Appraising and highlighting gaps among prophylactic intervention studies for reducing the incidence of postoperative nausea and vomiting in children: a systematic review.

OBJECTIVES: Postoperative nausea and vomiting (PONV) is a leading perioperative morbidity outcome following general anaesthesia. This systematic review aims to identify, appraise and summarise the evidence synthesis studies of prophylactic interventions that reduce the incidence of paediatric PONV, thereby highlighting knowledge gaps and avenues of future research. DESIGN: Systematic review using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews 2) tool and the ROBIS (Risk Of Bias In Systematic reviews) tool. DATA SOURCES: Seven major databases, including MEDLINE and EMBASE, from inception to 23 September 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Evidence synthesis studies of only randomised controlled trials that explored prophylactic interventions for PONV in children undergoing general anaesthesia. DATA EXTRACTION AND SYNTHESIS: Following screening process by two reviewers, data were extracted from all eligible studies, including demographic parameters and details of interventions. Eligible studies were categorised into 'pharmacological' and 'non-pharmacological' groups and high-risk surgical groups of 'strabismus' and 'tonsillectomy' for qualitative synthesis. RESULTS: There were 20 evidence synthesis reviews (17 meta-analyses, 2 systematic reviews, 1 network meta-analysis): 14 investigated pharmacological PONV prophylaxis in children, 5 investigated non-pharmacological interventions, 1 studied both pharmacological and non-pharmacological interventions. Monotherapy pharmacological prophylaxis agents, for example, dexamethasone (relative risk (RR) 0.49, 95% CI 0.41 to 0.58), 5-hydroxytryptamine (5-HT3) antagonists (OR 0.12, 95% CI 0.07 to 0.20) and α2-adrenoreceptor agonists (dexmedetomidine: RR 0.33, 95% CI 0.21 to 0.54), are more effective than placebo. A combination of pharmacological agents provided superior efficacy to monotherapy, particularly dexamethasone and 5-HT3 antagonists (RR 0.21, 95% credible interval 0.15 to 0.28). Acustimulation practice was consistently favourable in preventing PONV compared with placebo (RR 0.36, 95% CI 0.25 to 0.52). CONCLUSION: Monotherapy pharmacological prophylaxis is more effective than placebo in reducing the incidence of paediatric PONV, with the efficacy increased further by using combination pharmacotherapy. Further research must compare multiple treatment arms of pharmacological and non-pharmacological prophylaxes for PONV to identify the optimal multimodal prophylaxis regimen. PROSPERO REGISTRATION NUMBER: CRD42021236698.

Prophylaxis for pediatric postoperative nausea and vomiting: a scoping review of clinical trials.

PURPOSE: Postoperative nausea and vomiting (PONV) is common in pediatric patients undergoing general anesthesia, and clinicians seek prophylactic interventions to prevent its ill effects on patients as well as its ramifications on perioperative care. We sought to assess the body of evidence around prophylactic strategies, both pharmacologic and nonpharmacologic, targeting pediatric PONV. SOURCE: We searched MEDLINE, MEDLINE ePubs Ahead of Print and In-Process Citations, Embase Classic+Embase, the Cochrane Database of Systematic Reviews, Cochrane CENTRAL (via the Ovid platform), Scopus (Elsevier), Web of Science (Clarivate Analytics), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, and the International Standard Randomized Controlled Trial Number Registry, from their inception to 23 September 2022. PRINCIPAL FINDINGS: Of 188 clinical trials, 157 (83%) investigated pharmacologic interventions, 25 (13%) investigated nonpharmacologic interventions, and six (3%) investigated mixed pharmacologic and nonpharmacologic interventions. The most common surgeries investigated for pediatric PONV were strabismus surgery (68 trials, 36%) and tonsillectomy or tympanoplasty (45 trials, 23%). Of four measurement tools used to assess PONV in the included trials, the most common was clinical judgement (170 trials, 90%). CONCLUSION: The majority of data in pediatric PONV prophylaxis is based on pharmacologic interventions, with a paucity of research in nonpharmacologic or mixed interventions. Assessing and documenting PONV using tools such as the Baxter Animated Retching Faces Scale or PONV numeric scoring system may help standardize pediatric PONV prophylaxis research moving forward. Furthermore, concurrently assessing pain and adverse effects associated with PONV might further inform our understanding of this complex clinical entity.

RéSUMé: OBJECTIF: Les nausées et vomissements postopératoires (NVPO) sont fréquents chez la patientèle pédiatrique bénéficiant d'une anesthésie générale, et les équipes cliniques recherchent des interventions prophylactiques pour prévenir leurs effets néfastes sur les patient·es ainsi que leurs ramifications sur les soins périopératoires. Nous avons cherché à évaluer l'ensemble des données probantes entourant les stratégies prophylactiques pharmacologiques et non pharmacologiques ciblant les NVPO pédiatriques. SOURCES: Nous avons effectué des recherches dans les bases de données MEDLINE, MEDLINE ePubs Ahead of Print and In-Process Citations, Embase Classic+Embase, la base de données des revues systématiques Cochrane, Cochrane CENTRAL (via la plateforme Ovid), Scopus (Elsevier), Web of Science (Clarivate Analytics), ClinicalTrials.gov, le système d'enregistrement international des essais cliniques de l'OMS et le registre international normalisé des numéros d'essais contrôlés randomisés, depuis leur création jusqu'au 23 septembre 2022. CONSTATATIONS PRINCIPALES: Sur 188 études cliniques, 157 (83 %) portaient sur des interventions pharmacologiques, 25 (13 %) sur des interventions non pharmacologiques et six (3 %) sur des interventions pharmacologiques et non pharmacologiques mixtes. Les chirurgies les plus fréquemment étudiées pour les NVPO pédiatriques étaient les chirurgies de strabisme (68 études, 36 %) et les amygdalectomies ou tympanoplasties (45 études, 23 %). Parmi les quatre outils de mesure utilisés pour évaluer les NVPO dans les études incluses, le plus fréquemment utilisé était le jugement clinique (170 études, 90 %). CONCLUSION: La majorité des données sur les prophylaxies pédiatriques pour prévenir les NVPO sont basées sur des interventions pharmacologiques, avec peu de recherche sur les interventions non pharmacologiques ou mixtes. L'évaluation et la documentation des NVPO à l'aide d'outils tels que l'échelle Baxter Animated Retching Faces Scale ou un système de notation numérique des NVPO peuvent aider à normaliser la recherche sur la prophylaxie pédiatrique des NVPO à l'avenir. De plus, l'évaluation simultanée de la douleur et des effets indésirables associés aux NVPO pourrait éclairer davantage notre compréhension de cette entité clinique complexe.