PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Review of the Literature

Prevention of post-operative nausea and vomiting (PONV) with Antiemetics

Introduction

Post-operative nausea and vomiting (PONV) is defined as nausea, vomiting, or retching occurring within the first 48 hours status post-surgery in the inpatient population (Pierre & Whelan, 2013). As anesthesia continues to advance, post-operative nausea and vomiting still remains a topic of concern. With incidence as high as 30%  for all post-operative patients during the first 24 hours and as high as 80% occurrence for high risk patients; nausea and vomiting can delay recovery time, leading to extended hospital stay. (Pierre & Whelan, 2013). Patients have reported that nausea and vomiting postoperatively is more bothersome than the surgery and post-operative pain itself. In an attempt to improve patient satisfaction and outcomes multiple studies, reviews, and guidelines have been established. The present paper will review current trends in prevention of post-operative nausea and vomiting. PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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Review of Prior Research & related data

Study Findings
Gan, T. J., et al.(2014) Conducted a systematic review and concluded that combination prophylactic antiemetic therapy can reduce the incidence of post op nausea and vomiting and should be used for those at moderate to high risk.
Zheng, J., et al.(2016) Evaluated effects of naloxone on 90 patients status post laparoscopic cholecystectomy under total intravenous anesthesia on fentanyl patient controlled analgesic. Results showed a significant reduction in the incidence of nausea and vomiting with low dose naloxone.
Young, S., et al.(2016) In a randomized control trial of 108 patients, undergoing lumbar fusion, who had at least 3 risk factors for PONV, received either IV Precedex (dexmedetomidine) (dexmedetomidine group) or 0.9% normal saline bolus (control group) 30 min prior to completion of surgery. Followed by postop, Fentanyl PCA with or without dexmedetomidine found adding dexmedetomidine to a fentanyl-based PCA drug mixture reduces the frequency and severity of acute postoperative nausea. PHARMACOLOGICAL MANAGEMENT OF PONV PAPER
Talebpour, M., et al. (2017) Analysis of controlled study of 8 patients undergoing laprosopic gastric plication treated with Promethazine/Dexamethasone or Metoclopramide /Dexamethasone post procedure in the recovery room. Showed that Promethazine/Dexamethasone deemed to be more effective at preventing nausea and vomiting post operatively than metoclopramide/dexamethasone.

 

Pharmacological intervention

  • At least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively= combination therapy
  • Anti-emetics Therapy - The recommended first- and second-line classes of pharmacologic antiemetics for PONV prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to):
    • NK-1 Receptor Antagonists
      • Akynzeo
      • aprepitant
      • Emend
      • fosaprepitant
      • netupitant/palonosetron
      • rolapitant
      • Varubi
    • 5-Hydroxytryptamine (5-HT3) Receptor Antagonists
      • Alosetron
      • Dolasetron
      • Granisetron
      • Ondansetron
      • Palonosetron
    • Glucocorticoids
      • prednisolone
    • Phenothiazines
      • prochlorperazine
      • chlorpromazine
      • fluphenazine
      • perphenazine,
      • trifluoperazine
      • thioridazine
      • mesoridazine
    • Phenylethylamines
      • Phenelzine
      • Phenformin
      • fanetizole,
    • Butyrophenones
      • Haloperidol
      • Benperidol
      • Droperidol
    • Antihistamines
      • Brompheniramine
      • Cetirizine
      • Chlorpheniramine
      • Clemastine
      • Diphenhydramine
      • Fexofenadine
      • Loratadine
    • Anticholinergics
      • diphenhydramine
      • trihexyphenidyl
      • benztropine mesylate
      • biperiden
      • Clomipramine
      • Chlorpromazine

 

PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Reference

Pierre, S., Whelan, R. Nausea and vomiting after surgery, Continuing Education in Anaesthesia Critical Care & Pain, 13(1). https://doi.org/10.1093/bjaceaccp/mks046.

Talebpour, M., Ghiasnejad Omrani, N., Imani, F., Shariat Moharari, R., Pourfakhr, P., & Khajavi, M. R. (2017). Comparison Effect of Promethazine/Dexamethasone and Metoclopramide /Dexamethasone on Postoperative Nausea and Vomiting after Laparascopic Gastric Placation: A Randomized Clinical Trial. Anesthesiology and Pain Medicine7(4), e57810. http://doi.org/10.5812/aapm.57810.

Tong J. Gan, Pierre Diemunsch, Ashraf S. Habib, Anthony Kovac, Peter Kranke, Tricia A. Meyer, Mehernoor Watcha, Frances Chung, Shane Angus, Christian C. Apfel, et al.(2014). Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia,118(1):85-113. doi:10.1213/ANE.0000000000000002.

Young Song, Jae-Kwang Shim, Jong-Wook Song, Eui-Kyung Kim, Young-Lan Kwak. (2016).
Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients: A randomised controlled trial.  European Academy of Anesthesiology, 33(2): 75–83. doi: 10.1097/EJA.0000000000000327.

Zheng, J., Han, W., Han, X.-D., Ma, X.-Y., & Zhang, P. (2016). Effect of naloxone on intravenous fentanyl patient-controlled analgesia after laparoscopic cholecystectomy. Medicine95(48). http://doi.org/10.1097/MD.0000000000005074.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

1.) SAMBA Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: An Executive Summary for Perianesthesia Nurses

Hooper, V. D. Journal of PeriAnesthesia Nursing 30 (5): 377-382.(2015)

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2.) Consensus guidelines for the management of postoperative nausea and vomiting

Gan, T. J., et al. Anesth Analg 118 (1): 85-113.(2014)

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

NLM 24356162

3.) Effect of naloxone on intravenous fentanyl patient-controlled analgesia after laparoscopic cholecystectomy

Zheng, J., et al. Medicine 95 (44): e5074-e5074.(2016)

This study aims to evaluate the effect of naloxone on intravenous fentanyl patient-controlled analgesia after laparoscopic cholecystectomy under total intravenous anesthesia.A total of 90 patients, who underwent intravenous fentanyl patient-controlled analgesia after laparoscopic cholecystectomy under total intravenous anesthesia, were included into this study. All patients were randomly divided into 3 groups (each group, n=30): naloxone group (naloxone+fentanyl), tropisetron group (tropisetron+fentanyl), and fentanyl group (fentanyl). Patients in each group were given a corresponding dose of naloxone. Postoperative analgesia effect and the incidence of side effects such as nausea and vomiting were observed.Small doses of naloxone or tropisetron combined with fentanyl used for intravenous patient-controlled analgesia can significantly reduce the incidence of nausea and vomiting. Six hours after surgery, visual analogue scale (VAS) scores were significantly lower in patients that underwent intravenous patient-controlled analgesia using low-dose naloxone combined with fentanyl compared with patients who received fentanyl alone; however, the postoperative analgesic effect of tropisetron was not observed. Compared with the combination of tropisetron and fentanyl, low-dose naloxone combined with fentanyl can obviously reduce the incidence of nausea and vomiting in patients who underwent intravenous patient-controlled analgesia after laparoscopic cholecystectomy, and enhance the analgesic effect of fentanyl 6 hours after surgery.Low-dose naloxone can reduce the incidence of nausea and vomiting in patients who underwent laparoscopic cholecystectomy under total intravenous anesthesia, and exhibits a certain synergic analgesic effect.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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4.) Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients: A randomised controlled trial

Young, S., et al. European Journal of Anaesthesiology (Lippincott Williams & Wilkins) 33 (2): 75- 83.(2016)

 

