Efectividad de la profilaxis antiemética en el posoperatorio de pacientes operados por cirugía de mínimo acceso

Anestesia, náuseas y vómitos postoperatorios van unidas prácticamente desde que la anestesia general se introdujo en la práctica clínica quirúrgica, y todavía en la actualidad sigue presentando una incidencia inaceptablemente alta. Con el objetivo de evaluarla efectividad de la medicación preanestésica antiemética con ondansetrón en comparación con dexametasona, en la prevención de la aparición de náuseas y vómitos postoperatorios, se realizó un estudio prospectivo, cuasiexperimental, con grupo control no equivalente en pacientes operados por cirugía de mínimo acceso en el hospital provincial general "Carlos Manuel de Céspedes″ de Bayamo, entre septiembre 2017 hasta diciembre 2020, distribuidos aleatoriamente en dos grupos de 78 pacientes cada uno: el grupo I tratado con ondansetrón, y el grupo II tratado con dexametasona. Fueron utilizados el test del Xi-cuadrado (X2), y la prueba de diferencias de proporciones, con un valor de p = 0,05; los pacientes entre 40 a 49 años de edad, el sexo femenino, ASA II, sin antecedentes de náuseas y vómitos; y con estratificación de riesgo intermedio de nausea y vómitos, fueron más frecuente en el grupo al que se le administró dexametasona. En el grupo I, el mayor número de pacientes tuvo intensidad leve y un número reducido de pacientes requirieron rescate antiemético con dimenhidrinato. En el grupo II, el mayor número de pacientes reportó intensidad moderada seguida de fuerte, requiriendo rescate antiemético. Se concluyó que la administración de ondansetrón en monoterapia es más efectiva en la prevención de la aparición de náuseas y vómitos postoperatorios que la administración de dexametasona.

Postoperative anaesthesia, nausea and vomiting have been linked practically since general anaesthesia was introduced into clinical surgical practice, and still today it continues to have an unacceptably high incidence. With the objective of evaluating the effectiveness of preanesthetic antiemetic medication with ondansetron compared to dexamethasone, in the prevention of the appearance of postoperative nausea and vomiting, a prospective, quasi-experimental study was carried out with a control group not equivalent in patients operated by minimally accessible surgery in the general provincial hospital "Carlos Manuel de Céspedes" of Bayamo. between September 2017 to December 2020, randomly distributed into two groups of 78 patients each: group I treated with ondansetron, and group II treated with dexamethasone. The Xi-square test (X2) and the proportions differences test were used, with a value of p = 0.05; patients between 40 and 49 years of age, female, ASA II, with no history of nausea and vomiting; and with intermediate risk stratification of nausea and vomiting, were more frequent in the group administered dexamethasone. In group I, the largest number of patients had mild intensity and a small number of patients required antiemetic rescue with dimenhydrinate. In group II, the largest number of patients reported moderate intensity followed by strong intensity, requiring antiemetic rescue. It was concluded that ondansetron monotherapy is more effective in preventing postoperative nausea and vomiting than dexamethasone administration.

Anestesia pós-operatória, náuseas e vômitos têm sido associados praticamente desde que a anestesia geral foi introduzida na prática clínica cirúrgica, e ainda hoje continua a ter uma incidência inaceitavelmente alta. Como objetivo de avaliar a eficácia da medicação antiemética pré-anestésica com ondansetrona comparada à dexametasona na prevenção do aparecimento de náuseas e vômitos pós-operatórios, foi realizado um estudo prospectivo, quase experimental, com um grupo controle não equivalente em pacientes operados por cirurgia minimamente acessível no hospital geral provincial "Carlos Manuel de Céspedes" de Bayamo entre setembro de 2017 a dezembro de 2020, distribuídos aleatoriamente em dois grupos de 78 pacientes cada: grupo I tratado com ondansetron e grupo II tratado com dexametasona. Foram utilizados o teste do xi-quadrado (X2) e o teste de diferenças de proporções, com valor de p = 0,05; pacientes entre 40 e 49 anos, sexo feminino, ASA II, sem história de náuseas e vômitos; e com estratificação de risco intermediário para náuseas e vômitos, foram mais frequentes no grupo que recebeu dexametasona. No grupo I, o maior número de pacientes apresentou intensidade leve e um pequeno número de pacientes necessitou de resgate antiemético com dimenidrinato. No grupo II, o maior número de pacientes relatou intensidade moderada seguida de intensidade forte, necessitando de resgate antiemético. Concluiu-se que a monoterapia com ondansetrona é mais efetiva na prevenção de náuseas e vômitos pós-operatórios do que a administração de dexametasona.

