumo Histórico: Náusea e Vômito no Pós-Operatório (NVPO) é um evento adverso frequente da anestesia geral. Várias classes de antieméticos, incluindo antagonistas do receptor 5-Hidroxitriptamina3 (5-HT3) e antagonistas do receptor da Neurocinina-1 (NK-1), têm sido utilizados para tratar a NVPO. Objetivo: Comparar o efeito antiemético dos antagonistas do receptor NK-1, incluindo o fosaprepitanto. Fontes de dados: Foram utilizadas bases de dados on-line (PubMed, MEDLINE, Scopus, The Cochrane Library). Critérios de elegibilidade do estudo, participantes e intervenções: Foram incluídos Estudos Clínicos Randomizados (ECR) realizados em pacientes acima de 18 anos classificação ASA I a III, com o objetivo de avaliar a eficácia de antieméticos que incluíssem antagonistas do receptor NK-1 e antagonistas do receptor 5-HT3, e que comparassem a incidência de NVPO. Métodos de avaliação e síntese do estudo: Todas as avaliações estatísticas foram realizadas por abordagem de efeito aleatório e foram calculadas razões de chances e Intervalos de Confiança de 95%. Resultados: As doses de 40 mg e 80 mg de aprepitanto reduziram significantemente a incidência de vômito no período de 0 a 24 horas pós-operatórias (razão de chances [OR = 0,40]; Intervalo de Confiança de 95% [95% IC] 0,30-0,54; p < 0,001 e OR = 0,32; 95% IC 0,19-0,56; p < 0,001). O fosaprepitanto pode também reduzir significantemente a incidência de vômito tanto de 0-24 horas como no período de 0-48 horas pós-operatórias (OR = 0,07; 95% IC 0,02-0,24; p < 0,001 e OR = 0,07; 95% IC 0,02-0,23; p < 0,001). Limitações: Os fatores de risco para NVPO não foram analisados, ECRs usando múltiplos antieméticos foram incluídos, ECRs para fosaprepitanto tinham amostras pequenas, podendo haver algum viés. Conclusões e implicações dos principais achados: Aprepitanto e fosaprepitanto podem ser drogas antieméticas profiláticas efetivas para vômito no pós-operatório. No entanto, são necessários mais estudos para elaboração de meta-análises de melhor qualidade. Número de registro da revisão sistemática: CRD42019120188.

¿Puede el fentanilo intratecal disminuir la aparición de náuseas y vómito en comparación con ondansetrón intravenoso durante cesárea electiva? Revisión sistemática de la literatura y metaanálisis / Can intrathecal fentanyl decrease the occurrence of nausea and vomiting compared with intravenous ondansetron during elective cesarean section? Literature Systematic review and meta-analysis

Elective caesarean section is one of the surgeries with the highest intraoperative incidence of nausea, retching and vomiting (IONV), due, among other causes, to the use of anesthetics during the procedure. Some clinical trials have associated the use of low-dose intrathecal (IT) fentanyl with a lower incidence of nausea, retching and vomiting compared to other anesthetics used during caesarean sections. In this context, the objective of this meta-analysis was to evaluate the decrease in the appearance of nausea and vomiting during elective caesarean section with the application of IT fentanyl when compared with the use of intravenous ondansetron (EV). A systematic search was conducted in the main databases (PubMed, EMBASE, ClinicalTrials.gov, Cochrane Library and Google Scholar) for Randomized Clinical Trials (RCTs) that evaluated the use of IT fentanyl compared to ondansetron EV to decrease the occurrence and incidence of IONV during elective caesarean section. The meta-analysis showed a reduction in the incidence of nausea (RR 0.52, 95% CI 0.29-0.93, P = 0.03), gagging (RR 0.39, 95% CI 0, 18-0.88, P = 0.02) and vomiting (RR 0.26, 95% CI 0.11-0.64, P = 0.003) in the group of patients treated with IT fentanyl compared to the group treated with EV ondansetron. From the results, it is suggested that the administration of 12.5 to 20 µg of IT fentanyl may decrease the incidence of IONV in patients undergoing elective caesarean section, although the importance of more high-quality RCTs is highlighted.