Background: Dexmedetomidine, an α2 adrenergic receptor agonist, has analgesic, sedative and sympatholytic properties, with a lack of respiratory depression. It is licensed only for intensive care sedation.Objective: The objective of this study is to investigate whether intravenous (i.v.) patient-controlled analgesia (PCA) with dexmedetomidine added to a fentanyl-based drug mixture could reduce postoperative nausea and vomiting (PONV) in highly susceptible patients undergoing lumbar spinal surgery.Design: A randomised, double-blinded study.Setting: At a tertiary university hospital between September 2012 and September 2013.Patients: One hundred and eight patients undergoing level 1 or 2 posterior lumbar spinal fusion who had at least three risk factors for PONV (female, nonsmoker, use of postoperative opioids) were randomised into two groups. Three patients were excluded from analysis and 105 patients completed the study.Methods: Patients received either dexmedetomidine 0.5 μg kg−1 i.v. (dexmedetomidine group) or 0.9% normal saline (control group) 30 min before the completion of surgery followed by fentanyl 0.5 μg kg−1 and 4 mg ondansetron. Postoperatively, the PCA (fentanyl 10 μg kg−1 with 120 mg ketorolac, with or without dexmedetomidine 10 μg kg−1 made up to a total volume of 100 ml) was programmed to deliver 1 ml bolus (lockout 15 min) with a continuous background infusion of 2 ml h−1. The PCA was used for the first 48 h postoperatively.Main Outcome Measures: The incidence and severity of PONV, cumulative dose of PCA fentanyl consumed and pain scores were assessed for 48 h.Results: The dexmedetomidine group experienced less nausea during the time interval 1 to 3 h postoperatively compared with the control group [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.13 to 0.77; P = 0.019]. The intensity of nausea between the groups during the first 48 h was comparable, but the dexmedetomidine group had a lower incidence of moderate to severe nausea (OR 0.28; 95% CI 0.12 to 0.67; P < 0.003). Pain scores were not significantly different between the groups, but patients in the dexmedetomidine group required less fentanyl and less rescue analgesia in the first 12 h. Compared with the control group, patients in the dexmedetomidine group experienced almost twice as many episodes of hypotension and bradycardia, but this failed to reach statistical significance.Conclusion: Adding dexmedetomidine to a fentanyl-based PCA drug mixture reduces the frequency and severity of acute postoperative nausea in highly susceptible patients.Trial Registration: Clinicaltrials.gov identifier: NCT01840254.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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5.) Effect of cerebral oxygen saturation on postoperative nausea and vomiting in female laparoscopic surgery patients

WenJun, G., et al. Medicine 96 (41): 1-5.(2017)

Background: The purpose of this study was to investigate effect of cerebral oxygen saturation (SCTO2) on postoperative nausea and vomiting (PONV) in female patients who underwent laparoscopic surgery.Methods: This study included 90 female patients who underwent laparoscopic surgery (60 cases of gynecological operations and 30 cases of gallbladder operations). All patients were allocated into 3 groups of 30 patients each: group A (gynecological laparoscopic surgery), group B (gynecological laparoscopic surgery with mannitol treatment) and group C (laparoscopic cholecystectomy surgery). Perioperative SCTO2, mean blood flow velocity of vertebral artery (VM), vascular resistance index of vertebral artery (RI), and PONV (within 48 hours after surgery) were investigated.Results: No differences in age, body weight, operation time, and hemoglobin levels were observed among the patients (P > .05). The SCTO2 values for groups B and C were lower than those for group A in both brain hemispheres at T4 and T5 (P < .05). The VM was higher in group B than in groups A and C at T3 (P < .05), but differences in VM were not observed between groups B and C at T4 or T5. However, the VM of group A was still

lower than the other groups (P < .05), and no difference in VM was observed among the 3 groups at T6 (P > .05). The RI was higher in group C than in groups A and B at T4 (P < .05). The incidence of PONV within 48 hours after surgery was significantly higher in group A than in the other 2 groups (P < .05).Conclusion: Strategies that maintain normal SCTO2 may reduce the incidence of PONV in female patients who underwent laparoscopy surgery by reducing perioperative intracranial pressure.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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6.) Acupressure for post-operative nausea and vomiting: A pilot randomised controlled trial

Wendt, T., et al. Australian Critical Care 28 (1): 49-49.(2015)

Despite optimal pharmacological interventions, post-operative nausea and vomiting (PONV) is prevalent in patients following surgery. Vomiting is ranked the most undesirable outcome experienced by patients post- operatively. Acupressure has been recommended for the prevention of PONV but evidence to date is limited in the cardiac surgical population. This study aims to assess the feasibility and the efficacy of pericardium channel (PC) 6 acupoint stimulation versus placebo on PONV in cardiac surgical patients. This two-group, randomised, controlled, pilot trial was conducted at a tertiary referral intensive care unit in Brisbane. Twenty-nine patients were randomly assigned to receive the acupressure (bead) or placebo (non-bead) wristband. Wristbands were applied to both wrists post-operatively in the ICU and were removed at 36 h. Incidence of PONV, and need for rescue antiemetics were assessed up to 36 h. A Quality of Recovery (QoR) survey was conducted at day four. Thirteen patients were randomised to the acupressure group (8 males), and 16 patients to the placebo group (13 male). The mean Apfel risk score (predictor of PONV 0 = low risk and 4 = high risk) was two in both groups. The mean anaesthesia and cardiopulmonary bypass times were longer in the acupressure group (287.50min, 102.50min) than the placebo group (255.71 min, 78.86min). Although patient reports of nausea were similar between groups (46%, 50%), only 15% of patients vomited in the acupressure group as opposed to 53% in the placebo group. The use of rescue antiemetic therapy did not differ between groups (75%, 73%). The mean QoR score at day four was the same between groups (74.50,74.31). These interim results indicate that PC 6 acupoint stimulation is associated with less vomiting up to 36 h post cardiac surgery. A larger sample is required to determine the feasibility of conducting a multi-centre study.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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7.) The efficacy of gabapentin in reducing pain intensity and postoperative nausea and vomiting following laparoscopic cholecystectomy: A meta-analysis

 

Wang, L., et al. Medicine 96 (35): e8007-e8007.(2017)

Background: It is unknown whether gabapentin is effective in reducing acute pain following laparoscopic cholecystectomy. The purpose of the current meta-analysis was to evaluate the efficacy of gabapentin in reducing pain intensity and postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy.Methods: All randomized controlled trials (RCTs) evaluating the efficacy of gabapentin in reducing pain intensity and PONV after laparoscopic cholecystectomy were searched on the following databases: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Google database, the Chinese Wanfang database, and the China National Knowledge Infrastructure (CNKI). The most recent literature search was conducted on March 21, 2017. Outcomes including visual analog scale (VAS) at 12 and 24 hours, total morphine consumption, and the occurrence of PONV. Continuous outcomes were expressed as the weighted mean difference (WMD) and 95% confidence interval (CI), and the one discontinuous outcome was expressed as risk ratio (RR) and 95% CI. Stata 12.0 software was used for meta-analysis.Results: A total of 9 studies involving 966 patients were identified. In total, there were 484 gabapentin subjects and 482 controls. Compared with the control group, gabapentin was associated with lower VAS at 12 hours (WMD = -10.18, 95% CI: -17.36 to -2.80, P = .007) and 24 hours (WMD = -6.33, 95% CI: -8.41 to -4.25, P = .000), which was equivalent on a 110-point VAS scale to 10.18 points at 12 hours and 6.33 points at 24 hours. Compared with the control group, gabapentin was associated with less total morphine consumption by approximately 110.83 mg (WMD = -110.83, 95% CI: -183.25 to -38.42, P = .003). In addition, the occurrence of nausea and vomiting in gabapentin was decreased (25.2% vs 47.6, RR = 0.53, 95% CI: 0.44-0.63, P = .000).Conclusion: Gabapentin was efficacious in reducing postoperative pain, total morphine consumption, and morphine-related complications following laparoscopic cholecystectomy. In addition, there was a negative correlation between the gabapentin dosage and the occurrence of nausea and vomiting. The number of included studies is limited, and more studies are needed to verify the effects of gabapentin in laparoscopic cholecystectomy patients.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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8.) Usichenko, T. I. and T. Hesse (2016). Appropriate timing and intensity of PC6 stimulation for the prevention of postoperative nausea and vomiting...Liodden I, Sandvik L, Valeberg BT, et al. Acupuncture versus usual care for postoperative nausea and vomiting in children after tonsillectomy/ adenoidectomy: a pragmatic, multicentre, double-blinded, randomised trial. Acupunct Med 2015;33:196–203, BMJ Publishing Group. 34: 70-71.

