A Single Prophylactic Dose of Ondansetron Given at Cessation of Postoperative Propofol Sedation Decreases Postoperative Nausea and Vomiting in Cardiac Surgery Patients: A Randomized Controlled Trial

Abstract

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common occurrence after cardiac surgery. However, in contrast to other surgical populations, routine PONV prophylaxis is not a standard of care in cardiac surgery. We hypothesized that routine administration of a single prophylactic dose of ondansetron (4 mg) at the time of stopping postoperative propofol sedation before extubation in the cardiac surgery intensive care unit would decrease the incidence of PONV. METHODS: With institutional human ethics board approval and written informed consent, we conducted a randomized controlled trial in patients ≥19 years of age with no history of PONV undergoing elective or urgent cardiac surgery procedures requiring cardiopulmonary bypass. The primary outcome was the incidence of PONV in the first 24 hours postextubation, compared by the χ2 test. Secondary outcomes included the incidence and times to first dose of rescue antiemetic treatment administration, the incidence of headaches, and the incidence of ventricular arrhythmias. RESULTS: PONV within the first 24 hours postextubation occurred in 33 of 77 patients (43%) in the ondansetron group versus 50 of 82 patients (61%) in the placebo group (relative risk, 0.70 [95% confidence interval {CI}, 0.51–0.95]; absolute risk difference, −18% [95% CI, −33 to −2]; number needed to treat, 5.5 [95% CI, 3.0–58.4]; χ2 test, P = .022). Kaplan-Meier “survival” analysis of the times to first rescue antiemetic treatment administration over 24 hours indicated that patients in the ondansetron group fared better than those in the placebo group (log-rank [Mantel-Cox] test; P = .028). Overall, 32 of 77 patients (42%) in the ondansetron group received rescue antiemetic treatment over the first 24 hours postextubation versus 47 of 82 patients (57%) in the placebo group (relative risk, 0.73 [95% CI, 0.52–1.00]; absolute risk difference, −16% [95% CI, −31 to 1]); P = .047. There were no significant differences between the groups in the incidence of postoperative headache (ondansetron group, 5 of 77 patients [6%] versus placebo group, 4 of 82 patients [5%]; Fisher exact test; P = .740) or ventricular arrhythmias (ondansetron group, 2 of 77 patients [3%] versus placebo group, 4 of 82 patients [5%]; P = .68). CONCLUSIONS: These findings support the routine administration of ondansetron prophylaxis at the time of discontinuation of postoperative propofol sedation before extubation in patients following cardiac surgery. Further research is warranted to optimize PONV prophylaxis in cardiac surgery patients.

Early Postoperative Ondansetron Exposure is Associated with Reduced 90-Day Mortality in Patients Undergoing Cardiac Surgery

“…Although the pathophysiology of postoperative nausea and vomiting (PONV) is unclear, the control of PONV through 5-hydroxytryptamine 3 (5-HT3), dopamine, neurokinin 1, and acetylcholine receptor antagonism has become the mainstay of anti-emetic treatment. For cardiac surgical patients, the incidence of PONV is considerable and ranges as high as 43%–69% ( 1 – 3 ). However, PONV prophylaxis is not a widespread routine care in patients undergoing cardiac surgery.…”

“…The 5-HT3 receptor antagonist ondansetron is the most commonly used anti-emetic agent as the “gold standard” in the management of postoperative nausea and vomiting in noncardiac surgical patients ( 4 ). In patients undergoing cardiac surgery, ondansetron has also shown prophylactic effect on PONV ( 1 , 3 ). However, the adverse effect of QT interval prolongation induced by ondansetron administration raises safety concerns about its use in cardiac surgical patients ( 5 – 8 ).…”

Predictors and nomogram models for postoperative headache in patients undergoing heart valve surgery

“…Several related risk factors have been reported, such as age, female gender, previous history of headache, and anaesthetic drugs (13,18,22). However, there are only few reports available about the development of POH after cardiac surgery, and basically it's just used as a secondary outcome (23). To our knowledge, there are no prior studies identifying the risk factors of POH after cardiac surgery, let alone a risk model that can be used to early predict the occurrence of POH.…”

Nomogram for Postoperative Headache in Adult Patients Undergoing Elective Cardiac Surgery

“… 15 , 17 , 21 Nevertheless, there is little information regarding the development of POH in patients undergoing cardiac surgery, even if just used as a secondary outcome. 22 To the best of our knowledge, there are no previous studies aiming to explore risk factors for POH after ECS, not to mention the development and validation of a risk prediction model.…”