Total intravenous anesthesia vs inhalational anesthesia in patients undergoing surgery under general anesthesia. Cost-minimization study / Anestesia total endovenosa vs. anestesia basada en halogenados en pacientes llevados a cirugía bajo anestesia general. Estudio de minimización de costos

Abstract Introduction: The methods most frequently used at the present time in Colombia for the administration of general anesthesia are based on halogenated and intravenous drugs. However, in view of the lack of differential clinical outcomes, the existence of cost variations between the two is not clear. Objective: To determine the expected cost of the use of both techniques in patients taken to surgery, within the framework of the Colombian national health system. Methods: A cost minimization study was carried out using the decision tree as the analytical model. A time frame of 6 postoperative hours was used as the assumption. Only direct healthcare-related costs were included using a case study approach. An econometric model was used based on the frequency with which each technology is applied and the type of drug used, and a deterministic and probabilistic sensitivity analysis was performed. Results: For the case study, total intravenous anesthesia (TIVA) is more costly than the inhalational technique, with an incremental cost of $102,718 per patient. The deterministic analysis shows that both the incidence of postoperative nausea and vomiting (PONV) as well as the use of target controlled infusion (TCI) techniques are the main cost determinants. The probabilistic analysis shows that the cost difference can even be nil in more than 50% of the simulated settings, when the difference in the risk of PONV is higher. Conclusions: Although the total intravenous technique can be more costly than the inhalational technique, this difference is offset by a lower cost of the postanesthesia care unit, given the lower risk of postoperative nausea and vomiting.

Resumen Introducción: Actualmente, los métodos más usados en Colombia para la administración de anestesia general son las técnicas basadas en halogenados y en medicamentos intravenosos. No obstante, y ante la falta de desenlaces clínicos diferenciales, no es claro si existe una variación en los costos. Objetivo: Determinar el costo esperado del uso de ambas técnicas en pacientes llevados a cirugía bajo la perspectiva del sistema nacional de salud colombiano. Métodos: Se realizó un estudio de minimización de costos. Se empleó el árbol de decisión como modelo analítico. Se asumió un horizonte temporal de 6 horas postoperatorio. Se incluyeron solo los costos sanitarios directos mediante un caso tipo. Se empleó un modelo econométrico basado en la frecuencia de uso de cada tecnología y medicamento empleado y se realizó análisis de sensibilidad determinístico y probabilístico. Resultados: Para el caso tipo, la técnica total endovenosa es más costosa que la técnica basada en halogenados, con un costo incremental de $102.718 por paciente. El análisis determinístico muestra que tanto la incidencia de náuseas y vómito postoperatorio como el uso de tecnologías TCI (targetcontrolled infution) son los principales determinantes de estos costos. El análisis probabilístico muestra que la diferencia de costos puede ser incluso de cero pesos en más del 50 % de los escenarios simulados cuando se tiene una mayor diferencia del riesgo de náuseas y vómito postoperatorio. Conclusiones: Aunque la técnica total endovenosa puede ser más costosa que la basada en halogenados, esto se compensa con un costo inferior en la unidad de recuperación postanestésica debido a un menor riesgo de náuseas y vómito postoperatorio.

Amisulprida una nueva profilaxis contra las náuseas y vómitos postoperatorios: una revisión de la literatura / Amisulpride new prophylaxis against postoperative nausea and vomiting: a review of the literature

