To assess the use of rescue antiemetic medication following 5-HT3 receptor antagonist (5-HT3RA) plus dexamethasone therapy versus monotherapy with a 5-HT3RA for prophylaxis of postoperative nausea and vomiting (PONV).
Data Sources:
Reports of randomized, controlled trials were identified via a MEDLINE search (1966–September 2005) using the key terms ondansetron, dolasetron, tropisetron, granisetron, 5-HT3, PONV, vomiting, emesis, and nausea.
Study Selection and Data Extraction:
Randomized, controlled trials of adult populations that had treatment arms comparing 5-HT3RA/dexamethasone combination therapy with 5-HT3RA or dexamethasone monotherapies versus placebo or 5-HT3RA versus dexamethasone or placebo were selected for analysis. Another criterion was that a proportion of patients required rescue medication 48 hours or less following surgery.
Data Synthesis:
Odds ratios (ORs) with 95% confidence interval were calculated to determine incidence rates for use of rescue medications within early (0–6 h), late (6–24 h), and overall (0–24 or 48 h) postoperative periods. Overall effect sizes were calculated by pooling ORs within fixed and random effects models.
Conclusions:
Prophylaxis with 5-HT3RA/dexamethasone was associated with lower use of rescue antiemetics than 5-HT3RA (ORpooled = 0.48; 95% CI 0.29 to 0.77) or dexamethasone (ORpooled = 0.26; 95% CI 0.12–0.57) monotherapy during the overall postoperative period. Insufficient data were available to assess rescue use during early or late postoperative periods. It appears that patients at high risk of PONV who are treated prophylactically with combination 5-HT3RA/dexamethasone therapy are overall less likely to require rescue medication than if treated with 5-HT3RAs or dexamethasone alone. Additional large prospective studies are needed to determine the optimal regimen and timing of administration of prophylactic antiemetic therapy for different surgical populations.
FortierJ, ChungF, SuJ.Unanticipated admission after ambulatory surgery—a prospective study. Can J Anaesth1998;45:612–9.
2.
GoldBS, KitzDS, LeckyJH, NeuhausJM. Unanticipated admission to the hospital following ambulatory surgery. JAMA1989;262:3008–10.
3.
WatchaMF, WhitePF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology1992;77:162–84.
4.
KovacAL. Prevention and treatment of postoperative nausea and vomiting. Drugs2000;59:213–43.
5.
HigginsGA, KilpatrickGJ, BunceKT, JonesBJ, TyersMB. 5-HT3 receptor antagonists injected into the area postrema inhibit cisplatin-induced emesis in the ferret. Br J Pharmacol1989;97:247–55.
6.
ButlerA, HillJM, IrelandSJ, JordanCC, TyersMB. Pharmacological properties of GR38032F, a novel antagonist at 5-HT3 receptors. Br J Pharmacol1988;94:397–412.
7.
PearmanMH. Single dose intravenous ondansetron in the prevention of postoperative nausea and vomiting. Anaesthesia1994;49(suppl):11–5.
8.
ApfelCC, KorttilaK, AbdallaM.A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med2004;350:2441–51.
9.
KovacAL, O'connorTA, PearmanMH. Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomiting: a randomized, double-blind, placebo-controlled multicenter trial. J Clin Anesth1999;11:453–9.
10.
SuenTK, GinTA, ChenPP, RowbottomYM, CritchleyLA, RayAK. Ondansetron 4 mg for the prevention of nausea and vomiting after minor laparoscopic gynaecological surgery. Anaesth Intensive Care1994;22:142–6.
11.
KreislerNS, SpiekermannBF, AscariCM. Small-dose droperidol effectively reduces nausea in a general surgical adult patient population. Anesth Analg2000;91:1256–61.
12.
FortneyJT, GanTJ, GraczykS.A comparison of the efficacy, safety, and patient satisfaction of ondansetron versus droperidol as antiemetics for elective outpatient surgical procedures. S3A-409 and S3A-410 Study Groups. Anesth Analg1998;86:731–8.
13.
WhitePF, WatchaMF. Postoperative nausea and vomiting: prophylaxis versus treatment. Anesth Analg1999;89:1337–9.
