February 1, 2000

Multimodal Antiemetic Management Prevents Early Postoperative Vomiting after Outpatient Laparoscopy.

Commentary by David Lubarsky, M.D.

Return to the Current Literature Review Index Page

see abstract below

Dr. Scuderi et al. provide an interesting examination of what many of us have devised on our own, something I refer to as an "antiemetic anesthetic."

The nature of Dr. Scuderi’s hypothesis was that he could virtually eliminate PONV in a high risk population of 60 patients by actively managing known or suspected factors that cause PONV. His regimen is detailed in Table 1 of his paper.

These methods include:

• The use of preoperative anxiolysis preventing air gulping
• Three prophylactic anti-emetics (10 mg dexamethasone, 0.625 mg droperidol, and 1 mg ondansetron) + gastric emptying
• TIVA (total intravenous anesthesia) using propofol induction/infusion
• non-lingering narcotics (eg. remifentanil)
• non-steroidal pain killers in place of narctocis (eg. ketorolac)
• no nitrous oxide or potent inhaled anesthetics
• avoidance of muscle relaxants/necessary reversal
• vigorous hydration.

My own "cocktail" is amazingly similar, though I differ in a less rigorous hydration, use of sevoflurane instead of remifentanil, and the addition of ranitidine. Anecdotally, my results mirror his, and I congratulate his research team on the rigorous effort it takes to evaluate and publish an excellent regimen. Given the information in my last AnesthesiaWeb review I would also suggest lowering the dexamethasone dose to 5 mg.

Scuderi and his colleagues compared a group of patients receiving the above regimen to 42 patients receiving a routine balanced anesthetic with muscle relaxants and the "routine" 4 mg dose of ondansetron. A third placebo group of 37 patients got a routine anesthetic and no antiemetic prophylaxis.

Predictably, those receiving no prophylaxis were a) subject to much more PONV — 41% required treatment for vomiting/nausea; and b) less satisfied with their care. Frankly, there can be NO excuse for letting high risk patients receive anesthesia without antiemetic prophylaxis today. The only question is which drug or drugs you will use.

One of 60 patients in the treated group required treatment for nausea, none vomited, and all were ready for discharge much sooner than the placebo group. Of interest, however, was that despite the better results achieved,, satisfaction in the group treated with the Scuderi super regimen was not higher than the satisfaction of the group treated only with ondansetron. So, is it worth the extra effort/cost? I believe so. Satisfaction is only a measure of reality versus expectation. Patients fear and expect PONV. IF there is little vomiting (7% in ondansetron only group), but a fair amount of nausea (24%), that may meet public expectations. If the public knew the Scuderi technique could eliminate PONV as we know it, they might not be so satisfied with some nausea in the PACU. Twenty years ago, I was quite satisfied with my father’s hand me down 1969 Buick Electra 225. I had no knowledge of new cars, and no money for them either as I entered medical school. However, if I knew that just by asking I could have driven a brand new Cadillac, I might not have been so satisfied with what I got!! I couldn’t get that Cadillac, but you can both inform your patients about, and deliver to them, Cadillac care .

What is the cost of Dr. Scuderi’s Cadillac "antiemetic anesthetic?" Here’s my summation - extra LR is cheap (<$1), midazolam is already routine in most patients AND generic, and equal to its price from a year ago; 1 mg ondanseton is probably about $2. Dexamethasone and droperidol both cost less than a pack of chewing gum. The only expensive part of the technique was propofol and remifentanil — at $8-12/vial. But you DO have to anesthetize the patient with something. Not bad for inducing and maintaining a controlled coma with no intraoperative or postoperative side effects. Avoiding muscle relaxants and reversal actually fully offset the additional costs of TIVA. 30 mg Ketorolac — a couple of bucks in generic form. So, even as a cost conscious manager, I can fully recommend this approach.

In the past, I have employed similar techniques for patients at VERY high risk, or where the risk of PONV is high for me (anesthetizing a VIP!). I believe this article will cause me to change my practice and extend a similar regimen to all patients at significant risk of PONV.

This is our most common problem in the PACU. You can prevent it. And you should.

ABSTRACT

Multimodal antiemetic management prevents early postoperative vomiting afteroutpatient laparoscopy.

AUTHORS:
Scuderi PE, James RL, Harris L, Mims GR 3rd

SOURCE:
Anesth Analg 2000 Dec;91(6):1408-14

ABSTRACT:
Because no completely effective antiemetic exists for the prevention of postoperative nausea and vomiting (PONV), we hypothesize that a multimodal approach to management of PONV may reduce both vomiting and the need for rescue antiemetics in high-risk patients. After IRB approval, women undergoing outpatient laparoscopy were randomized to one of three groups. Group I (n = 60) was managed by using a predefined multimodal clinical care algorithm. Patients undergoing the same surgical procedure who received a standard balanced outpatient anesthetic with ondansetron 4 mg (Group II, n = 42) or placebo (Group III, n = 37) prophylaxis were chosen to establish baseline incidence of nausea and vomiting. None of the Group I patients vomited before discharge, compared with 7% in Group II (P: = 0.07) and 22% in Group III (P: = 0.0003). However, one patient (2%) in Group I required treatment for symptoms in the postanesthesia care unit, compared with 24% in Group II (P: < 0. 0001) and 41% in Group III (P: < 0.0001). Time to discharge-ready was significantly shorter in Group I (128, 118-139 min; mean, 95% confidence interval) versus Group II (162, 145-181 min; P: = 0.0015) and Group III (192, 166-222 min; P: = 0.0001). Patient satisfaction with control of PONV was not different between Group I and Group II. Return to normal daily activity and overall satisfaction were not different among groups. Multimodal management resulted in a 98% complete response rate and a 0% incidence of vomiting before discharge; however, this improvement did not result in an increased level of patient satisfaction when compared with routine monotherapy prophylaxis. We conclude that both multimodal management and routine monotherapy antiemetic prophylaxis resulted in an increased level of patient satisfaction than symptomatic treatment in this high-risk population. Implications: Use of a multimodal clinical care algorithm eliminates predischarge vomiting and improves satisfaction in patients undergoing outpatient laparoscopy.