A meta-analysis of prevention of postoperative nausea and vomiting: Randomised controlled trials by Fujii et al. Compared with other authors

Consultant Anaesthetist, Torbay Hospital, South Devon NHS Foundation Trust, Torquay, UK.
Anaesthesia (Impact Factor: 3.38). 06/2012; 67(10):1076-90. DOI: 10.1111/j.1365-2044.2012.07232.x
Source: PubMed


The population sampling in randomised controlled trials by Fujii et al. have been shown to exhibit unusual distributions. This systematic review analysed the effectiveness of prophylactic antiemetics in trials by Fujii et al. compared with other authors. Granisetron was more effective in trials by Fujii et al., relative risk ratios (RRR (95% CI)): nausea 0.53 (0.42-0.67), p = 0.00021; vomiting 0.60 (0.50-0.73), p = 0.00094. Ramosetron was also more effective in studies by Fujii et al.: vomiting 0.60 (0.39-0.91), p = 0.02; nausea or vomiting 0.71 (0.56-0.91); p = 0.006. In comparison with granisetron, droperidol was less effective in trials by Fujii et al. than others: nausea 2.41 (1.72-3.36), p = 2.5 × 10(-7) ; vomiting 1.73 (1.26-2.38), p = 6.4 × 10(-4) . Postoperative nausea and vomiting was less likely to trigger rescue antiemesis after granisetron and metoclopramide in studies by Fujii et al., 0.40 (0.27-0.60), p = 9.7 × 10(-6) . Triggered rates of rescue were not different in studies by others for droperidol, granisetron and metoclopramide, but were less common after granisetron than droperidol and metoclopramide in studies by Fujii et al., 0.50 (0.38-0.66), p = 1.7 × 10(-6) and 0.47 (0.34-0.64), p = 2.6 × 10(-6) , respectively. There was no synergism between antiemetics in trials by other authors. In contrast, in studies by Fujii et al., postoperative nausea and vomiting was more likely if granisetron was administered alone: nausea 4.20 (1.94-9.08), p = 2.6 × 10(-4) ; vomiting 4.50 (2.55-7.97), p = 2.3 × 10(-7) ; nausea or vomiting 5.00 (2.84-8.81), p = 2.5 × 10(-8) . Similarly, droperidol was less effective in studies by Fujii et al. if administered alone: vomiting 2.76 (1.25-6.11), p = 0.01; nausea or vomiting 2.96 (1.46-6.00), p = 2.7 × 10(-3) . The conclusion is that if, as recommended, data with unusual distributions are removed from meta-analysis and articles by Fujii et al. excluded, then the antiemetic effects of granisetron and ramosetron are greatly reduced; further, there is no evidence of synergism between antiemetics and indeed, some evidence of antagonism between antiemetic agents.

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    • "Determination of baseline risk in these populations is difficult because designing a trial keeping a placebo group is not ethical in view of high incidence of PONV after strabismus surgery. Carlisle[26]in 2012 conducted a meta-analysis to know the impact of trials by Fujii et al. and found that after removing such trials there is no evidence of synergism between any antiemetics. Moreover exact mechanism of dexamethasone for PONV prophylaxis is not known; Chatterjee et al.[27]mentioned, " likely mechanisms are prostaglandin inhibition in peripherally, with facilitation of serotonergic antagonism and endorphin release centrally. "
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    ABSTRACT: Aim. Efficacy of granisetron and combination of granisetron and dexamethasone was evaluated for prevention of postoperative nausea and vomiting (PONV) in children undergoing elective strabismus surgery. Methods. A total of 136 children (1–15 years) were included. Children received either granisetron (40 mcg/kg) [group G] or combination of granisetron (40 mcg/kg) and dexamethasone (150 mcg/kg) [group GD]. Intraoperative fentanyl requirement and incidence and severity of oculocardiac reflex were assessed. PONV severity was assessed for first 24 hours and if score was >2, it was treated with metoclopramide. Postoperative analgesia was administered with intravenous fentanyl and ibuprofen. Results. The demographic profile, muscles operated, and fentanyl requirement were comparable. Complete response to PONV in first 24 hours was observed in 75% (51/68) of children in group G and 76.9% (50/65) of children in group GD, which was comparable statistically ( p = 0.96 , Fisher exact test; OR 1.11, 95% CI 0.50, 2.46). Incidence of PONV between 0 and 24 hours was comparable. One child in group G required rescue antiemetic in first 24 hours and none of the children had severe PONV in group GD. There was no significant difference in incidence or severity of oculocardiac reflex. Conclusion. Dexamethasone did not increase efficacy of granisetron for prevention of PONV in elective pediatric strabismus surgery. Registration number of clinical trial was CTRI/2009/091/001000.
    Full-text · Article · Jan 2016 · Anesthesiology Research and Practice
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    ABSTRACT: Postoperative nausea and vomiting (PONV) constitutes a significant factor in delaying recovery after anesthesia and impairing patient satisfaction. To date the prevention of PONV using single or multimodal interventions, usually based on risk assessment, has gained some popularity. However, comprehensive implementation and knowledge transfer of the latest accomplishments in the prevention of PONV is only slowly being adopted into clinical practice. Preventing PONV is the first step in avoiding refractory PONV. This review comments mainly on the management of refractory PONV. As the data on coping with established PONV are rare, further studies focusing on treatment of established PONV are needed.
    No preview · Article · Sep 2012 · Anesthesiology Clinics
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