Omitting Antagonism of Neuromuscular Block: Effect on Postoperative Nausea and Vomiting and Risk of Residual Paralysis. A Systematic Review

Abstract

We have estimated the effect of omitting antagonism of neuromuscular block on postoperative nausea and vomiting. A systematic search (MEDLINE, EMBASE, Biological Abstracts, Cochrane library, reference lists and hand searching; no language restriction, up to March 1998) was performed for relevant randomized controlled trials. In eight studies (1134 patients), antagonism with neostigmine or edrophonium was compared with spontaneous recovery after general anaesthesia with pancuronium, vecuronium, mivacurium or tubocurarine. On combining neostigmine data, there was no evidence of an antiemetic effect when it was omitted. However, the highest incidence of emesis with neostigmine 1.5 mg was lower than the lowest incidence of emesis with 2.5 mg. Numbers-needed-to-treat to prevent emesis by omitting neostigmine compared with using it were consistently negative with 1.5 mg, and consistently positive (3-6) with 2.5 mg. There was a lack of evidence for edrophonium. In two studies, three patients with spontaneous recovery after mivacurium or vecuronium needed rescue anticholinesterase drugs because of clinically relevant muscle weakness (number-needed-to-harm, 30). Omitting neostigmine may have a clinically relevant antiemetic effect when high doses are used. Omitting antagonism, however, introduces a non-negligent risk of residual paralysis even with short-acting neuromuscular blocking agents.

Postoperative �belkeit und Erbrechen

“…Die Antagonisierung von nichtdepolarisierenden Muskelrelaxanzien ist ebenfalls emetogen, wobei dies nach einer Metaanalyse vor allem für Dosierungen von mehr als 2,5 mg Neostigmin gelten soll [64].Da in Studien bei höheren Dosierungen überwiegend Glycopyrrolat und bei niedrigeren Dosierungen überwiegend Atropin zur Verwendung kam,ist eine definitive Aussage schwierig,da Atropin im Gegensatz zu Glycopyrrolat zentrale antiemetische Wirkungen besitzt und mit weniger Erbrechen assoziiert ist [17].…”

Comparison of the effects of sugammadex and neostigmine on postoperative nausea and vomiting

“…6 Cholinesterase inhibitors have been implicated in the development of PONV as a result of their potent muscarinic effects upon the gastrointestinal tract and the vomiting center in the brain. 7 Neostigmine, used at the end of surgery for residual neuromuscular block, is associated with increased the risk of PONV, especially when used in large doses (>2.5 mg). 7 Some previous studies have recommended avoiding the use of acetyl choline esterase inhibitors to reduce postoperative vomiting.…”

“…7 Neostigmine, used at the end of surgery for residual neuromuscular block, is associated with increased the risk of PONV, especially when used in large doses (>2.5 mg). 7 Some previous studies have recommended avoiding the use of acetyl choline esterase inhibitors to reduce postoperative vomiting. 8 Sugammadex is a ␥ cyclodextrin agent that selectively binds steroidal neuromuscular blockers such as rocuronium.…”

Succinylcholin-Update

“…[95]. Die Reversierung von Restblockaden bewirkt keine relevante Zunahme von postoperativer Übelkeit und Erbrechen (PONV) [93].…”