La cesárea electiva es una de las cirugías con mayor incidencia intraoperatoria de náuseas, arcadas y vómito (NAV), debido entre otras causas, al uso de anestésicos durante el procedimiento. Algunos ensayos clínicos han asociado el uso de fentanilo intratecal (IT) a dosis bajas con una menor incidencia de náuseas, arcadas y vómito en comparación con otros anestésicos usados durante las cesáreas. En este contexto el objetivo de este metaanálisis fue evaluar la disminución en la aparición de náuseas y vómito durante cesárea electiva con la aplicación de fentanilo IT al compararlo con el uso de ondansetrón intravenoso (EV). Se realizó una búsqueda sistemática en las principales bases de datos (PubMed, EMBASE, ClinicalTrials.gov, Cochrane Library y Google Scholar) para ensayos clínicos aleatorizados (ECA) que evaluaron el uso del fentanilo IT en comparación con ondansetrón EV para disminuir la aparición e incidencia de IONV durante cesárea electiva. En el metaanálisis se evidenció una reducción en la incidencia de náusea (RR 0,52, 95% IC 0,29-0,93, P = 0,03), arcada (RR 0,39, 95% IC 0,18-0,88, P = 0,02) y vómito (RR 0,26, 95% IC 0,11-0,64, P = 0,003) en el grupo de pacientes tratados con fentanilo IT comparado con el grupo tratado con ondansetrón EV. A partir de los resultados, se sugiere que la administración de 12,5 a 20 µg de fentanilo IT puede disminuir la incidencia de NAV intraoperatorias en pacientes sometidas a cesárea electiva, aunque se resalta la importancia de más ECA de alta calidad.

Bromopride, metoclopramide, or ondansetron for the treatment of vomiting in the pediatric emergency department: a randomized controlled trial / Bromoprida, metoclopramida ou ondansetrona no tratamento de vômito no departamento de emergência pediátrica: ensaio controlado randomizado

Abstract Objective: To compare the effectiveness of a single intramuscular dose of bromopride, metoclopramide, or ondansetron for treating vomiting. Methods: Randomized controlled trial including children 1-12 years of age presenting with acute vomiting at the pediatric emergency department. Outcomes: Number of children that stopped vomiting at one, six, and 24 h following treatment; episodes of diarrhea; acceptance of oral liquids; intravenous rehydration; return to hospital and side effects. Results: There were 175 children who completed the study. Within the first hour after treatment, all drugs were equally effective, with ondansetron preventing vomiting in 100%, bromopride in 96.6%, and metoclopramide in 94.8% of children (p = 0.288). Within six hours, ondansetron was successful in preventing vomiting in 98.3% of children, compared to bromopride and metoclopramide, which were successful in 91.5% and 84.4% of patients, respectively (p = 0.023). Within 24 h, ondansetron was superior to both other agents, as it remained efficacious in reducing vomiting in 96.6% of children, as opposed to 67.8% and 67.2% with bromopride and metoclopramide, respectively (p = 0.001). The ondansetron group showed better acceptance of oral liquids (p = 0.05) when compared to the bromopride and metoclopramide. The ondansetron group did not show any side effects in 75.9% of cases, compared to 54.2% and 53.5% in the bromopride and metoclopramide groups, respectively. Somnolence was the most common side effect. Conclusions: A single dose of ondansetron is superior to bromopride and metoclopramide in preventing vomiting six hours and 24 h following treatment. Oral fluid intake after receiving medication was statistically better with Ondansetronwhile also having less side effects compared to the other two agents.