Introducción: las náuseas y vómitos postoperatorios (PONV) son una complicación postoperatoria común de la anestesia, por lo que la búsqueda de nuevas profilaxis efectivas ha aumentado durante los últimos años, en este contexto se perfila como una opción efectiva el amisulprida, antipsicótico que actúa bloqueando los receptores dopaminérgicos D2 y D3, en dosis bajas. Métodos: se realizó una búsqueda en bases de datos establecidas como: Pubmed, Embase, Google Scholar, Medline y la Cochrane central registed of controlled trials. Con las siguientes definiciones clave: "NV" or "postoperative nausea and vomiting" or "postoperative nausea" or "postoperative vomiting" and "Amisulpride" or "APD421", con el fin de cumplir el objetivo general de verificar la efectividad de amisulprida como medicamento profiláctico en manejo de PONV. Resultados: se evaluaron 3 estudios multicéntricos randomizados controlados, con alto grado de confiabilidad y buena calidad metodológica. Se evidencia que el amisulprida es un medicamento profiláctico efectivo contra PONV y con buen perfil de seguridad. Discusión/Conclusión: el amisulprida es un medicamento profiláctico eficaz para prevención de PONV, en dosis óptima de 5 mg, administrado durante el intraoperatorio de cirugías electivas en que se utilice anestesia general en pacientes de moderado a alto riesgo de PONV según escala de Apfel.

Introduction: postoperative nausea and vomiting (PONV) are common postoperative complications of anaesthesia, that is why the search for new effective prophylaxis has increased in recent years. Between the drugs that have been tested for this purpose, Amisulpride, an antipsychotic that blocks D2 and D3 dopaminergic receptors, seems to be an effective option when used in low doses. Methods: This search was done by using databases such as Pubmed, Embase, Google Scholar, Medline and the Cochrane central register of controlled. With the following keywords: "NV" or "postoperative nausea and vomiting" or "postoperative nausea" or "postoperative vomiting" and"Amisulpride" or "APD421", with the purpose of verifying the effectiveness of Amisulpride as prophylactic medication in PONV man-agement, which is our main objective. Results: 3 randomised, controlled, multicenter, with high reliability and good methodological quality studies were evaluated. Evidence suggests that Amisulpride is effective as a prophylactic medication against PONV, and it also has a good safety profile. Discussion/Conclusion: Amisulpride administered in an optimal dose of 5 mg during intraoperative elective surgeries that required general anaesthesia, showed to be effective in preventing PONV as a prophylactic drug in patients with moderate to high risk of PONV according to the Apfel scale.

Prevalencia de náusea y vómito postoperatorio en colecistectomía laparoscópica en un tercer nivel de atención / Prevalence of postoperative nausea and vomiting in laparoscopic cholecystectomy at a third level of care

Resumen: Introducción: La náusea y el vómito son complicaciones frecuentes de la anestesia. La prevención de esta complicación es fundamental desde el período preanestésico. Su etiología es multifactorial con prevalencias variables que van de 20 a 92%. Objetivo: Conocer la prevalencia de náusea y vómito postoperatorio en colecistectomía laparoscópica en un hospital de tercer nivel de atención. Material y métodos: Se realizó un estudio observacional, descriptivo, prospectivo y longitudinal, en pacientes a quienes se programó para colecistectomía laparoscópica electiva en un hospital de tercer nivel de atención, se midió la presentación de náusea, vómito y de la combinación de ambos síntomas, al despertar del paciente, a la primera, segunda y a las 24 horas del postoperatorio. Resultados: Ingresaron 224 pacientes de los cuales el sexo femenino representó el 75.45% (169), con edad promedio de 44.4 ± 13.9 años. La prevalencia de náusea en las primeras 24 horas fue de 33.03% y ésta fue precedida del vómito en 93.24% de los casos con una prevalencia de 31.25%. La combinación de ambos síntomas, náusea y vómito postoperatorio, tuvo una prevalencia de 33.5%. El tipo de medicación profiláctica que recibió la mayoría fue monoterapia con ondansetrón con el 48.86%, la prevalencia de náusea y/o vómito postoperatorio no tuvo diferencias en el tratamiento profiláctico utilizado. El tratamiento con opioides es uno de los factores que se asoció a una mayor presentación de náusea y/o vómito.