9.) The efficacy of PC6 acupressure with Sea-Band® on reducing postoperative nausea and vomiting in patients after hysterectomy: A randomized controlled trial

Thorn, H., et al. Journal of Nursing Education & Practice 6 (2): 115-122.(2016)

Aims and objectives: To assess whether bilateral stimulation of the PC6 acupuncture point with Sea-Band R could reduce patients' experience of postoperative nausea and vomiting (PONV) after hysterectomy. PONV has high prevalence among gynecological patients. Acupressure bands have been suggested to lessen PONV, however; the antiemetic effectiveness of using acupressure band is still not clarified. Methods: Design: Randomized, non- blinded, single centre trial in a teaching hospital in Denmark. Seventy-two women scheduled for vaginal or laparoscopic hysterectomy of benign indication, were enrolled in this randomized trial. The women were allocated either to the PC6 group or to the control group. The PC6 group wore Sea-Band R wristbands bilaterally for 24 h. The main outcome was complete response i.e., no PONV and rescue antiemetic. Results: Sixty-two participants (PC6 n = 32; control n = 30) were analyzed. There was no statistically significant difference in complete response between the groups (PC6 group, 50% versus control group 43%) or the incidence of PONV within the first 24 h postoperatively (PC6 group, 47% versus control group 60%) or in need of rescue antiemetic (PC6 group 38% versus control group 33%). Conclusions: At the same time as this study started, a new antiemetic was introduced to the clinic and hence interfered with the calculation of sample size and influenced the results. The study did not support the study hypotheses. PC6 acupressure bilaterally for 24 h did not result in significant preventive effects in reducing PONV nor did it result in reduced length of postoperative hospital stay.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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10.) Examining the efficacy of stimulating the PC6 wrist acupuncture point for preventing postoperative nausea and vomiting: A Cochrane review summary

Stott, A. International Journal of Nursing Studies 64 139-141.(2016) EBSCOhost ccm

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11.) Effects of hypercapnia on postoperative nausea and vomiting after laparoscopic surgery: a double-blind randomized controlled study

Son, J.-S., et al. Surgical Endoscopy 31 (11): 4576-4582.(2017)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Background: Laparoscopic surgery is associated with a high incidence of postoperative nausea and vomiting (PONV). The use of CO2 pneumoperitoneum has been proposed as a potential cause of high PONV incidence. However, intraoperative hypercarbia may be related to enhanced perfusion to the main effector sites for PONV, including the brain and gastrointestinal tract. In this study, we investigated whether an increase in intraoperative CO2 partial pressure in arterial blood (PaCO2) reduces the incidence of PONV.Methods: This study enrolled 400 female patients aged 20-60 years who were undergoing laparoscopic gynecologic surgery. The patients were allocated randomly to one of three groups with the following intraoperative PaCO2 levels: 36-40 mmHg (Group 1), 41-45 mmHg (Group 2), or 46-50 mmHg (Group 3). The anesthetic regimen used a standardized total intravenous anesthesia consisting of propofol and remifentanil for all patients. The arterial blood gas analysis was performed to identify the difference in CO2 partial pressure between arterial blood and end-tidal gas. The PONV incidence was evaluated for the periods of 0-2, 2-6, and 6-24 h after anesthesia. The incidence and severity of PONV and the administration of rescue antiemetics were recorded.Results: The three groups were comparable for the patient, anesthesia, and surgical characteristics. The average PaCO2 level during surgery was 38-39, 43-44, and 47-
48 mmHg in Groups 1, 2, and 3, respectively. The incidence and severity of PONV and use of rescue antiemetics were not significantly different among the groups. The overall incidence of nausea during the first 24-h postoperative period was 54, 48, and 50% in Groups 1, 2, and 3, respectively (P = 0.593).Conclusion: Our data suggest that mild to moderate intraoperative hypercapnia did not decrease the incidence and severity of PONV or the requirement for rescue antiemetics after gynecologic laparoscopic surgery.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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12.) Reducing the Incidence of Postoperative Nausea and Vomiting Begins With Risk Screening: An Evaluation of the Evidence

Smith, C. A. and L. Ruth-Sahd. Journal of PeriAnesthesia Nursing 31 (2): 158-171.(2016)

Postoperative nausea and vomiting (PONV) is a daily concern for patients and perianesthesia nurses. PONV is experienced by approximately one third of all surgical patients. Identification of patients at risk for PONV through preoperative risk assessment is an effective means in reducing the incidence of PONV. Perianesthesia nurses are positioned to implement such risk assessments by using simplified risk scores to identify moderate to high-risk patients. Risk assessment allows for facilitation of targeted prophylaxis which positively impacts the patients’ surgical outcome and experience. Targeted prophylaxis is efficacious in reducing the institutional incidence of PONV which decreases resource utilization and cost. The perianesthesia nurse is the crucial component in minimizing the PONV in the post-surgical patient. This evaluation of the evidence reveals that preoperative PONV risk screening leads to decreased incidence of PONV for the surgical patient, improves patient satisfaction and reduces postoperative complications.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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13.) Haloperidol Versus 5HT3 Receptor Antagonists for Postoperative Vomiting and QTc Prolongation: A Noninferiority MetaAnalysis and Trial Sequential Analysis of Randomized Controlled Trials

Singh, P. M., et al. Journal of Clinical Pharmacology 58 (2): 131-143.(2018)

Abstract: Haloperidol is an antipsychotic with well‐known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta‐analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5‐HT3‐receptor antagonists (5‐HT3‐RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double‐blinded trials were included in the final analysis. Twenty‐four‐hour vomiting incidence was similar in groups (fixed effects, <italic>P</italic> = 0.52, I2 = 0%). Trial‐sequential analysis confirmed noninferiority of haloperidol over 5‐HT3‐RAs (α = 5%, β = 20%, δ = 10%), with “information size” being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5‐HT3‐RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, <italic>P</italic> = 0.23, I2 = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial‐sequential analysis showed statistical equivalence (α = 5%, β = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X‐intercept = 2.07, <italic>P</italic> = 0.10). We conclude that haloperidol is equivalent to the well‐established 5‐HT3‐RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5‐HT3‐RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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14.) Effects of preoperative carbohydrates drinks on immediate postoperative outcome after day care laparoscopic cholecystectomy

Singh, B., et al. Surgical Endoscopy 29 (11): 3267-3272.(2015)

Background: Postoperative nausea and vomiting is the most common cause for unexpected hospital admission of patients undergoing day care surgery. Overnight fasting changes patient metabolic state and influences their perioperative stress response. Preoperative carbohydrate loading may have accelerated recovery and better overall outcome after major abdominal surgery. The aim of the study was to investigate the effects of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting and pain after day care laparoscopic cholecystectomy.Methods: A total of 120 patients posted for day care laparoscopic cholecystectomy were included in the study and were randomized into three groups. Group A (Cases)-receiving the carbohydrate-rich drink before surgery (CHO), group B (placebo)-receiving the placebo drink before surgery and group C (controls)-fasting from midnight before surgery. Postoperative nausea and vomiting and visual analogue score for pain were noted and analyzed for 24 h.Results: Mean score of nausea in 0-4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4-12 and 12-24 h between groups was not significant (p = 0.066), (p = 0.257). Mean score of vomiting in 0-4 and 4-12 h in group A was significantly less than that of group B and group C (p = 0.004), (p = 0.001). Mean score of pain in group A was significantly less when compared to group B and group C in 0-4 h (p = 0.001) and 4-12 h (0.005).Conclusion: Perioperative consumption of a carbohydrate-rich drink can minimize postoperative nausea, vomiting and pain in patients undergoing outpatient cholecystectomy. Consumption of carbohydrate drinks up to 2 h prior to surgery is not associated with additional complications.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

 

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  1. Language: English. Entry Date: 20160602. Revision Date: 20171020. Publication Type: journal article

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15.) Postoperative Nausea and Vomiting: Palonosetron with Dexamethasone vs. Ondansetron with Dexamethasone in Laparoscopic Hysterectomies

Sharma, A. N. G. and P. Shankaranarayana. Oman Medical Journal 30 (4): 252-256.(2015)

Objectives: Postoperative nausea and vomiting (PONV) is the most common complication seen following laparoscopic surgery. Our study sought to evaluate the efficacy of the newer drug palonosetron with that of ondansetron, in combination with dexamethasone, for PONV in patients undergoing laparoscopic hysterectomies. Methods: A total of 90 patients, aged between 30-50 years old, posted for elective laparoscopic hysterectomies under general anesthesia belonging to the American Society of Anesthesiologist (ASA) physical status I and II were included in the study. Patients were randomly divided into one of two groups (n=45). Before induction, patients in the first group (group I) received 0.075mgpalonosetron with 8mg dexamethasone and patients in the second group (group II) received 4mg ondansetron with 8mg dexamethasone. Postoperatively, any incidences of early or delayed vomiting, requirement of rescue antiemetic, and side effects were recorded. Patient's hemodynamics were also monitored. Statistical analysis was done using Student's test, chi-square test, and Fisher's exact test. Results: Preoperative, intraoperative, and postoperative heart rate, mean arterial pressure, peripheral capillary oxygen saturation were statistically not significant (p>0.050) in either group. In group II, eight patients had nausea in the first two hours and three patients had nausea in the two to six-hour postoperative period. In group I, three patients experienced nausea in the first six hours period. Eight patients in group II had vomited in the first two- hour period compared to one patient in group I (p=0.013). The requirement of rescue antiemetic was greater in group II than group I (20% vs. 4%). No side effects of antiemetic use were observed in either group. Conclusion: The combination of palonosetron with dexamethasone is more effective in treating early, delayed, and long term PONV compared to ondansetron with dexamethasone in patients undergoing elective laparoscopic hysterectomies under general anesthesia.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20161118. Revision Date: 20161118. Publication Type: Article

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16.) Improving Prevention and Treatment of PONV