Resumo Objetivo: Para comparar a eficacia de uma unica dose intramuscular de bromoprida, metoclopramida ou ondansetrona no tratamento de vomito. Métodos: Ensaio controlado randomizado incluindo crianc¸as de 1 a 12 anos de idade que apresentam vomito agudo no departamento de emergencia pediatrica. Desfechos: Numero de crianças que pararam de vomitar 1, 6 e 24 horas apos o tratamento; episodios de diarreia; aceitac¸ao de liquidos orais; reidratac¸ao intravenosa, retorno ao hospital e efeitos colaterais. Resultados: 175 crianças concluiram o estudo. Na primeira hora apos o tratamento, todos os medicamentos foram igualmente eficazes, sendo que a ondansetrona preveniu vomito em 100%, a bromoprida em 96,6% e metoclopramida em 94,8% das crianças (p = 0,288). Em 6 horas, a ondansetrona mostrou sucesso na prevençao do vomito em 98,3% das crianças, em comparac¸ao a bromoprida e a metoclopramida, que mostraram sucesso em 91,5% e 84,4% dos pacientes, respectivamente (p = 0,023). Em 24 horas, a ondansetrona foi superior aos dois outros agentes, pois ela continuou eficaz na reduçao do vomito em 96,6% das crianças, diferente de 67,8% e 67,2% com bromoprida e metoclopramida, respectivamente (p = 0,001). O grupo de ondansetrona mostrou melhor aceitaçao de liquidos orais (p = 0,05) em comparaçao a bromoprida e metoclopramida. O grupo de ondansetrona nao mostrou efeitos colaterais em 75,9% dos casos, em comparaçao a 54,2% e 53,5% dos grupos de bromoprida e metoclopramida. O efeito colateral mais comum foi sonolencia. Conclusões: Uma unica dose de ondansetrona e superior a bromoprida e metoclopramida no tratamento de vomito 6 horas e 24 horas apos o tratamento. A ingestao de fluidos orais apos receber medicaçao foi estatisticamente melhor com ondansetrona, ao mesmo tempo em que tambem apresentando menos efeitos colaterais em comparaçao aos outros dois agentes.

Prevención y tratamiento de pacientes con náuseas y vómitos postoperatorios / Prevention and treatment of patients with postoperative nausea and vomiting

Resumen Las náuseas y vómitos postoperatorios (NVPO) son un problema frecuente en los pacientes quirúrgicos. Cuando no son prevenidos adecuadamente pueden provocar mayor morbilidad, estadía prolongada en la unidad de recuperación postoperatoria y hospitalización no planificada. El objetivo del equipo quirúrgico debe ser la profilaxis de las NVPO más que su tratamiento, con el fin de disminuir significativamente su incidencia y complicaciones asociadas. Los principales factores de riesgo para NVPO son: sexo femenino, historia de NVPO en cirugías previas y/o cinetosis, no fumar, uso de opioides sistémicos en el postoperatorio, someterse a ciertos tipos de cirugía (como colecistectomía, cirugía laparoscópica y cirugía ginecológica), utilizar anestésicos volátiles y/u óxido nitroso intraoperatorios, y duración de la cirugía. Sugerimos objetivar el riesgo de NVPO utilizando las escalas de riesgo de NVPO de Apfel o Koivuranta. Los principales fármacos antieméticos usados como profilaxis y tratamiento en el período perioperatorio son dexametasona, ondansetrón y droperidol. Existen estrategias generales que se pueden utilizar para reducir el riesgo quirúrgico basal de NVPO como evitar la anestesia general, privilegiando la anestesia regional, utilizar propofol para la inducción y mantención de la anestesia, evitar el uso de óxido nitroso y/o anestésicos inhalatorios, minimizar el uso postoperatorio de opioides sistémicos y recibir una hidratación intravenosa abundante durante la cirugía. La etiología de las NVPO es multifactorial, por lo que la prevención y tratamiento deben incluir diferentes clases de antieméticos, que actúen sobre los diferentes receptores de náuseas y/o vómitos hasta el momento conocidos, junto con las estrategias generales antes mencionadas.

