Multimodal Antiemetic Managemnet Prevents
Early Postoperative Vomiting After Outpatient Laparoscopy
Scuderi et al. Anesth Analg 2000;91:1408-14
Reviewed by: R. Prasad, MD
Summary:
-
Their clinical care algorithm resulted in 2% nausea, 0% vomiting before
discharge (better than ondansetron prophylaxis or placebo) after outpt
gyn laparoscopy
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However, no diff (vs. ondansetron) in pt satisfaction
Comments:
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Interesting in that the study shows that this multimodal approach can significantly
reduce PONV. Would need further study to decide which elements of their
algorithm are necessary.
-
Incidence of rescue in ondan group lower than expected (lower than used
in power analysis) ... study has less power than anticipated to detect
differences between these groups (I, II)
Methods:
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139 females, outpt GYN laparoscopy under GA
| Group |
N |
Tx |
| I |
60 |
Midaz/Drop 0.625mg/Dexameth 10mg. TIVA GA/ETT: Prop/Remi (no NMR).
25 ml/kg IVF. Ketorolac 30mg 30 min after induction. Ondan 1mg at end. |
| II |
42 |
Midaz/Fent/Propofol/Rocuronium. GA/ETT: Sevo/Nitrous. Ondan 4mg
before emergence. No ketorolac. |
| III |
37 |
Midaz/Fent/Propofol/Rocuronium GA/ETT: Sevo/Nitrous. Saline before
emergence. No ketorolac. |
-
Power analyses
-
I needed 60 for 95% upper confidence interval that failure rate (vomiting,
or need for rescue) <=5%.
-
II needed 42 for 90% power to detect diff from I, assuming incidence
of rescue in II to be 30% and 5% in I.
-
III needed 37 for 90% power to detect diff vs. I, assuming incidence
of rescue in III of 40% (vs. 5% in I).
-
Collected info on nausea (0-10 scale) at intervals, vomiting, need for
rescue, fentanyl dose (OR, PACU), time to discharge readiness, 24h and
5d satisfaction
Results:
-
Partial data only. * = signif diff vs II and III
| Parameter |
I |
II |
III |
| Weight(lb) |
143* |
160 |
155 |
| Fentanyl(mcg) |
53* |
128 |
142 |
| Complete Response (%) |
98* |
76 |
59 |
| TxReqdNausea (%) |
2* |
17 |
35 |
| TxReqdEmesis (%) |
0 |
7 |
5 |
| TxReqdTotal (%) |
2* |
24 |
41 |
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Overall Efficacy (*=sig vs. II, $=sig vs.III)
| Parameter |
I |
II |
III |
| Vomiting before d/c (%) |
0$ |
7 |
22 |
| Vomiting after d/c (%) |
12$ |
21 |
32 |
| Ready for d/c (min) |
128*$ |
162 |
192 |
| Satisfaction Score<10 (%) |
5$ |
6 |
37 |
Home-Amb-Card-Crit-Neuro-OB-Orth-Pain-Ped-Reg-Tran-Vasc-Misc