Serra, R. Journal of PeriAnesthesia Nursing 28 (3): e20-e20.(2013) EBSCOhost ccm

PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

  1. Language: English. Entry Date: 20131114. Revision Date: 20150711. Publication Type: Journal Article

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17.) Comparison of dexamethasone or intravenous fluids or combination of both on postoperative nausea, vomiting and pain in pediatric strabismus surgery

Sayed, J. A., et al. Journal of Clinical Anesthesia 34 136-142.(2016)

Background: Strabismus surgery is perhaps a pediatric surgical procedure that has the strongest evidence of postoperative nausea and vomiting (PONV) risk. This randomized controlled blind study was designed to evaluate the efficacy of combined therapy of dexamethasone and intraoperative superhydration vs their monotherapy on the incidence and severity of PONV and on pain intensity after pediatric strabismus surgery.Methods: A total of 120 children aged 6 to 12 years undergoing strabismus surgery were randomized to equally 3 groups to receive 0.15 mg/kg dexamethasone (dexamethasone group) or intraoperative superhydration of lactated Ringer's solution in a dose of 30 mL/kg per fasting time (superhydration group), or a combination of dexamethasone and intraoperative fluid in the same strategy (combination therapy group). The incidence and severity of PONV and pain using visual analog scale score, and need for supplemental antiemetic and analgesic therapy and their consumptions were assessed and compared in the 3 studied groups for 24 hours postoperatively.Results: The incidence of PONV and postoperative vomiting was significantly lower (P> .001) in the combination therapy group (5% and 5% respectively) compared with the dexamethasone group (35% and 30%) and superhydration group (32.5% and 35%). There was no significant difference among patients in the superhydration group and dexamethasone group in the cumulative incidences of PONV in the whole 24 hours postoperatively. Postoperative aggregated visual analog scale pain score and total acetaminophen consumption showed a significant reduction (P> .05) in the combination therapy group together with significant prolongation of time to the first analgesic request compared with both the superhydration group and the dexamethasone group.Conclusion: Combined therapy of 0.15 mg/kg dexamethasone 1 minute before induction and intraoperative fluid superhydration is an effective and safe way to reduce PONV and pain better than monotherapy of dexamethasone, or intraoperative superhydration separately for pediatric strabismus surgery.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20170401. Revision Date: 20170727. Publication Type: journal article

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18.) Prevention of Post Operative Nausea and Vomiting with Pre-Operative Intervention

Richardson, M., et al. Journal of PeriAnesthesia Nursing 30 (4): e39-e39.(2015)
EBSCOhost ccm
108506194. Language: English. Entry Date: 20151012. Revision Date: 20151012. Publication Type: Article

 

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19.) Preoperative intravenous glucocorticoids can decrease acute pain and postoperative nausea and vomiting after total hip arthroplasty: A PRISMA-compliant meta-analysis

Qing, Y., et al. Medicine 96 (47): 1-8.(2017)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Background: A systematic review and meta-analysis of published randomized controlled trials (RCTs) were performed to assess the efficacy and safety of preoperative intravenous glucocorticoids versus controls for the prevention of postoperative acute pain and postoperative nausea and vomiting (PONV) after primary total hip arthroplasty (THA).Methods: A computer literature search of electronic databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China National Knowledge Infrastructure (CNKI), and China Wanfang database, was conducted to identify the relevant RCTs comparing preoperative intravenous glucocorticoids versus placebos for reducing acute pain and PONV in THA patients. The primary outcomes included the use of the visual analog scale (VAS) with rest or mobilization at 6, 24, 48, and 72 hours and the occurrence of PONV. The secondary outcome was total morphine consumption. We calculated the risk ratio (RR) with a 95% confidence interval (95% CI) for dichotomous outcomes, and the weighted mean difference (WMD) with a 95% CI for continuous outcomes.Results: Pooled data from 7 RCTs (411 THAs) favored preoperative intravenous glucocorticoids against acute pain intensity at 4, 24, and 48 hours (P < .05). There was no significant difference between the VAS with rest or mobilization at 72 hours (P > .05). Subsequently, preoperative intravenous glucocorticoids provided a total morphine-sparing effect of 9.36 mg (WMD = -9.36, 95% CI = -12.33 to - 6.38, P = .000). In addition, preoperative intravenous glucocorticoids were associated with a significant reduction of the occurrence of PONV (RR = 0.41, 95% CI = 0.30-0.57, P = .000).Conclusion: Intravenous glucocorticoids can decrease early pain intensity and PONV after THA. However, the low number of studies and variation in dosing regimens limits the evidence for its use. Thus, more high-quality RCTs are still needed to identify the optimal drug and the safety of intravenous glucocorticoids.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20180211. Revision Date: 20180205. Publication Type: journal article. Journal Subset: Biomedical

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20.) Effectiveness of postoperative intravenous acetaminophen (Acelio) after gastrectomy: A propensity score-matched analysis

Ohkura, Y., et al. Medicine 95 (44): e5352-e5352.(2016)

The aim of this study was to investigate the efficacy of postoperative scheduled intravenous acetaminophen to reduce the opioid use and enhance recovery after gastrectomy.Opioid use is reportedly associated with delayed recovery of gastrointestinal (GI) peristalsis and postoperative nausea/vomiting (PONV) despite of acceptable efficacy for pain control.Of 147 and 96 consecutive patients who underwent gastrectomy for gastric cancer before and after introduction of postoperative scheduled intravenous acetaminophen, propensity score matched population was created and short-term clinical outcomes were compared.Significant defervescence was demonstrated in Acetaminophen group (A-group) compared with control group (C-group) during the perioperative period (P < 0.001), whereas no significant difference was observed in postoperative inflammatory parameters. The incidence of postoperative complications was similar between the groups. The number of patient-controlled analgesia (PCA) pushes was significantly reduced in the A-group (P = 0.007) and the frequency of use of other nonopioid analgesics was also significantly reduced in the A-group (P < 0.001). Both daily and cumulative opioid use was significantly reduced in the A-group (P < 0.001). The time to first flatus and defecation was decreased in the A- group (P < 0.001 and P = 0.038, respectively). The incidence of PONV was significantly reduced from 26.0% to 12.5% after introduction of intravenous acetaminophen (P = 0.017), and hospital stay tended to be decreased in the A- group (13.2 vs 14.7 days, P = 0.069)Postoperative scheduled intravenous acetaminophen decreased opioid use and may be associated with enhanced recovery after gastrectomy.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20170210. Revision Date: 20170919. Publication Type: journal article. Journal Subset: Biomedical

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21.) A Comparison of Fosaprepitant and Ondansetron for Preventing Postoperative Nausea and Vomiting in Moderate to High Risk Patients: A Retrospective Database Analysis

Murakami, C., et al. BioMed Research International 1-5.(2017)

Postoperative nausea and vomiting (PONV) occur in 30–50% of patients undergoing general anesthesia and in 70– 80% of high PONV risk patients. In this study, we investigated the efficacy of fosaprepitant, a neurokinin-1 (NK1) receptor antagonist, compared to ondansetron, a selective 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, in moderate to high PONV risk patients from our previous randomized controlled trials. Patients (171 patients from 4 pooled studies) with the Apfel simplified score ≥ 2 and undergoing general anesthesia were randomly allocated to receive intravenous fosaprepitant 150 mg (NK1 group, n=82) and intravenous ondansetron 4 mg (ONS group, n=89) before induction of anesthesia. Incidence of vomiting was significantly lower in the NK1 group compared to the ONS group 0–2, 0–24, and 0–48 hours after surgery (2 versus 17%, 2 versus 28%, and 2 versus 29%, resp.). However, no significant differences in PONV, complete response, rescue antiemetic use, and nausea score were observed between groups 0–48 hours after surgery. In moderate to high PONV risk patients, fosaprepitant decreased the incidence of vomiting and was superior to ondansetron in preventing postoperative vomiting 0–48 hours after surgery.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20171220. Revision Date: 20171220. Publication Type: Article

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22.) Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy?: A randomized control trial

Mishra, A., et al. Journal of Clinical Anesthesia 40 7-10.(2017)