Abstract Postoperative nausea and vomiting (PONV) are a common problem in surgical patients. When not properly prevented, they can lead to increased morbidity, prolonged stay in the postoperative recovery unit and unplanned hospitalization. The objective of the surgical team should be the prophylaxis of PONV rather than its treatment, in order to significantly reduce its incidence and associated complications. The main risk factors for PONV are: female sex, history of PONV in prior surgeries and/or motion sickness, non-smoking, use of systemic opioids postoperatively, undergo certain types of surgery (such as cholecystectomy, laparoscopic surgery and gynecological surgery), use volatile anesthetics and/or intraoperative nitrous oxide, and duration of surgery. We suggest to objectify the risk of PONV using the Apfel or Koivuranta PONV risk scales. The main anti-emetic drugs used as prophylaxis and treatment in the perioperative period are dexamethasone, ondansetron and droperidol. There are general strategies that can be used to reduce the baseline surgical risk of PONV such as avoiding general anesthesia, favoring regional anesthesia, using propofol for induction and maintenance of general anesthesia, avoiding the use of nitrous oxide and/or inhalational anesthetics, minimizing the postoperative use of systemic opioids and to receive an abundant intravenous hydration during surgery. The etiology of PONV is multifactorial, so prevention and treatment should include different classes of antiemetics, acting on the different receptors of nausea and/or vomiting so far known, together with the general strategies mentioned above.

Orthodontic approach to treat complex hypodontia using miniscrews in a growing patient

This article reports orthodontic treatment of a case of hypodontia of five premolars in an 11-year-old female patient with a positive tooth size-arch length discrepancy in both dental arches. The patient had a straight profile with balanced facial growth. Setup manufacture revealed the possibility of achieving ideal occlusion by mesializing permanent molars up to 15 mm, in addition to keeping a primary molar in the dental arch. With the aid of absolute anchorage, the proposed mechanics was performed and the occlusion predicted in the setup was achieved, while profile and facial growth pattern were maintained. The use of miniscrews for extensive orthodontic movements was successful. Furthermore, one primary molar was extensively mesialized. The indication of gingivoplasty to correct gingival smile proved effective. This is considered a useful technique for orthodontists.

Este artigo apresenta o tratamento ortodôntico de um caso com hipodontia de cinco pré-molares, em uma paciente, de 11 anos de idade, com discrepância positiva de modelo em ambas as arcadas. A paciente apresentava perfil reto, com crescimento facial equilibrado. Por meio da confecção de set-up, verificou-se a possibilidade de se estabelecer uma oclusão ideal por meio da mesialização, de até 15mm, dos molares permanentes e manutenção de um molar decíduo no arco. Com o auxílio de ancoragem absoluta, foi realizada a mecânica proposta, alcançando-se a oclusão prevista em set-up, além da manutenção do perfil e do padrão de crescimento facial. A utilização de mini-implantes para grandes movimentos ortodônticos foi favorável, incluindo a extensa mesialização de um molar decíduo. A indicação da gengivoplastia para correção do sorriso gengival se mostrou acertada, sendo essa uma técnica de grande auxílio à Ortodontia.

Efectos extrapiramidales por metoclopramida en embarazo y recién nacido / Extrapyramidal effects for metoclopramide in pregnancy and newborn

Las náuseas y la emesis son complicaciones posoperatorias que pueden derivar en bronco aspiración, una situación clínica potencialmente fatal. Para su prevención, se usan medicamentos como la metoclopramida. Se presenta un reporte de caso de extrapiramidalismo por metoclopramida en el recién nacido y la madre. Es una reacción secundaria a un medicamento, clasificada como un evento serio y definitivo, de tipo A. Se requiere considerar el balance entre riesgo y beneficio de este medicamento en este tipo de condiciones, como también considerar otras medidas que eviten estos casos. El reporte de reacciones adversas a medicamentos es una actividad que contribuye al uso seguro de los medicamentos.