14.
TramerMR, ReynoldsDJ, MooreRA, McQuayHJ. Efficacy, dose-response, and safety of ondansetron in prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized placebo-controlled trials. Anesthesiology1997;87:1277–89.
15.
FigueredoED, CanosaLG. Ondansetron in the prophylaxis of postoperative vomiting: a meta-analysis. J Clin Anesth1998;10:211–21.
16.
TramerMR. A rational approach to the control of postoperative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues. Acta Anaesthesiol Scand2001;45:4–13.
17.
GuptaA, WuCL, ElkassabanyN, KrugCE, ParkerSD, FleisherLA. Does the routine prophylactic use of antiemetics affect the incidence of postdischarge nausea and vomiting following ambulatory surgery?: a systematic review of randomized controlled trials. Anesthesiology2003;99:488–95.
18.
Kazemi-KjellbergF, HenziI, TramerMR. Treatment of established postoperative nausea and vomiting: a quantitative systematic review. BMC Anesthesiol2001;1:2.
19.
EberhartLH, MorinAM, HoerleS, WulfH, GeldnerG.Droperidol and dolasetron alone or in combination for prevention of postoperative nausea and vomiting after vitrectomy. Ophthalmology2004;111:1569–75.
20.
LoewenP, LambS, ClugstonP.Randomized, double-blind trial of dolasetron versus droperidol for prophylaxis of postoperative nausea and vomiting in patients undergoing TRAM flap breast reconstruction surgery. Ann Plast Surg2003;51:472–7.
21.
AwadIT, MurphyD, StackD, SwantonBJ, MeekeRI, ShortenGD. A comparison of the effects of droperidol and the combination of droperidol and ondansetron on postoperative nausea and vomiting for patients undergoing laparoscopic cholecystectomy. J Clin Anesth2002;14:481–5.
22.
FablingJM, GanTJ, El MoalemHE, WarnerDS, BorelCO. A randomized, double-blinded comparison of ondansetron, droperidol, and placebo for prevention of postoperative nausea and vomiting after supratentorial craniotomy. Anesth Analg2000;91:358–61.
23.
ReihnerE, GrunditzR, GieseckeK, GustafssonLL. Postoperative nausea and vomiting after breast surgery: efficacy of prophylactic ondansetron and droperidol in a randomized placebo-controlled study. Eur J Anaesthesiol2000;17:197–203.
24.
PeixotoAJ, Peixoto FilhoAJ, LeaesLF, CelichMF, BarrosMA. Efficacy of prophylactic droperidol, ondansetron or both in the prevention of postoperative nausea and vomiting in major gynaecological surgery. A prospective, randomized, double-blind clinical trial. Eur J Anaesthesiol2000;17:611–5.
25.
FujiiY, TanakaH, SomekawaY.Granisetron, droperidol, and metoclopramide for the treatment of established postoperative nausea and vomiting in women undergoing gynecologic surgery. Am J Obstet Gynecol2000;182:13–6.
26.
FujiiY, TanakaH, KobayashiN.Granisetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting after thyroidectomy. Laryngoscope1999;109:664–7.
27.
FujiiY, ToyookaH, TanakaH.Prevention of postoperative nausea and vomiting with a combination of granisetron and droperidol. Anesth Analg1998;86:613–6.
28.
FujiiY, ToyookaH, TanakaH.Prevention of postoperative nausea and vomiting in female patients during menstruation: comparison of droperidol, metoclopramide and granisetron. Br J Anaesth1998;80:248–9.
29.
FujiiY, SaitohY, TanakaH, ToyookaH.Prevention of PONV with granisetron, droperidol or metoclopramide in patients with postoperative emesis. Can J Anaesth1998;45:153–6.
30.
KoivurantaM, LaaraE, RantaP, RavaskaP, AlahuhtaS.Comparison of ondansetron and droperidol in the prevention of postoperative nausea and vomiting after laparoscopic surgery in women. A randomised, double-blind, placebo-controlled trial. Acta Anaesthesiol Scand1997;41:1273–9.