Study Objective: To compare the incidence of postoperative nausea and vomiting (PONV) during perioperative administration of 5% dextrose and normal saline in laparoscopic cholecystectomy.Design: Prospective, randomized, double-blind trial.Setting: Operating rooms in a tertiary care hospital of Northern India.Patients: One hundred patients with American Society of Anesthesiologists status I to II undergoing laparoscopic cholecystectomy were enrolled in this study.Interventions: Patients were randomized into two groups [normal saline (NS) group and 5% dextrose (D) group]. Both the groups received Ringer acetate (Sterofundin ISO) intravenously as a maintenance fluid during intraoperative period. Besides this, patients of group NS received 250ml of 0.9% normal saline and patients of group D received 5% dextrose @ 100ml/h started at the time when gall bladder was taken out. It was continued in the postoperative period with the same rate till it gets finished.Measurements: Incidence of PONV, Apfel score, intraoperative opioids used and consumption of rescue antiemetics.Main Results: Demographic data was statistically similar. Out of total 100 patients, 47 patients (47%) had PONV. In group D, 14 patients (28%) had PONV while in group NS, 33 patients (66%) had PONV within 24h of surgery (p value 0.001). The incidence of PONV was reduced by 38% in group D which is significantly lower when compared with that of group NS (p value 0.001). The consumption of single dose of rescue antiemetics in group D was also reduced by 26% when compared to that of group NS (p value 0.002).Conclusions: Perioperative administration of 5% dextrose in patients undergoing laparoscopic surgery can reduce PONV significantly and even if PONV occurs, the quantity of rescue antiemetics to combat PONV is also reduced significantly.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20171114. Revision Date: 20180205. Publication Type: journal article

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23.) Aprepitant: A New Modality for the Prevention of Postoperative Nausea and Vomiting: An Evidence-Based Review

Milnes, V., et al. Journal of PeriAnesthesia Nursing 30 (5): 406-417.(2015)

Purpose Postoperative nausea and vomiting (PONV) affects as many as 30% of surgical patients. Aprepitant, an antagonist of the neurokinin-1 receptor with a 40% half-life, may be effective for prophylaxis for PONV. This review describes the evidence of adding aprepitant to antiemetic therapy for PONV prophylaxis. Methods A literature search was conducted to answer the population-intervention-comparison-outcome-time (PICOT) question: In adult patients undergoing general anesthesia (P), does aprepitant (I) decrease PONV (O) postoperatively (T) as compared to patients receiving other antiemetic therapy or a placebo (C)? Results Eight randomized controlled trials, one prognostic study, and one post hoc analysis were appraised. Perioperatively, aprepitant decreased the severity and number of episodes of PONV. Discussion Aprepitant appears to be more effective in decreasing the incidence of PONV postoperatively as compared with ondansetron. It is recommended that aprepitant is used to treat patients at risk for PONV and for whom PONV could lead to catastrophic adverse outcomes.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20150929. Revision Date: 20150929. Publication Type: Article

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24.) Does Type of Pharyngeal Packing during Sinonasal Surgery Have an Effect on PONV and Throat Pain?

Meco, B. C., et al. Otolaryngology-Head & Neck Surgery 154 (4): 742-747.(2016)

Objective: Postoperative nausea and vomiting (PONV) is a common problem that affects up to 30% of all surgical patients after general anaesthesia, which increases in sinonasal surgery due the very potent emetic effect of ingested blood that is swallowed during the procedures. Therefore, a hypo/oropharyngeal packing is commonly placed in an effort to prevent blood ingestion. The primary aim of this study was to compare the efficacy of 3 packing types in preventing PONV and to compare the results with patients who received no packing. The secondary aim was to compare the postoperative throat pain in all 4 groups.Study Design: A prospective double- blind randomized controlled study.Setting: A university hospital.Subjects and Methods: After Institutional Review Board approval and informed consent, 201 adult patients scheduled for sinonasal surgery were randomized to 4 groups to have dry packing (n = 52), packing soaked with water (n = 48), packing soaked with chlorhexidine gluconate and benzydamine hydrochloride (n = 51), or no packing (n = 50). Postoperative PONV and throat pain were assessed.Results: Demographic data, procedural characteristics, and PONV risk scores were similar among groups. The PONV incidences, throat pain scores, and analgesic use were comparable in all 4 groups.Conclusion: Despite commonly used practices, usage of different types of pharyngeal packing did not affect incidence of PONV and throat pain, nor did usage of no packing.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20160820. Revision Date: 20160831. Publication Type: journal article

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25.) Nausea and Vomiting in Daycase Surgery -- a Quality Indicator

Mayhew, D., et al. Journal of One-Day Surgery 27 (1): 9-17.(2017)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20170309. Revision Date: 20170309. Publication Type: Article

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26.) Acupuncture versus usual care for postoperative nausea and vomiting in children after tonsillectomy/adenoidectomy: a pragmatic, multicentre, double-blinded, randomised trial

Liodden, I., et al. Acupuncture in Medicine 33 (3): 196-203.(2015)

Objectives To investigate the effect of a standardised acupuncture on nausea and vomiting in children after tonsillectomy with or without adenoidectomy when possible placebo effects were precluded. Methods A pragmatic, multicentre, double-blinded, randomised controlled trial. The study was conducted over 10 months in 2012-2013 at three ambulatory clinics. Two hundred and eighty-two children, age 1-11 years, American Society of Anesthesiologists grade ≤II, were included. To equalise expectancy effects, all parents were told that their child would receive acupuncture. However, children were randomly allocated to perioperative bilateral needling acupuncture at PC6, depth 7 mm, mean time 17 min (SD 5-45) during anaesthesia plus usual care, or to usual care only. The regional ethics committee approved this approach. Primary endpoints were nausea and vomiting 24 h postoperatively. Results This study did not demonstrate any effect of acupuncture (95% CI) compared with standard care. The overall vomiting in the acupuncture and usual-care groups was 44.2% and 47.9%, respectively. Nausea was experienced by 31.7% in the acupuncture group and by 32.6% in the usual-care group. The test power was acceptable for comparisons of vomiting. Conclusions The findings suggest that when controlling for possible placebo effects standardised PC6 acupuncture needling during anaesthesia without further stimulation of PC6 is not effective in reducing nausea and vomiting in children after tonsillectomy with or without adenoidectomy. Future studies should investigate acupuncture treatment which balances adequate dose and technique and a feasible, child-friendly acupuncture treatment. Trial registration number ClinicalTrials.gov NCT01729052.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20150707. Revision Date: 20150923. Publication Type: Journal Article

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27.) A Meta-Analysis of Palonosetron for the Prevention of Postoperative Nausea and Vomiting in Adults

Li, Y., et al. Journal of PeriAnesthesia Nursing 30 (5): 398-405.(2015)

Purpose The aim of this meta-analysis was to evaluate the effectiveness and adverse effects of palonosetron in the prevention of postoperative nausea and vomiting (PONV). Design A meta-analysis using a systematic search strategy was performed. Methods A meta-analysis of randomized controlled clinical trials was performed to compare palonosetron with first-generation 5-hydroxytryptamine 3 receptor antagonist (5-HT3RA) or placebo to prevent PONV. Fixed or random effect models were used to combine homogenous data. Findings A total of 10 randomized controlled clinical trials including 1,827 patients were identified. The data showed statistically significant differences in favor of palonosetron (0.075 mg) in the prevention of acute PONV ( P < .00001) and delayed PONV ( P < .002), reducing the risk of PONV by 49% and 51%, respectively. Subgroup analyses indicated significant differences in favor of palonosetron compared with placebo ( P < .00001) or first-generation 5-HT3RA ( P = .002). There were no significant differences in the occurrence of headache, dizziness, and constipation between palonosetron and control groups ( P = .85, P = .22, and P = .30, respectively). Conclusions The results of this meta-analysis suggest that intravenous palonosetron could become a prophylactic antiemetic 5-HT3RA in the prevention of PONV compared with first-generation 5-HT3RAs or placebo. No increased risk of side effects with palonosetron were found.

EBSCOhost ccm
109885189. Language: English. Entry Date: 20150929. Revision Date: 20150929. Publication Type: Article

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28.) Effects of Electroacupuncture Administered 24hours Prior to Surgery on Postoperative Nausea and Vomiting and Pain in Patients Undergoing Gynecologic Laparoscopic Surgery: A Feasibility Study

Li, S., et al. Explore: The Journal of Science & Healing 13 (5): 313-318.(2017)

