Multimodal Antiemetic Management Prevents Early Postoperative Vomiting After Outpatient Laparoscopy

Abstract

Because no completely effective antiemetic exists for the prevention of postoperative nausea and vomiting (PONV), we hypothesize that a multimodal approach to management of PONV may reduce both vomiting and the need for rescue antiemetics in high-risk patients. After IRB approval, women undergoing outpatient laparoscopy were randomized to one of three groups. Group I (n = 60) was managed by using a predefined multimodal clinical care algorithm. Patients undergoing the same surgical procedure who received a standard balanced outpatient anesthetic with ondansetron 4 mg (Group II, n = 42) or placebo (Group III, n = 37) prophylaxis were chosen to establish baseline incidence of nausea and vomiting. None of the Group I patients vomited before discharge, compared with 7% in Group II (P = 0.07) and 22% in Group III (P = 0.0003). However, one patient (2%) in Group I required treatment for symptoms in the postanesthesia care unit, compared with 24% in Group II (P<0.0001) and 41% in Group III (P< 0.0001). Time to discharge-ready was significantly shorter in Group I (128, 118-139 min; mean, 95% confidence interval) versus Group II (162, 145-181 min; P = 0.0015) and Group III (192, 166-222 min; P = 0.0001). Patient satisfaction with control of PONV was not different between Group I and Group II. Return to normal daily activity and overall satisfaction were not different among groups. Multimodal management resulted in a 98% complete response rate and a 0% incidence of vomiting before discharge; however, this improvement did not result in an increased level of patient satisfaction when compared with routine monotherapy prophylaxis. We conclude that both multimodal management and routine monotherapy antiemetic prophylaxis resulted in an increased level of patient satisfaction than symptomatic treatment in this high-risk population.

Evidence-based management of postoperative nausea and vomiting: a review

“…No patient in this group vomited before discharge, compared with 7% of patients in the ondansetron group (P = 0.07) and 22% of patients in the placebo group (P = 0.0003). 123 Subsequently, more studies confirmed the efficacy of a multimodal approach, especially in high-risk patients (IIIA). 124,125 P Po os st t--d di is sc ch ha ar rg ge e n na au us se ea a a an nd d v vo om mi it ti in ng g Ambulatory surgery is continuing to grow.…”

Náuseas e vômitos no pós-operatório: uma revisão do "pequeno-grande" problema

“…Assim os modelos preditivos de risco para NVPO que incluem o tipo de cirurgia não fornecem maior valor preditivo, quando comparados com os modelos simplificados 14,15 . A duração da intervenção e a experiência do cirurgião (associada com a intensidade das manipulações viscerais) são também apontadas como fatores de risco 16 . Fatores relacionados com a anestesia influenciam a incidên-cia de NVPO 16 .…”

Une approche préventive adaptée aux risques réduit l’incidence générale de nausées et de vomissements postopératoires en milieu hospitalier

“…8 Omitting volatile anesthetics as a major risk factor for early PONV 15 and using propofol for maintenance instead could decrease the incidence in patients with three or four risk factors. Thus, a multimodal approach 16 may be warranted in high-risk patients.…”