31.
FujiiY, ToyookaH, TanakaH.Prevention of PONV with granisetron, droperidol and metoclopramide in female patients with history of motion sickness. Can J Anaesth1997;44:820–4.
32.
JellishWS, ThaljiZ, FluterE, LeonettiJP. Ondansetron versus droperidol or placebo when given prophylactically for the prevention of postoperative nausea and vomiting in patients undergoing middle ear procedures. J Clin Anesth1997;9:451–6.
33.
WrenchIJ, WardJE, WalderAD, HobbsGJ. The prevention of postoperative nausea and vomiting using a combination of ondansetron and droperidol. Anaesthesia1996;51:776–8.
34.
PaechMJ, LeeBH, EvansSF. The effect of anaesthetic technique on postoperative nausea and vomiting after day-case gynaecological laparoscopy. Anaesth Intensive Care2002;30:153–9.
35.
AlexanderR, LovellAT, SeingryD, JonesRM. Comparison of ondansetron and droperidol in reducing postoperative nausea and vomiting associated with patient-controlled analgesia. Anaesthesia1995;50:1086–8.
36.
FujiiY, TanakaH, ToyookaH.Prevention of postoperative nausea and vomiting with granisetron: a randomized, double-blind comparison with droperidol. Can J Anaesth1995;42:852–6.
37.
GanTJ, CollisR, HetreedM.Double-blind comparison of ondansetron, droperidol and saline in the prevention of postoperative nausea and vomiting. Br J Anaesth1994;72:544–7.
38.
HabibAS, GanTJ. Food and drug administration black box warning on the perioperative use of droperidol: a review of the cases. Anesth Analg2003;96:1377–9.
39.
HabibAS, El MoalemHE, GanTJ. The efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexamethasone. A meta-analysis of randomized controlled trials. Can J Anaesth2004;51:311–9.
40.
KrankeP, ApfelCC, GreimCA, RoewerN.Methodological problems arising from ‘serial publishing’ on the effectiveness of granisetron in PONV. Br J Anaesth1999;82:481–3.
41.
KrankeP, ApfelCC, EberhartLH, GeorgieffM, RoewerN.The influence of a dominating centre on a quantitative systematic review of granisetron for preventing postoperative nausea and vomiting. Acta Anaesthesiol Scand2001;45:659–70.
42.
ApfelCC, KrankeP, GreimCA, RoewerN.Non-systematic serial publishing is not appropriate and ethically questionable. Acta Anaesthesiol Scand1999;43:486–7.
43.
KrankeP, ApfelCC, RoewerN, FujiiY.Reported data on granisetron and postoperative nausea and vomiting by Fujii et al. are incredibly nice! Anesth Analg2000;90:1004–7.
44.
PandaNB, BharadwajN, KapoorP, ChariP, PandaNK. Prevention of nausea and vomiting after middle ear surgery: combination of ondansetron and dexamethasone is the right choice. J Otolaryngol2004;33:88–92.
45.
GanTJ, JiaoKR, ZennM, GeorgiadeG.A randomized controlled comparison of electro-acupoint stimulation or ondansetron versus placebo for the prevention of postoperative nausea and vomiting. Anesth Analg2004;99:1070–5.
46.
SinhaPK, AmbeshSP. Ondansetron in prophylaxis of postoperative nausea and vomiting in patients undergoing breast surgery: a placebo-controlled double blind study. J Indian Med Assoc2004;102:73–9.
47.
HanaokaK, ToyookaH, KugimiyaT, OhashiY.Efficacy of prophylactic intravenous granisetron in postoperative emesis in adults. J Anesth2004;18:158–65.
48.
SzarvasS, ChellapuriRS, HarmonDC, OwensJ, MurphyD, ShortenGD. A comparison of dexamethasone, ondansetron, and dexamethasone plus ondansetron as prophylactic antiemetic and antipruritic therapy in patients receiving intrathecal morphine for major orthopedic surgery. Anesth Analg2003;97:259–63.
49.