Objective: Our study aimed to investigate the feasibility and effectiveness of preoperative electroacupuncture (EA), delivered 24hours before surgery, on postoperative nausea and vomiting (PONV) and postoperative pain in patients undergoing gynecologic laparoscopic surgery.Methods: In this randomized controlled trial, 40 patients scheduled for elective gynecologic laparoscopic surgery were randomly assigned to the usual care (UC) group and the EA group (n = 20 each). Both groups received the routine treatment consisting of intravenous dexamethasone (5mg) after induction of anesthesia and intravenous tropisetron (5mg) before the end of the operation. The patients in the EA group received EA at bilateral neiguan (PC6) and zusanli (ST36) within 24hours prior to the surgery. The incidence and severity of PONV and pain were recorded at 6hours, 12hours, and 24hours after the operation. Time to first flatus passage was also recorded. Bonferroni-corrected independent sample t-tests were used to analyze the data.Results: In the first six hours after surgery, 15% and 20% of the patients experienced postoperative nausea in the EA and the UC groups, respectively. The incidences of postoperative vomiting were 5% for the EA group and 20% for the UC group. PONV reduced to zero over 12hours in both groups and there was no statistically significant difference in PONV between the two groups at any time point. The EA group rated their postoperative pain statistically significantly lower than the UC group did at six hours postoperative (EA: 1.9 ± .8; UC: 2.9 ± .9, P = .001). The two groups did not differ in pain at 12 and 24hours. The EA group had a shorter time to pass first flatus than the UC group did (EA: 20.3hours ± 6.1; UC: 26.4 ± 5.2, P = .002). The common EA-related adverse effects were minor, and did not require medical attention. The patients tolerated the EA treatment well.Conclusion: It is feasible and safe to deliver one-session EA treatment within 24hours preoperatively to preempt postoperative pain. One-session preoperative EA may also accelerate motility of the gastrointestinal track. Properly powered studies are needed to further test the effectiveness of preoperative EA on PONV.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: In Process. Revision Date: 20170919. Publication Type: journal article. Journal Subset: Alternative/Complementary Therapies

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29.) Effectiveness of Ginger Essential Oil on Postoperative Nausea and Vomiting in Abdominal Surgery Patients

Lee, Y. R. and H. S. Shin. Journal of Alternative & Complementary Medicine 23 (3): 196-200.(2017)

Background: The purpose of this study was to examine the effectiveness of aromatherapy with ginger essential oil on nausea and vomiting in abdominal surgery patients. Method: This was a quasi-experimental study with a nonequivalent control group and repeated measures. The experimental group ( n = 30) received ginger essential oil inhalation. The placebo control group ( n = 30) received normal saline inhalation. The level of postoperative nausea and vomiting was measured using a Korean version of the Index of Nausea, Vomiting, and Retching (INVR) at baseline and at 6, 12, and 24 h after aromatherapy administration. The data were collected from July 23 to August 22, 2012. Results: Nausea and vomiting scores were significantly lower in the experimental group with ginger essential oil inhalation than those in the placebo control group with normal saline. In the experimental group, the nausea and vomiting scores decreased considerably in the first 6 h after inhaled aromatherapy with ginger essential oil. Conclusion: Findings indicate that ginger essential oil inhalation has implications for alleviating postoperative nausea and vomiting in abdominal surgery patients.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20170320. Revision Date: 20170325. Publication Type: Article

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30.) Electroacupuncture on PC6 prevents opioid-induced nausea and vomiting after laparoscopic surgery

Lee, S., et al. Chinese Journal of Integrative Medicine 19 (4): 277-281.(2013)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Objective: To investigate the treatment time dependence of electroacupuncture (EA) on Neiguan (PC6) for preventing postoperative nausea and vomiting (PONV). Methods: One hundred and seventy-eight patients, who had received intravenous patient-controlled analgesia (PCA) with Fentanyl, were assigned randomly to three groups using random numbers: a pre-operative EA group (PrEA), a post-operative EA group (PoEA), and a non- acupuncture control group (NC). An anesthetist evaluated the incidence and severity of nausea and vomiting for 48 h after surgery blindly. The main outcomes were severity and freguency of PONV, which were measured with a self-reported questionnaire and a confirmation from the anesthetist. The data were analyzed with ANOVA and Z- test. Results: The incidence of nausea and vomiting was significantly lower in the PrEA group than the NC group during 48 h after surgery ( P<0.01, P<0.05). The incidence of vomiting was also significantly lower in the PrEA group than the PoEA group ( P<0.05). The PoEA subjects evidenced no significant differences compared with the NC subjects in terms of the incidence of nausea and vomiting ( P<0.05). The severity of nausea was significantly lower in the PrEA group than in the NC and PoEA groups ( P<0.05). Conclusions: EA on PC6 is effective in the prevention of PONV, and pre-operative acupuncture is more effective than post-operative acupuncture.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20130404. Revision Date: 20150818. Publication Type: Journal Article

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31.) Effective Dose of Ramosetron for Prophylaxis of Postoperative Nausea and Vomiting in High-Risk Patients

Lee, S., et al. BioMed Research International 2015 1-6.(2015)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Background. Postoperative nausea and vomiting (PONV) are common adverse events with an incidence of up to 80% in high-risk patients. Ramosetron, a selective 5-HT3 receptor antagonist, is widely used to prevent PONV. The purpose of this study was to evaluate the effective dose of ramosetron for the prevention of PONV in high-risk patients. Methods. Fifty-one patients were randomly allocated to 3 groups and were administered ramosetron 0.3 mg (group A), 0.45 mg (group B), or 0.6 mg (group C), at the end of their surgery. The episodes of PONV were assessed 1, 6, 24, and 48 hours after the injection and all the adverse events were observed. Results. The complete response rate in the postoperative period 6–24 hours after the anesthesia was higher in group C than in group A: 93% versus 44%. Group C’s experience score of Rhodes index was lower than group A’s: 0.81 ± 2.56 versus 3.94 ± 5.25. No adverse drug reaction could be observed in all groups. Conclusions. The effective dose of ramosetron to be injected for the near-complete prophylaxis of PONV 6 to 24 hours after surgery in high-risk patients is a 0.6 mg bolus injection at the end of the surgery.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

EBSCOhost ccm

  1. Language: English. Entry Date: 20151008. Revision Date: 20151008. Publication Type: Article

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32.) Go-rei-San, a Kampo Medicine, Reduces Postoperative Nausea and Vomiting: A Prospective, Single-Blind, Randomized Trial

Kori, K., et al. Journal of Alternative & Complementary Medicine 19 (12): 946-950.(2013)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Objective: The objective of this study was to determine the efficacy of Go-rei-San (GRS), a Kampo medicine, in the treatment of postoperative nausea, vomiting, or both nausea and vomiting (PONV). Design: The study was a randomized, controlled, single-blind study of two groups of adult female patients who were scheduled to undergo benign gynecological laparoscopic surgery under general anesthesia. Patients in each group possessed an American Society of Anesthesiologists physical status of 1 (normal, healthy patient) to 2 (patient with a mild systemic disease). Patients were randomly assigned to the GRS group or the no-intervention group. Intervention: Patients in the GRS group were given 7.5 g of GRS orally the day before surgery. Outcome Measures: The primary outcome measure was the severity of nausea at 0-3 h and 0-24 h after tracheal extubation. The secondary outcome measures were the incidence of vomiting at 0-3 h and 0-24 h and the frequency of vomiting at 0-24 h. The severity of nausea was measured by the patient, who used an 11-point verbal scale to indicate her strongest nausea. Results: Of the 100 female patients selected for the study, 99 completed the trial, and no adverse events occurred. The severity of nausea, frequency of vomiting, and incidence of vomiting were significantly lower in the GRS group than in the no-intervention group. Conclusions: This study suggests that GRS may be effective for the reduction of PONV.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: 20131216. Revision Date: 20150820. Publication Type: Journal Article

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33.) Utilization of Preoperative Risk Assessment for Management of Postoperative Nausea and Vomiting (PONV)

Kinnavy, J. J. Journal of PeriAnesthesia Nursing 30 (4): e9-e10.(2015)

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  1. Language: English. Entry Date: 20151012. Revision Date: 20151012. Publication Type: Article

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34.) Comparison of Ramosetron and Palonosetron for Preventing Nausea and Vomiting after Spinal Surgery: Association With ABCB1 Polymorphisms

Jong Wook, S., et al. Journal of Neurosurgical Anesthesiology 29 (4): 406-414.(2017)

Background: Adenosine triphosphate-binding cassette subfamily B member 1 (ABCB1) polymorphisms may influence 5-hydroxytryptamine receptor antagonist efficacy by altering their efflux transportation. We evaluated the influence of ABCB1 polymorphisms on the efficacy of ramosetron compared with palonosetron in managing postoperative nausea and vomiting (PONV) in patients who received intravenous patient-controlled analgesia after spinal surgery.Methods: Patients were randomly allocated to receive 2 boluses (20 min before the end of surgery and 24 h after surgery) of either ramosetron 0.3 mg (n=150) or palonosetron 0.075 mg (n=146). The incidence and severity of PONV, fentanyl consumption, and pain intensity were serially assessed for postoperative 48 hours. ABCB1 3435C>T and 2677G>T/A polymorphisms were assessed.Results: The incidences of nausea were similar between the 2 groups in patients with the 3435TT (50% vs. 56%, ramosetron and palonosetron group, respectively, P>0.999) or 2677TT (50% vs. 56%, ramosetron and palonosetron group, respectively, P>0.999). Mild PONV were more frequent in the ramosetron group than in the palonosetron group among patients with 3435TT (91% vs. 33%, P=0.034) and 2677TT (92% vs. 20%, P=0.002) genotypes. The intensity of nausea experienced by ramosetron-group TT genotype patients (1 [1 to 2], 3435TT; 1 [1 to 2.5], 2677TT) was lower than that experienced by ramosetron- group non-TT genotype patients (3 [1 to 6], 3435 non-TT, P=0.030; 3 [1 to 6], 2677 non-TT, P=0.038) and palonosetron-group TT genotype patients (6 [2 to 7], 3435TT, P=0.010; 6 [4 to 7], 2677TT, P=0.002).Conclusions: Compared with palonosetron, ramosetron may be superior for reducing PONV severity, especially in patients with ABCB1 3435TT or 2677TT genotype.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: In Process. Revision Date: 20170913. Publication Type: journal article. Journal Subset: Biomedical