Postoperative nauseas and vomiting are complications that can lead to bronchoaspiration, a potentially fatal clinical event. Medications such as metoclopramide are used to prevent them. A case report of extrapyramidal signs in a newborn and mother metoclopramide is presented. It has been classified as a serious drug reaction, type A. The risk-benefit balance of this drug in such conditions should be considered as well as other measures to prevent such events. The reporting of adverse drug reactions is an activity that contributes to the safe use of medicines.

Association of 5-HT3B Receptor Gene Polymorphisms with the Efficacy of Ondansetron for Postoperative Nausea and Vomiting

PURPOSE: Postoperative nausea and vomiting (PONV) is a common problem after general anesthesia. Although 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists have significantly reduced PONV, over 35% of patients treated with ondansetron can experience PONV. In this study, we investigated whether the Y129S and -100_-102AAG deletion polymorphisms of the 5-HT3B receptor gene affect the efficacy of ondansetron in preventing PONV. MATERIALS AND METHODS: Two hundred and forty-five adult patients who underwent laparoscopic cholecystectomy were enrolled. Ondansetron 0.1 mg/kg was intravenously administered 30 minutes before the end of surgery. Genomic DNA was prepared from blood samples using a nucleic acid isolation device. Both the Y129S variant and the -100_-102AAG deletion variant were screened for using a single base primer extension assay and a DNA direct sequencing method, respectively. The relationship between genetic polymorphisms and clinical outcomes of ondansetron treatment was investigated. RESULTS: Among the 5-HT3B AAG deletion genotypes, the incidence of PONV was higher in patients with the homomutant than with other genotypes during the first 2 hours after surgery (p=0.02). There were no significant differences in the incidence of PONV among genotypes at 2-24 hours after surgery. In the Y129S variants of the 5-HT3B receptor gene, there were no significant differences in the incidence of PONV among genotypes during the first 2 hours and at 2-24 hours after surgery. CONCLUSION: The response to ondansetron for PONV was significantly influenced by the -100_-102AAG deletion polymorphisms of the 5-HT3B gene. Thus, the -100_-102AAG deletion variants may be a pharmacogenetic predictor for responsiveness to ondansetron for PONV.

Paralytic Ileus and Prophylactic Gastrointestinal Motility Medication after Spinal Operation

PURPOSE: To investigate the prevalence of paralytic ileus after spinal operation in the supine or prone operative position and to determine the efficacy of prophylactic gastrointestinal motility medications in preventing symptomatic paralytic ileus after a spinal operation. MATERIALS AND METHODS: All patients received spinal surgery in the supine or prone operative position. The study period was divided into two phases: first, to analyze the prevalence of radiographic and symptomatic paralytic ileus after a spinal operation, and second, to determine the therapeutic effects of prophylactic gastrointestinal motility medications (postoperative intravenous injection of scopolamine butylbromide and metoclopramide hydrochloride) on symptomatic paralytic ileus after a spinal operation. RESULTS: Basic demographic data were not different. In the first phase of this study, 27 patients (32.9%) with radiographic paralytic ileus and 11 patients (13.4%) with symptomatic paralytic ileus were observed. Radiographic paralytic ileus was more often noted in patients who underwent an operation in the prone position (p=0.044); whereas the occurrence of symptomatic paralytic ileus was not different between the supine and prone positioned patients (p=0.385). In the second phase, prophylactic medications were shown to be ineffective in preventing symptomatic paralytic ileus after spinal surgery [symptomatic paralytic ileus was observed in 11.1% (4/36) with prophylactic medication and 16.7% (5/30) with a placebo, p=0.513]. CONCLUSION: Spinal surgery in the prone position was shown to increase the likelihood of radiographic paralytic ileus occurrence, but not symptomatic paralytic ileus. Unfortunately, the prophylactic medications to prevent symptomatic paralytic ileus after spine surgery were shown to be ineffective.

