Management of postoperative nausea and vomiting: focus on palonosetron

Abstract

Postoperative nausea and vomiting (PONV) remains a signifi cant problem in modern anesthetic practice, with an incidence in high-risk groups of up to 80%. In addition to being unpleasant and distressing for the patient, PONV has the potential to adversely affect patient and surgical outcomes. Advances in PONV prophylaxis over recent years include using non-pharmacological means to reduce baseline risk, a change to less emetogenic anesthetic techniques and the combination of multiple antiemetic drugs. The 5-hydroxytryptamine-3 (5-HT 3 ) antagonists have proven a particularly valuable addition to the armamentarium against PONV. Palonosetron is a second-generation 5-HT 3 antagonist that has recently been approved for prophylaxis against PONV. It has unique structural, pharmacological and clinical properties that distinguish it from other agents in its class. This review summarizes current evidence on PONV prophylaxis, reviews the 5-HT 3 antagonists in particular and focuses on the established and future roles of palonosetron. Keywords: palonosetron, antiemetics, 5-HT 3 antagonists, postoperative nausea and vomiting Management of postoperative nausea and vomiting: an overviewPostoperative nausea and vomiting (PONV) is the most common complication of surgery and anesthesia. Both health care professionals and patients rate its avoidance and control of similar importance to that of alleviating pain. [1][2][3][4] In addition to patient dissatisfaction, 5 PONV may have adverse consequences such as delayed recovery, unexpected hospital admission and delayed return to work of ambulatory patients. Rarely postsurgical morbidities such as wound dehiscence, pulmonary aspiration, surgical site bleeding and dehydration occur.6 Nausea occurs in approximately 20% of patients in the recovery room and in 50% thereafter, with vomiting in 5% and 25% respectively.7 Although children more than 3 years of age are at higher risk than adults, 8 in some high-risk adult populations the incidence of PONV is 80% or more. 9,10It is diffi cult to quantify the risk of PONV for any individual patient both because of the many pre-, intra-and postoperative factors that contribute to PONV and uncertainty about the relative impact of these potential infl uences. Activation of the vomiting center or the sensation of nausea may result from stimulation of the chemoreceptor trigger zone (eg, drugs, metabolic stimuli), the vestibular apparatus (motion), visceral afferent inputs (eg, gut distension or stasis, surgical stimulation of viscera, cardiovascular disturbance) and cortical inputs (eg, anxiety, pain, hypoxia, sensory stimuli, psychological associations, raised intracranial pressure). At least 3 nerves and 7 neurotransmitters are involved, making prophylaxis and treatment complex. In general a number of patient, surgical and anesthetic factors affect the risk of PONV 6 and various patient risk assessment scores have been developed. The best known and validated is a simple 4-point score based mainly on patient characteristics. These are fema...

Comparison of palonosetron with combined palonosetron and midazolam for preventing postoperative nausea and vomiting after laparoscopic cholecystectomy

“…Although 0.075 mg of palonosetron is an approved dose for the control of PONV for 24 hours after surgery, [26] the efficacy of single injection would be maintained for much longer time after treatment, due to its long half-life of 40 hours [27] . Especially, palonosetron is known to work better in delayed nausea and vomiting [6] . Additional studies would be needed for validation.…”

“…[27] Especially, palonosetron is known to work better in delayed nausea and vomiting. [6] Additional studies would be needed for validation. Fourthly, we checked some side effects related to the use of midazolam including drowsiness, headache, and dizziness.…”

“…Palonosetron, a 5-hydroxytryptamine (5-HT 3 ) receptor antagonist, is commonly used for the prophylaxis and treatment of PONV due to its better efficacy and favorable side effects. This agent has a greater receptor affinity with longer duration of action as compared to traditional antiemetics such as ondansetron [6] . However, incidence of PONV was up to 50% in patients given either palonosetron or ramosetron after laparoscopic surgery (or in high-risk patients) [7] …”

“…This agent has a greater receptor affinity with longer duration of action as compared to traditional antiemetics such as ondansetron. [6] However, incidence of PONV was up to 50% in patients given either palonosetron or ramosetron after laparoscopic surgery (or in high-risk patients). [7] Midazolam is a short acting benzodiazepine that possesses anxiolytic, amnestic, and anesthetic properties.…”

PONV prophylaxis after laparoscopic procedures - Comparison between Palonosetron 0.075mg, Palonosetron 0.15mg and a Palonosetron-Dexamethasone combination : a randomised controlled trial

“…Postoperative emesis not only predisposes patients to wound dehiscence and psychological distress (3), but frequently delays their discharge from the hospital after planned ambulatory surgery (4). The ondansetron and palonosetron as first and second generation of 5-hydroxytryptamine-3 (5-HT3) receptor antagonists are commonly used for the prevention of PONV in moderate to high-risk patients because of better efficacy and favorable side effects as compared to other antiemetics (5,6). Compared with ondansetron, palonosetron has greater affinity for 5-HT3 receptors (7), although a recent meta-analysis has shown that palonosetron was not more efficacious than ondansetron in the prevention of early PONV after laparoscopic surgery (8).…”