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35.) Haloperidol dose combined with dexamethasone for PONV prophylaxis in high-risk patients undergoing gynecological laparoscopic surgery: a prospective, randomized, double-blind, dose- response and placebo-controlled study

Jin, J., et al. BMC Anesthesiology 15 (1): 1-6.(2015)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Background: Low-dose haloperidol is known to be effective for the prevention of postoperative nausea and vomiting (PONV). However, precise dose-response studies have not been completed, especially in patients at high risk for PONV who require combination therapy. This study sought to identify which dose of haloperidol 1mg or 2mg could be combined with dexamethasone without adverse effects in high-risk patients undergoing gynecological laparoscopic surgery. Methods: Female adults (n = 150) with three established PONV risk factors based on Apfel's score were randomized into one of three study groups. At the end of anesthesia, groups H0, H1, and H2 were given intravenous (IV) saline, haloperidol 1 mg, and haloperidol 2 mg, respectively. All patients were given dexamethasone 5 mg during the induction of anesthesia. The overall early (0-2 h) and late (2-24 h) incidences of nausea, vomiting, rescue anti-emetic administration, pain, and adverse effects (cardiac arrhythmias and extrapyramidal effects) were assessed postoperatively. The sedation score was recorded in the postanesthesia care unit (PACU). Results: The total incidence of PONV over 24 h was significantly lower in groups H1 (29 %) and H2 (24 %) than in group H0 (54 %; P = 0.003), but there was no significant difference between groups H1 and H2. In the PACU, group H2 had a higher sedation score than groups H1 and H0 (P < 0.001). Conclusions: For high-risk PONV patients undergoing gynecological laparoscopic surgery, when used with dexamethasone, 1-mg haloperidol was equally effective as 2 mg in terms of preventing PONV with the less sedative effect. Trial Registration: ClinicalTrials.gov (NCT01639599).

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  1. Language: English. Entry Date: 20151022. Revision Date: 20151022. Publication Type: Article

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36.) Acupuncture in the Management of Intraoperative Nausea and Vomiting

Gouveia, F., et al. Journal of Acupuncture & Meridian Studies 9 (6): 325-329.(2016)

Intraoperative and postoperative nausea and vomiting (IONV and PONV, respectively) are common complications of anesthesia with significant associated morbidity. Strategies for their prevention and treatment have been organized in pharmacological and nonpharmacological measures. Acupuncture at PC6 has demonstrated efficacy in randomized trials, although evidence regarding its efficacy in treating IONV and PONV has not yet been fully established. We present the case of a patient who underwent peripheral vascular surgery on a limb under a subarachnoid block and who developed IONV refractory to conventional pharmacological therapy. Acupuncture at the PC6 and the TF4 points proved to be an effective alternative treatment to conventional pharmacological treatment and resulted in almost immediate cessation of IONV.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: 20170111. Revision Date: 20170111. Publication Type: Article

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37.) The Use of Short-Term Acupressure to Prevent Long-Term PONV: Was This a Case of Too Little, Too Late?

Gilbert, R. T., et al. Journal of PeriAnesthesia Nursing 32 (5): 445-452.(2017)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Purpose Postoperative nausea and vomiting (PONV) is a common surgical complication that contributes to poor patient outcomes. The purpose of this study was to determine if acupressure to the P6 pressure point during the immediate postoperative period decreased PONV for the first 24 postoperative hours. Design This was a double- blind, randomized study. Methods Experimental group participants wore a wristband, which administered acupressure to the P6 pressure point of one wrist. Control group wristbands were malpositioned. Bands remained on until patients were discharged from the postanesthesia care unit or up to a maximum of 2 hours. Data on nausea, vomiting, and antiemetic use were tracked for the first 24 postoperative hours. Finding There were no statistically significant between-group differences in PONV or antiemetic use. Conclusions Short-term postoperative acupressure to one wrist did not lead to a 24-hour decrease in nausea, vomiting, or antiemetic use.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: 20171223. Revision Date: 20171223. Publication Type: Article

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38.) Short-Term Acupressure Does not Prevent Long-Term Post-Operative Nausea and Vomiting

Gilbert, R. T., et al. Journal of PeriAnesthesia Nursing 30 (4): e43-e44.(2015)

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  1. Language: English. Entry Date: 20151012. Revision Date: 20151012. Publication Type: Article

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39.) Dexamethasone 8 mg Versus Dexamethasone 4 mg with Propofol 0.5 mg/kg for the Prevention of Postoperative Nausea and Vomiting after Laparoscopic Gynaecology Procedure

Firdaus, K., et al. International Medical Journal 23 (1): 43-46.(2016)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Background and Aims: This was a prospective randomized double blind study to compare dexamethasone 8 mg with dexamethasone 4 mg plus subhypnotic dose of propofol 0.5 mg/kg as prophylaxis against post operative nausea and vomiting (PONV) in patients undergoing laparoscopic gynaecology procedures. Methods: One hundred ASA physical status Class I and II patients scheduled for elective laparoscopic gynaecological procedures under general anaesthesia were randomized into two groups: Group A received 8 mg dexamethasone plus 0.05 ml/kg of normal saline while Group B received 4 mg dexamethasone with 0.5 mg/kg of propofol. The 24 hour observation of PONV and need for rescue antiemetics were recorded at four occasions: at recovery and post operative periods of 1-6 hours, 7-12 hours and 13-24 hours. Results: Overall incidence of PONV in Group A and Group B was 20% and 16% respectively. There was no significant difference between the two groups in terms of PONV episodes and rescue antiemetics requirements. Significantly more patients in Group B had post operative drowsiness compared to Group A. No other side effects were noted in both groups during 24 hours observation period. Conclusion: The study showed that combination of dexamethasone 4 mg with subhypnotic dose of propofol 0.5 mg/kg was comparable to dexamethasone 8 mg in the prevention of post operative nausea and vomiting in patients undergoing laparoscopic gynaecological procedures.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

BUY A PLAGIARISM-FREE PAPER HERE

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  1. Language: English. Entry Date: 20170809. Revision Date: 20170809. Publication Type: Article

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40.) Effects of P6 Acustimulation With the ReliefBand on Postoperative Nausea and Vomiting in Patients Undergoing Gynecological Laparoscopy

Ertas, G., et al. Holistic Nursing Practice 29 (1): 6-12.(2015)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

We investigated the effects of P6 acustimulation on the incidence of postoperative nausea and vomiting (PONV), antiemetic requirements, and side effects in patients undergoing gynecological laparoscopy with a high risk of PONV. Sixty-two patients were divided into 2 groups randomly: a ReliefBand group (RB group) and a sham ReliefBand group (S group). The P6 acustimulation device (ReliefBand Medical Technologies LLC, Chicago, Illinois) was wrapped around the wrists of the patients 15 to 30 minutes before the operation and activated before the induction of anesthesia. The patients’ hemodynamic parameters, nausea scale (verbal rating scale), pain scale (visual analogue scale), PONV score, rescue antiemetics, analgesic requirements, adverse effects, and satisfaction scores in the first 24 hours were recorded. The verbal rating scale scores in the early postoperative period and 6 hours postoperatively were significantly higher in the RB group than in the S group. The PONV scores at 15 minutes and at 6 and 12 hours postoperatively were significantly higher in the S group than in the RB group. The verbal rating scale scores of the patients with higher Apfel risk scores (3 or 4 points) in the early postoperative period and 6 hours postoperatively were significantly lower in the RB group than in the S group. The PONV scores of the patients with high Apfel risk scores at 15 minutes and at 6 and 12 hours postoperatively were significantly lower in the RB group than in the S group. The number of patients and doses of antiemetics required were significantly lower in the RB group than in the S group. Patient satisfaction scores were significantly higher in the RB group than in the S group. Acustimulation with the P6 ReliefBand decreased the severity of nausea, PONV scores, and antiemetic requirements in the early postoperative period of gynecological laparoscopy patients.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: 20141223. Revision Date: 20150710. Publication Type: Journal Article