Palonosetron versus granisetron in combination with aprepitant for the prevention of chemotherapy-induced nausea and vomiting in patients with gynecologic cancer / 부인종양

OBJECTIVE: There is no research regarding the appropriate antiemetic agents for female patients, especially those receiving moderately emetogenic chemotherapy (MEC). We evaluated the antiemetic efficacy of a combination of 5-HT3 receptor with/without aprepitant in patients with gynecological cancer treated with the TC (paclitaxel and carboplatin) regimen of MEC. METHODS: We enrolled 38 patients diagnosed with gynecologic cancer and scheduled to receive the TC regimen. The patients were randomly assigned to receive a 5-HT3 receptor antagonist, either palonosetron in the first cycle followed by granisetron in the second cycle or vice versa. In the third cycle, all patients received a combination of the 5-HT3 receptor and dexamethasone with/without aprepitant. RESULTS: When three drugs were administered, palonosetron consistently produced an equivalent complete response (CR) rate to granisetron in the acute phase (89.5% vs. 86.8%, p=0.87) and delayed phase (60.5% vs. 65.8%, p=0.79). With regard to the change in dietary intake, palonosetron exhibited similar efficacy to granisetron in the acute phase (92.1% vs. 89.4%, p=0.19) and delayed phase (65.7% vs. 68.4%, p=0.14). However, in the delayed phase, the addition of aprepitant therapy with a 5-HT3 receptor antagonist and dexamethasone produced a higher CR rate than a 5-HT3 receptor antagonist with dexamethasone (93.3% vs. 47.8%, p<0.001) and allowed the patients to maintain a higher level of dietary intake (93.3% vs. 56.5%, p<0.001). CONCLUSION: The addition of aprepitant therapy was more effective than the control therapy of a 5-HT3 receptor antagonist, and dexamethasone in gynecological cancer patients treated with the TC regimen.

Incidence and Risk Factors of Postoperative Nausea and Vomiting in Patients with Fentanyl-Based Intravenous Patient-Controlled Analgesia and Single Antiemetic Prophylaxis

PURPOSE: We evaluated the incidence and risk factors of postoperative nausea and vomiting (PONV) in patients with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) and single antiemetic prophylaxis of 5-hydroxytryptamine type 3 (5 HT3)-receptor antagonist after the general anesthesia. MATERIALS AND METHODS: In this retrospective study, incidence and risk factors for PONV were evaluated with fentanyl IV-PCA during postoperative 48 hours after various surgeries. RESULTS: Four hundred-forty patients (23%) of 1878 had showed PONV. PCA was discontinued temporarily in 268 patients (14%), mostly due to PONV (88% of 268 patients). In multivariate analysis, female, non-smoker, history of motion sickness or PONV, long duration of anesthesia (>180 min), use of desflurane and intraoperative remifentanil infusion were independent risk factors for PONV. If one, two, three, four, five, or six of these risk factors were present, the incidences of PONV were 18%, 19%, 22%, 31%, 42%, or 50%. Laparoscopic surgery and higher dose of fentanyl were not risk factors for PONV. CONCLUSION: Despite antiemetic prophylaxis with 5 HT3-receptor antagonist, 23% of patients with fentanyl-based IV-PCA after general anesthesia showed PONV. Long duration of anesthesia and use of desflurane were identified as risk factors, in addition to risk factors of Apfel's score (female, non-smoker, history of motion sickness or PONV). Also, intraoperative remifentanil infusion was risk factor independent of postoperative opioid use. As the incidence of PONV was up to 50% according to the number of risk factors, risk-adapted, multimodal or combination therapy should be applied.

timing of Ondansetron administration in prevention of postoperative nausea and vomiting a comparative study for female patients undergoing laparoscopic cholecystectomy