YuksekMS, AliciHA, ErdemAF, CesurM.Comparison of prophylactic anti-emetic effects of ondansetron and dexamethasone in women undergoing day-case gynaecological laparoscopic surgery. J Int Med Res2003;31:481–8.
50.
WattwilM, ThornSE, LovqvistA, WattwilL, GuptaA, LiljegrenG.Dexamethasone is as effective as ondansetron for the prevention of postoperative nausea and vomiting following breast surgery. Acta Anaesthesiol Scand2003;47:823–7.
51.
TzengJI, ChuKS, HoST, ChengKI, LiuKS, WangJJ. Prophylactic iv ondansetron reduces nausea, vomiting and pruritus following epidural morphine for postoperative pain control. Can J Anaesth2003;50:1023–6.
52.
AgarwalA, BoseN, GaurA, SinghU, GuptaMK, SinghD.Acupressure and ondansetron for postoperative nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth2002;49:554–60.
53.
WangJJ, TzengJI, HoST, ChenJY, ChuCC, SoEC. The prophylactic effect of tropisetron on epidural morphine-related nausea and vomiting: a comparison of dexamethasone with saline. Anesth Analg2002;94:749–53.
54.
WangJJ, HoST, UenYH. Small-dose dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy: a comparison of tropisetron with saline. Anesth Analg2002;95:229–32.
55.
WangJJ, WangPC, LiuYH, ChienCC. Low-dose dexamethasone reduces nausea and vomiting after tympanomastoid surgery: a comparison of tropisetron with saline. Am J Otolaryngol2002;23:267–71.
56.
SoJB, CheongKF, SngC, CheahWK, GohP.Ondansetron in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: a prospective randomized study. Surg Endose2002;16:286–8.
57.
KathirvelS, DashHH, BhatiaA, SubramaniamB, PrakashA, ShenoyS.Effect of prophylactic ondansetron on postoperative nausea and vomiting after elective craniotomy. J Neurosurg Anesthesiol2001;13:207–12.
58.
FujiiY, TanakaH, KawasakiT.Preoperative oral granisetron for the prevention of postoperative nausea and vomiting after breast surgery. Eur J Surg2001;167:184–7.
59.
FujiiY, TanakaH, KobayashiN.Granisetron/dexamethasone combination for the prevention of postoperative nausea and vomiting after thyroidectomy. Anaesth Intensive Care2000;28:266–9.
60.
PhilipBK, PearmanMH, KovacAL. Dolasetron for the prevention of postoperative nausea and vomiting following outpatient surgery with general anaesthesia: a randomized, placebo-controlled study. The Dolasetron PONV Prevention Study Group. Eur J Anaesthesiol2000;17:23–32.
61.
TsuiSL, NgKF, WongLC, TangGW, PunTC, YangJC. Prevention of postoperative nausea and vomiting in gynaecological laparotomies: a comparison of tropisetron and ondansetron. Anaesth Intensive Care1999;27:471–6.
62.
SinhaPK, TripathiM, AmbeshSP. Efficacy of ondansetron in prophylaxis of postoperative nausea and vomiting in patients following infratentorial surgery: a placebo-controlled prospective double-blind study. J Neurosurg Anesthesiol1999;11:6–10.
63.
FujiiY, TanakaH, ToyookaH.Prophylactic antiemetic therapy with granisetron–dexamethasone combination in women undergoing breast surgery. Acta Anaesthesiol Scand1998;42:1038–42.
64.
DiemunschP, KorttilaK, LeeserJ.Oral dolasetron mesylate for prevention of postoperative nausea and vomiting: a multicenter, double-blind, placebo-controlled study. The Oral Dolasetron PONV Prevention Study Group. J Clin Anesth1998;10:145–52.
65.
ScholzJ, HennesHJ, SteinfathM.Tropisetron or ondansetron compared with placebo for prevention of postoperative nausea and vomiting. Eur J Anaesthesiol1998;15:676–85.
McKenzieR, RileyTJ, TantisiraB, HamiltonDL. Effect of propofol for induction and ondansetron with or without dexamethasone for the prevention of nausea and vomiting after major gynecologic surgery. J Clin Anesth1997;9:15–20.
68.