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41.) Effects of preoperative dexamethasone on postoperative pain, nausea, vomiting and respiratory function in women undergoing conservative breast surgery for cancer: Results of a controlled clinical trial

Cortés‐Flores, A. O., et al. European Journal of Cancer Care 27 (1): 1-1.(2018)PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

The objective was to evaluate whether preoperative administration of dexamethasone improved postoperative nausea and vomiting (PONV), pain and respiratory function tests in women undergoing conservative surgery for breast cancer. This was a controlled clinical trial conducted between June 2013 and October 2014. Eighty patients were evaluated. Patients received a preoperative dose of 8 mg of dexamethasone (<italic>n</italic> = 40) or placebo (<italic>n</italic> = 40). The data on PONV and pain intensity was obtained and forced spirometry tests were performed, 1 hr before and at 1, 6, 12 and 24 hr after surgery. Any use of additional analgesic/antiemetic drugs was recorded. Patients were followed until 30 days after surgery for any surgical or medical complications. The pain intensity was lower in the treatment group for all periods; PONV was lower at 6, 12 and 24 hr; Additional analgesics/antiemetics were required less frequently (all <italic>p </italic><<italic> </italic>.05). Both groups exhibited a restrictive ventilatory pattern immediately after surgery, which was reversed in the following hours. However, spirometric values were higher in the dexamethasone group. There were no pulmonary or metabolic complications after surgery. Our conclusions were that dexamethasone significantly reduced the incidences of PONV, pain and improved respiratory parameters, and reduced the need for additional postoperative analgesic and antiemetic drugs.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: In Process. Revision Date: 20180130. Publication Type: Article. Journal Subset: Core Nursing

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42.) Prophylaxis of postoperative nausea and vomiting after cardiac surgery in high-risk patients: A randomized controlled study

Champion, S., et al. Annals of Cardiac Anaesthesia 21 (1): 8-14.(2018)

Context: The role of prophylaxis for postoperative nausea and vomiting (PONV) in cardiac surgery is under debate.Aims: To study the risk factors for PONV after cardiac surgery and the role of betamethasone with or without droperidol for its prevention.Setting and Design: Randomized open-label controlled study comparing standard care with PONV prophylaxis from February to November 2016.Methods: Five hundred and two patients with planned nonemergent cardiac surgery were included.Interventions: In the intervention arm, PONV prophylaxis (4 mg betamethasone with/without 0.625 mg droperidol) was administered in high-risk patients (two or more risk factors). Patients in the control arm were treated as per routine hospital practices.Results: Female sex, past history of PONV, and migraines were associated with a significantly increased risk of PONV, while motion sickness, smoking status, and volatile anesthetics were not. Pain and treatment with nefopam or ketoprofen were associated with an increased risk of PONV. PONV was less frequent in the active arm compared to controls (45.5% vs. 54.0%, P = 0.063; visual analogic scale 10.9 vs. 15.3 mm, P = 0.043). Among the 180 patients (35.6%) with ≥2 risk factors, prophylaxis was associated with reduced PONV (intention-to-treat: 46.8% vs. 67.8%, P = 0.0061; per- protocol: 39.2% vs. 69%, P = 0.0002). In multivariate analysis, prophylaxis was independently associated with PONV (odds ratio [OR]: 0.324, 95% confidence interval: 0.167-0.629, P = 0.0009), as were female sex, past history of PONV, and migraines (OR: 3.027, 3.031, and 2.160 respectively). No drug-related side effects were reported.Conclusion: Betamethasone with/without droperidol was effective in decreasing PONV in high risk cardiac surgical patients without any side effect.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: In Process. Revision Date: 20180211. Publication Type: journal article. Journal Subset: AsiaPHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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43.) Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review

Assante, J., et al. AANA Journal 83 (4): 281-288.(2015)

Postoperative nausea and vomiting is one of the most common complications affecting surgical patients. The glucocorticoid dexamethasone is often used for the prevention of postoperative nausea and vomiting. This literature review seeks to summarize research related to the use of a single perioperative dose of dexamethasone for prophylactic treatment of postoperative nausea and vomiting and its impact on surgical healing. Although the majority of the literature reviewed found no association between single-dose intraoperative dexamethasone and an increase in surgical site infections, the need for a large-scale randomized controlled trial is consistently mentioned. Prudent clinicians should always use the most current evidence with their best clinical judgment when making medication decisions for their patients.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: 20150819. Revision Date: 20150923. Publication Type: Journal Article

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44.) Comparison of Ramosetron with Palonosetron for Prevention of Postoperative Nausea and Vomiting in Patients Receiving Opioid-Based Intravenous Patient-Controlled Analgesia after Gynecological Laparoscopy

Ahn, E. J., et al. BioMed Research International 1-6.(2017)

We aimed to compare the effects of ramosetron and palonosetron in the prevention of postoperative nausea and vomiting (PONV) in patients that received opioid-based intravenous patient-controlled analgesia (IV-PCA) after gynecological laparoscopy. We reviewed the electronic medical records of 755 adults. Patients were classified into two groups, ramosetron (group R, n=589) versus palonosetron (group P, n=166). Based on their confounding factors, 152 subjects in each group were selected after the implementation of propensity score matching. The overall incidence of PONV at postoperative day (POD) 0 was lower in group R compared to group P (26.9% versus 36.8%; P=0.043). The severity of nausea was lower in group R than in group P on postoperative day (POD) 0 (P=0.012). Also, the complete responder proportion of patients was significantly higher in group R compared to that in group P on POD 0 (P=0.043). In conclusion, ramosetron showed a greater efficacy in the prevention of postoperative nausea at POD 0 compared to palonosetron in patients after gynecological laparoscopy.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

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  1. Language: English. Entry Date: 20170308. Revision Date: 20170308. Publication Type: Article

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45.) Pupillometry Accurately Predicts Postoperative Nausea and Vomiting, Allows Earlier Intervention

Operating Theatre Journal (307): 22-22.(2016)

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  1. Language: English. Entry Date: 20171211. Revision Date: 20171211. Publication Type: Article

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Drug Study Paper Rubric - 100 points

Scoring Guide Distinguished-10 Proficient-8 Basic-6 Unsatisfactory-0
Quality of Ideas 20% Incorporates specific ideas that enrich and relate to the specific topic. Incorporates adequate ideas that enrich and relate to the specific topic. Incorporates basic ideas that enrich and relate to the specific topic.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER Incorporates zero ideas that enrich and relate to the specific topic.
Makes no connection in the critical thinking process of pharmacodynamics.
Critical Analysis 30% Presents a clear articulation and insightful analysis of the important concepts or theories of pharmacodynamics. Adequately analyzes important concepts or theories; the insights presented are related to ideas of pharmacodynamis. Inadequately analyzes important concepts or theories; the insights presented are only loosely related to the understanding of pharmacodynamics.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER Contains little or no evidence of critical analysis; concepts or theories are largely restated without further analysis of pharmacodynamics.
Strength of Conclusion 20% Conclusion discusses how the research has had an impact on the learner's view of the topic, supported by references. Wraps up paper well.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER Conclusion discusses how the research has had an impact on the learner's view of the topic. Somewhat wraps up the paper. Conclusion is general and doesn't provide a clear statement on how the research has imppacted the learner's view of the topic. Conclusion does not address the impact of the research on the learner's view of the topic. Fails to adequately wrap up the paper.
Clarity and Organization 10% Presents vivid, precise language that engages the reader.

Language flows with rhythm and patterns and is appealing to the ear as well as the eye.

The language itself is a strong component of the essay.

Presents language that is appropriate and clear.

Sentences are well constructed so as to flow and contribute to understanding.

There are a few passages that are difficult to understand. The organization is generally good.

Presents language that is somewhat appropriate and clear.

Sentences were not well crafted. They get the point across but their very nature doesn't contribute to the flow of the essay.

The organization of the material is adequate.PHARMACOLOGICAL MANAGEMENT OF PONV PAPER

Presents language that is inappropriate and/or is unclear.

Sentences are awkward and difficult to follow.

Grammar and Style 10% Demonstrates facility with grammar, usage and mechanics of standard English.

Adheres to the required APA style and format; there are no errors.

Demonstrates competency with grammar, usage and mechanics of standard English.

There are 1-2 APA style and format errors.

Contains 1-2 errors in grammar, usage and mechanics in English. There are 3+ APA style and format errors, including reference citations. Contains 3+ serious errors in grammar, usage, and mechanics in English. There has been no attempt made to conform to APA style and format.
Timeliness 10% Delivered on due date. -None- Paper delivered on due date, not including all components. Delivered after due date.

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