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SURGERY

Meta-Analysis of the Use of Rescue Antiemetics Following PONV Prophylactic Failure with 5-HT₃ Antagonist/Dexamethasone Versus Single-Agent Therapies

¹ Professor of Anesthesiology, Department of Anesthesiology, University of Kansas Medical Center, Mail Stop 1034, 3901 Rainbow Blvd., Kansas City, KS 66160, fax 913/588-3365, akovac{at}kumc.edu

Reprints: Dr. Kovac.

OBJECTIVE: 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 (OR_pooled = 0.48; 95% CI 0.29 to 0.77) or dexamethasone (OR_pooled = 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.

Key Words: dolasetron, granisetron, 5-HT₃, ondansetron, postoperative nausea and vomiting

Published Online, May 2, 2006. www.theannals.com, DOI 10.1345/aph.1G338