KovacAL, ScuderiPE, BoernerTF. Treatment of postoperative nausea and vomiting with single intravenous doses of dolasetron mesylate: a multicenter trial. Dolasetron Mesylate PONV Treatment Study Group. Anesth Analg1997;85:546–52.
69.
DiemunschP, D'hollanderA, PaxtonL.Intravenous dolasetron mesilate in the prevention of postoperative nausea and vomiting in females undergoing gynecological surgery. J Clin Anesth1997;9:365–73.
70.
KorttilaK, ClergueF, LeeserJ.Intravenous dolasetron and ondansetron in prevention of postoperative nausea and vomiting: a multicenter, double-blind, placebo-controlled study. Acta Anaesthesiol Scand1997;41:914–22.
71.
MoensP, LevarletM, HendrickxP, De GuchteneereE.Single i.v. bolus dose of ondansetron in the prevention of postoperative nausea and emesis. Acta Anaesthesiol Belg1997;48:245–50.
72.
TaylorAM, RosenM, DiemunschPA, ThorinD, HouwelingPL. A double-blind, parallel-group, placebo-controlled, dose-ranging, multicenter study of intravenous granisetron in the treatment of postoperative nausea and vomiting in patients undergoing surgery with general anesthesia. J Clin Anesth1997;9:658–63.
73.
WilsonAJ, DiemunschP, LindequeBG. Single-dose i.v. granisetron in the prevention of postoperative nausea and vomiting. Br J Anaesth1996;76:515–8.
74.
Lopez-OlaondoL, CarrascosaF, PueyoFJ, MonederoP, BustoN, SaezA.Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting. Br J Anaesth1996;76:835–40.
75.
GanTJ, GinsbergB, GrantAP, GlassPS. Double-blind, randomized comparison of ondansetron and intraoperative propofol to prevent postoperative nausea and vomiting. Anesthesiology1996;85:1036–42.
76.
FujiiY, ToyookaH, TanakaH.Antiemetic effects of granisetron on postoperative nausea and vomiting in patients with and without motion sickness. Can J Anaesth1996;43:110–4.
77.
PaechMJ, PavyTJ, EvansSF. Single-dose prophylaxis for postoperative nausea and vomiting after major abdominal surgery: ondansetron versus droperidol. Anaesth Intensive Care1995;23:548–54.
78.
FujiiY, TanakaH, ToyookaH.Granisetron-dexamethasone combination reduces postoperative nausea and vomiting. Can J Anaesth1995;42:387–90.
79.
FujiiY, TanakaH, ToyookaH.Optimal anti-emetic dose of granisetron for preventing postoperative nausea and vomiting. Can J Anaesth1994;41:794–7.
80.
SungYF, WetchlerBV, DuncalfD, JoslynAF. A double-blind, placebo-controlled pilot study examining the effectiveness of intravenous ondansetron in the prevention of postoperative nausea and emesis. J Clin Anesth1993;5:22–9.
81.
LarijaniGE, GratzI, AfsharM, MinassianS.Treatment of postoperative nausea and vomiting with ondansetron: a randomized, double-blind comparison with placebo. Anesth Analg1991;73:246–9.
82.
GanTJ, MeyerT, ApfelCC. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg2003;97:62–71.
83.
HabibAS, GanTJ. The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: a preliminary report. J Clin Anesth2005;17:62–5.
84.
HenziI, WalderB, TramerMR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg2000;90:186–94.
85.
HabibAS, GanTJ. Combination antiemetics: what is the evidence?Int Anesthesiol Clin2003;41:119–44.
86.
D'angeloR, PhilipB, GanT.A randomized, double-blind, close-ranging, pilot study of intravenous granisetron in the prevention of postoperative nausea and vomiting in patients abdominal hysterectomy. Eur J Anaesthesiol2005;22:774–9.
87.
GanTJ, CoopA, PhilipBK. A randomized, double-blind study of granisetron plus dexamethasone versus ondasetron plus dexamethasone to prevent postoperative nausea and vomiting in patients undergoing abdominal hysterectomy. Anesth Analg2005;101:1323–9.