Postoperative nausea and vomiting [PONV] is a common distressing experience in patients following laparoscopic cholecystectomy. This study was aimed at comparing the better timing of Ondansetron administration in prevention of PONV in female patients underwent elective laparoscopic cholecystectomy done under general anesthesia. Fifty ASA physical status one and two female patients, aged 19 to 45 years, were enrolled in this prospective study to receive 4mg four Ondansetron preoperatively [Group A], or 4 mg four Ondansetron postoperatively [Group B], 25 patients each. A standardized general anesthetic technique was employed. Any episode of PONV was assessed at 8 hours postoperative period, every 2 hours, starting at time zone 0 [at post-anesthesia recovery unit], and ending at time zone 3 [hour 8 postoperatively]. Complete response is defined as no PONV during 8 hours postoperative period. Incomplete response is defined as developing of postoperative nausea only during 8 hours postoperative period. Failure of prevention is defined as developing of PONV during 8 hours postoperative period. Complete response occurred in 60 and 64% in Groups A and B respectively. Incomplete response occurred in 12 and 4% in Groups A and B respectively. Failure of prevention occurred in 28 and 32% in Groups A and B respectively. There is no significant clinical difference between preoperative or postoperative Ondansetron administration of the same dosage in both groups in prevention of postoperative nausea and vomiting.

Risk Assessment of Postoperative Nausea and Vomiting in the Intravenous Patient-Controlled Analgesia Environment: Predictive Values of the Apfel's Simplified Risk Score for Identification of High-Risk Patients

PURPOSE: Opioid-based intravenous patient-controlled analgesia (IV PCA) is popular method of postoperative pain control, but many patients suffer from IV PCA-related postoperative nausea and vomiting (PONV). In this retrospective observational study, we have determined independent predictors of IV PCA-related PONV and predictive values of the Apfel's simplified risk score in pursuance of identifying high-risk patients. MATERIALS AND METHODS: We analyzed 7000 patients who received IV PCA with background infusion after elective surgery. Patients who maintained IV PCA for a postoperative period of 48 hr (completion group, n=6128) were compared with those who have discontinued IV PCA within 48 hr of surgery due to intractable PONV (cessation group, n=872). Patients, anesthetics, and surgical factors known for predicting PONV were evaluated by logistic regression analysis to identify independent predictors of IV PCA related intractable PONV. RESULTS: In a stepwise multivariate analysis, weight, background infusion dose of fentanyl, addition of ketolorac to PCA, duration of anesthesia, general anesthesia, head and neck surgery, and Apfel's simplified risk score were revealed as independent risk factors for intractable PONV followed by the cessation of IV PCA. In addition, Apfel's simplified risk score, which demonstrated the highest odds ratio among the predictors, was strongly correlated with the cessation rate of IV PCA. CONCLUSION: Multimodal prophylactic antiemetic strategies and dose reduction of opioids may be considered as strategies for the prevention of PONV with the use of IV PCA, especially in patients with high Apfel's simplified risk scores.

Effect of Ondansetron combined with Dexamethasone on Postoperative Nausea & Vomiting and Pain of Patients with Laparoscopic Hysterectomy

PURPOSE: The purpose of this study was to compare the effects of ondansetron combined with dexamethasone on Post-Operative Nausea and Vomiting (PONV) and pain with ondansetron alone in patients with laparoscopy assisted vaginal hysterectomy under general anesthesia. METHODS: Data were collected from April 1 through September 30, 2005 using a double blind method. Ondansetron 4 mg and dexamethasone 10 mg were administered to the experimental group (25 patients), and ondansetron 4 mg only to the control group (25 patients). The medications were administered through an intravenous line at the beginning peritoneum suture. PONV by Index of Nausea Vomiting and Retching (INVR), nausea by Visual Analogue Scale (VAS), and pain (VAS) were assessed at postoperative 1 hr, 3 hr, 6 hr, 24 hr, and 48 hr. Data were analyzed using repeated measures ANOVA, and Bonferroni methods. RESULTS: The experimental group that received ondansetron combined with dexamethasone had less PONV (p=.048), and nausea (p=.012) than control group that received ondansetron alone. However, there was no difference in pain (p=.557) between the patients in the two groups. CONCLUSION: We conclude that the administration of ondansetron combined with dexamethasone is more effective than the administration of ondansetron alone to reduce PONV in patients with laparoscopic hysterectomy.