Abstract: Introduction: Postoperative nausea and vomiting are frequent complications of anesthesia, the prevention of this complication is fundamental from the pre-anesthetic period. Its etiology is multifactorial with variable prevalences ranging from 20 to 92%. Objective: To determine the prevalence of postoperative nausea and vomiting in laparoscopic cholecystectomy in a tertiary care hospital. Material and methods: An observational, descriptive, prospective and longitudinal study was conducted in patients who were scheduled for elective laparoscopic cholecystectomy in a tertiary care hospital, the presentation of nausea, vomiting and the combination of both symptoms was measured, upon awakening of the patient, the first, second and twenty-four postoperative. Results: 224 patients were included, of which the female sex represented 75.45%, with an average age of 44.4 ± 13.9 years. The prevalence of nausea in the first 24 hours was 33.03%. and it was preceded by vomiting in 93.24% of patients with a prevalence of 31.25%. the combination of both symptoms; postoperative nausea and vomiting, had a prevalence of 33.5%. The type of prophylactic medication that was received the majority was ondansetron with 48.86%, the prevalence of postoperative nausea and vomiting had no difference in the prophylactic treatment used. Treatment with opioids is one of the factors that was associated with a greater presentation of nausea and/or vomiting.

Small dose of propofol combined with dexamethasone for postoperative vomiting in pediatric Moyamoya disease patients: a prospective, observer-blinded, randomized controlled study / 대한마취과학회지

BACKGROUND: For effective postoperative antiemetic management in pediatric moyamoya disease patients receiving fentanyl based postoperative analgesia, a multimodal approach has been recommended. The uncertain efficacy of ondansetron for pediatric neurosurgical patients or the possible antiemetic effect of small dose of propofol motivated us to evaluate the preventive effect of a subhypnotic dose of propofol combined with dexamethasone on postoperative vomiting (POV), especially during immediate postoperative periods. METHODS: In a prospective observer-blind randomized controlled study, we compared dexamethasone 0.15 mg/kg alone (Group D) with dexamethasone combined with propofol of 0.5 mg/kg (Group DP) in 60 pediatric patients, aged 4-17 years, who underwent indirect bypass surgery and received fentanyl-based postoperative analgesia. Occurrence of vomiting and pain score (Wong-Baker facial score) and requirement of rescue analgesic and antiemetic were continually measured (0-2, 2-6, 6-12 and 12-24 postoperative hours). For statistical analysis, in addition to the Fisher's exact test, a generalized linear mixed model (GLMM) and the linear mixed model (LMM) for repeated measures were used for vomiting and pain scores, respectively. RESULTS: There was no statistical significance of POV incidence, requirement of rescue analgesic and pain score between the two groups at any measured intervals. The incidence of POV was 53.3% during 24 hours in both groups, and was especially 6.7% and 13.3% (P = 0.671) during 0-2 hr and 16.7% and 23.3% (P = 0.748) during 2-6 hr in group D and group DP, respectively. CONCLUSIONS: A small dose of propofol combined with dexamethasone appears ineffective to preventing POV in pediatric moyamoya patients receiving continuous fentanyl infusion.

The Prophylactic Antiemetic Effects of Combination of Ondansetron with Dexamethasone after Strabismus Surgery in Children / 대한마취과학회지

BACKGROUND: Postoperative vomiting (POV) is a common complication after pediatric strabismus surgery. The aim of this study was to evaluate the prophylactic antiemetic effects of a combination of ondansetron with dexamethasone after strabismus surgery in children. METHODS: In this prospective, randomized, double-blind, placebo-controlled study, 126 healthy children, aged 3-10 years, who underwent strabismus surgery under general anesthesia using sevoflurane were examined. The patients were divided randomly into three groups: Patients who received 100microgram/kg ondansetron with 100 microgram/kg dexamethasone (OD group, n = 42); 100microgram/kg ondansetron (O group, n = 42); and saline as placebo (P group, n = 42) after the induction of anesthesia. The incidence of vomiting, the patient's distress due to vomiting, the need for rescue antiemetics and parental satisfaction during the first 24 h after surgery were evaluated. RESULTS: The incidence of vomiting in group OD (5%) and group O (17%) during the first 24 h after surgery were significantly lower than in group P (40%) (P < 0.001, P < 0.05, respectively). The level of distress of the patients in group OD during the first 6 h after surgery was significantly lower than in group P (P < 0.05). The parents in group OD were more satisfied than those in group P (P < 0.05). However, the incidence of vomiting, patient's distress, need for rescue antiemetics, and parental satisfaction were comparable between groups OD and group D. CONCLUSIONS: A combination of ondansetron with dexamethasone and ondansetron alone were equally effective in preventing vomiting after strabismus surgery in children. However the combination of ondansetron with dexamerhasone, but not ondamsetrone alone, is more effective in reducing the level of patient's distress and incresing the level of parental satisfaction than the placebo.